Academic Cancer Programs Research Articles

Abstract PO1-09-05: Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration

Abstract Background: Rural disparity in Breast Cancer (BC) often relates to poor geographic access. We are small county in rural North Carolina with historically poor outcomes, including more advanced stages of BC at presentation, higher mastectomy rates, and higher BC-specific mortality rates than elsewhere. Beginning in 2002 we increased access to care by construction of a 19-bed Critical Access Hospital. With a higher median age population (10 years older), and cancer as the number one cause of death (30% of all deaths), we began to increase access to services with focus on cancer. Two decades later, we still do not provide all aspects of care locally, but through a model of collaboration we have increased access to all aspects of cancer care. Breast Cancer is the most common, and this report details the reversal in disparity seen rurally based on our model of collaboration with both a regional community cancer program and academic cancer program. Methods: We partnered with academic and community cancer centers in nearby counties to increase access to imaging, cancer specialists, radiation therapy and chemotherapy services, and support services for breast care. When we could not provide these services locally, we helped navigate patients to these other facilities to improve access. We invited dedicated breast surgeon from community cancer program to attend clinic weekly in our area. We created virtual breast-specific tumor boards to discuss 100% of cases prospectively, with improved access to pathologists, geneticists, fellowship-trained imaging specialists, breast surgeons and other multi-disciplinary care members (reconstructive surgery, PT/OT, integrative medicine, GYN). We became cancer accredited with both COC and NAPBC. We compare metrics pre/post-improvements. Results: Baseline: 1. Mortality rates: (2002-2006) 5-year BC mortality rates in our region averaged 32.3/100,000 population which was in the top quartile for the state, 30% higher than the state average. 2. Stages at presentation: 47% of BC stages were early (stages 0/1) in our service region compared to 62% elsewhere (NCDB data). Stage IV represented 6% in our region versus 4% elsewhere. 2500 mammograms/year at hospital at baseline. 3. Surgery/Radiation Therapy: Mastectomy rates averaged >50% in region, with correspondingly lower breast conserving rates than elsewhere due to lack of access to breast surgeons and radiation therapy services locally. Closest RT facility 80 miles. 4. Distances to high quality breast care averaged 150 miles. Closest Academic/Community Cancer Program 2-hour drive (one way). Post Collaboration: 1. Mortality rates: (2015-2019), 5-year BC mortality rates in our region averaged 16.3/100,000 population which is in the lowest quartile, 20% lower than the state average. 2. Stages at presentation: 74% of BC stages are early (stages 0/I) in our region versus 68% elsewhere. Stage IV now below parity with 3% locally versus 4% nationally. More than 5100 mammograms/year done currently at local hospital. 3. Surgery/Radiation Therapy: Mastectomy rates average 21%, with partial mastectomy rates of 79% in our area versus 70% elsewhere (NAPBC data) with RT services available locally. 4. Distances to quality breast care average 20 miles, and we are nationally accredited program in breast care as a critical access hospital. Analytic case load is now triple baseline numbers. Conclusion: We reversed the trend in rural disparity in breast cancer outcomes through model of collaboration. We increased screening rates locally, doubling the number of screening/diagnostic exams, increased the percentage of early stage at diagnosis, halved our mastectomy rates, and reduced BC-specific mortality 50% relative to baseline (and now 20% lower than state). We are now at parity with most BC-specific quality metrics reflecting a huge shift in rural disparity, which could only be achieved rurally through collaboration. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration This table depicts the changes in our region over time, which have brought us to parity with Breast Care nationally. Citation Format: Charles Shelton, Antonio Ruiz. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-05.

Demographics of the tumor formerly known as bronchiolo-alveolar carcinoma.

e20604 Background: Bronchiolo-alveolar carcinoma (BAC) is a rare subtype of non-small cell lung cancer of the lung periphery, often characterized by lepidic growth. Although BAC has undergone various reclassifications in recent years, International Classification of Disease codes still classifies these subtypes using the same codes that previously belonged to BAC. Changing diagnostic criteria and other factors cause BAC to be among the most overdiagnosed forms of lung cancer and thus a demographic study could provide insight into trends. Methods: A retrospective cohort analysis utilizing the National Cancer Database (NCDB) from 2004 – 2020 included patients with malignant forms of BAC (Invasive mucinous adenocarcinoma, mixed invasive mucinous, and nonmucinous adenocarcinoma) confirmed through histology. Demographic factors such as sex, age, race, Hispanic status, median household income, insurance status, facility type, county population, distance from facility, and Charlson Deyo score were analyzed by descriptive statistics and incidence trends. Results: In total, 12,607 patients were identified in the database with a confirmed diagnosis of BAC between 2004 – 2020. The number of cases per year remained steady (mean = 565.4) until 2018. From 2018 to 2020, the average number of diagnoses per year was 1575.0. The average age of diagnosis was 69.3 years (SD = 10.7, range = 10 to > 90 years). 58.1% of the cases were female patients. The top primary sites were the lower and upper lobes (46.2% and 39.9% respectively). The majority (59.2%) had Charlson-Deyo comorbidity scores of 0. Most cases occurred in Non-Hispanic White persons (86.8%). More patients were in the top quartile of income earners (34.0%) compared to those in lower quartiles. Medicare was the insurance provider for most patients (65.0%). More patients were diagnosed in counties with a population over 1 million (52.4%). More patients were treated in comprehensive community cancer programs (38.1%) followed closely by academic cancer programs (35.2%). Patients lived an average of 31.6 miles (SD = 113.0, range = 0.1 – 2390.7) from the treatment facility. Conclusions: This is the first NCDB analysis on the demographics of BAC. The sudden rise in cases per year in 2018 aligns with the changing pathologic and histologic definitions for BAC. A 2006 review of BAC found that 50-70% of cases occur in female patients, similar to our results. The majority of BAC patients tend to be non-Hispanic and White with a primary site diagnosis in the lower lobe, followed by the upper lobe. BAC patients are more likely to be in the top income quartile, live in densely-populated metropolitan areas, and receive treatment in a non-academic program. Further research is needed to better understand the impact of demographic, socioeconomic, and environmental factors on the diagnosis and prognosis of BAC, especially because its diagnostic criteria have changed recently.

Survival benefit and optimal timing for re-resection in patients with gallbladder cancer: A National Cancer Database analysis.

614 Background: Often times, gallbladder cancer is diagnosed incidentally after cholecystectomy. Most patients will then undergo re-resection for potential residual disease, however overall survival (OS) benefit data in this scenario is variable. Further, limited literature regarding optimal time to re-resection exists. Prior studies found the optimal time to re-resection to be approximately 4-8 weeks after initial diagnosis; however, additional data is needed to further validate these findings. In this National Cancer Database(NCDB) analysis we compare OS in patients diagnosed with T1b – T3 gallbladder cancer who underwent re-resection and evaluate if time to resection impacts OS. Methods: We reviewed the NCDB for patients who had received initial cholecystectomy for gallbladder cancer and were subsequently eligible for re-resection based on tumor stage (T1b-T3 disease) from 2004-2018. We excluded patients with metastatic M1 disease and T0, T1a, T1, or T4 disease. Patients with re-resection were further subdivided into four cohorts based on time to re-resection: 0-4 weeks, 5-8 weeks, 9-12 weeks and >12 weeks. We used a Cox proportional hazards ratio to identify factors associated with worse survival and logistic regression to evaluate characteristics associated with re-resection. OS was calculated using Kaplan Meier curves. Results: 791 (5.82%) patients received re-resection of 13,601patients meeting inclusion and exclusion criteria. Cox proportional hazards analysis showed a Comorbidity Score of 1 was associated with worse survival. Patients with higher Comorbidity Scores (1,2, or 3) and treatment at comprehensive community, integrated or academic cancer programs were less likely to undergo re-resection (in comparison to community programs). Patients treated at an Urban facility or diagnosed from 2009-2018 were more likely to undergo re-resection. The cohort with no re-resection had the lowest median OS [17.61 months; CI 17.05- 18.20] and re-resection showed significantly improved OS [HR 0.87; 95 CI 0.77-0.98; p=0.02]. Significantly improved survival was noted when re-resection was completed at 5-8 weeks [HR 0.67; CI 0.57- 0.81], 9-12 weeks [HR 0.64; CI 0.52- 0.79], or >12 weeks [HR 0.61; CI 0.47- 0.78]. Conclusions: Despite the retrospective nature and small sample size of our study, the results are consistent with prior studies depicting a survival benefit with re-resection. Additionally, optimal timing to re-resection supports previous data showing a clear benefit at any time >4 weeks. However, there was no significant survival difference as to whether re-resection was completed at 5-8 weeks, 9-12 weeks, or > 12 weeks post initial cholecystectomy. Decreased post-operative inflammation and accurate staging at >4 weeks may account for improved survival with later re-resection; however, future investigations are warranted to delineate underlying causes.

Survival Outcomes in Women with Unilateral, Triple-Negative, Breast Cancer Correlated with Contralateral Prophylactic Mastectomy.

Despite increased utilization of contralateral prophylactic mastectomy (CPM), there is insufficient evidence that it improves survival in average-risk women with unilateral breast cancer. CPM may be of heightened interest to patients with triple negative breast cancer (TNBC) because these patients are more likely to have BRCA1 mutation-associated disease and are not candidates for the chemoprevention benefits of adjuvant endocrine therapy. Survival and recurrence outcomes were evaluated for all TNBC patients from a multi-institutional database (1999-2018) at two academic cancer programs in two metropolitan cities of the Northeast and Midwest. Median follow-up time was 3.7years. Seven hundred and nighty six TNBC patients were evaluated and 15.45% underwent CPM. Women undergoing CPM were more likely to be white (p < 0.001), younger (p < 0.001), and underwent genetic testing (p < 0.001). A borderline survival benefit was observed for TNBC patients undergoing CPM (5-year overall survival 95.1% vs. 85.0%; p = 0.05). There was no difference in survival when BRCA mutation carriers were excluded (5-year overall survival 94.1% vs. 85.2%; p = 0.12). For BRCA mutation carriers, a numeric trend was observed for improved survival for patients undergoing CPM (5-year overall survival 97.2% vs. 84.1%; p = 0.35). Among patients not undergoing CPM, the rate of developing a new primary breast cancer was 2.2% (15/673). Among these 15 patients, 20% (3/15) were known BRCA mutation carriers. Our data demonstrate no survival benefit for TNBC patients without BRCA1/2 mutations undergoing CPM.

Abstract P3-01-09: Mri in the pre-operative workup of breast cancer patients

Abstract PurposeThe utility of pre-operative MRI (preop MRI) for patients with a new breast cancer diagnosis is controversial. Recently there has been increased use of routine MRI during preoperative workup to evaluate for areas necessitating additional biopsy and planning of operative resection extent; however, these practices carry the risk of delaying treatment, and subjecting patients to unnecessary biopsies and overly extensive resections. Triple negative breast cancer (TNBC) is more difficult to detect on mammography compared to non-TNBC, and patients with TNBC do not receive the chemoprevention benefits of adjuvant endocrine therapy; preop breast MRI to detect mammographically occult foci of disease may therefore be more relevant for patients with TNBC. MethodsOutcomes were evaluated for TNBC patients treated in the prospectively-maintained database of an academic cancer program in a metropolitan city of the Northeast, 1998-2018. ResultsOf 428 TNBC cases, 35.7% (153) had pre-op MRI. 43.6% (61) of 140 TNBC cases ≤50 years old had pre-op MRI compared to 31.9% of 288 TNBC cases &amp;gt;50 years old (p=0.016). There were no differences in race, or stage at presentation between those who had pre-op MRI and those who did not. 34% (52) of pre-op MRI TNBC cases underwent additional biopsies versus 0.43% (1) of TNBC patients who did not have pre-op MRI (p&amp;lt;0.0001). Average time to treatment was 29.5 days for pre-op MRI TNBC cases compared to 25 days for TNBC patients who did not have pre-op MRI (p=0.0026). 9.8% (15) of pre-op MRI TNBC cases underwent re-excisions versus 17.7% (41) of TNBC patients who did not have pre-op MRI (p=0.076). Of those who had mastectomies, patients who had pre-op MRI were more likely to have bilateral mastectomies (21.6% (33) pre-op MRI TNBC v 12.9% (30) of TNBC patients who did not have pre-op MRI (p=0.0471)). Five-year overall survival was no different between patients who had pre-op MRI and those who did not (95.2% vs 95.3% respectively; p=0.79). Among patients undergoing breast conserving surgery, there were no significant differences in the rates of local recurrence between patients that had preop MRI compared to those that did not (13.1% vs 9.1% p=0.392). ConclusionOur data demonstrated that preop MRI in TNBC patients was associated with additional biopsies, more extensive breast surgery, and longer time to treatment. Preop MRI had no impact on survival or local recurrence among patients undergoing breast conserving surgery. Citation Format: Solange Bayard, Genevieve Fasano, Yalei Chen, Jennifer Marti, Rache Simmons, Alexander Swistel, Michelle Drotman, Melissa Davis, Lisa Newman. Mri in the pre-operative workup of breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-01-09.

Integration of Robotic Navigational Bronchoscopy Into a Community Academic Cancer Program

Integration of Robotic Navigational Bronchoscopy Into a Community Academic Cancer Program

Screening mammography mitigates breast cancer disparities through early detection of triple negative breast cancer

PurposeScreening mammography improves breast cancer survival through early detection, but Triple Negative Breast Cancer (TNBC) is more difficult to detect on mammography and has lower survival compared to non-TNBC, even when detected at early stages. TNBC is twice as common among African American (AA) compared to White American (WA) women, thereby contributing to the 40% higher breast cancer mortality rates observed in AA women. The role of screening mammography in addressing breast cancer disparities is therefore worthy of study. MethodsOutcomes were evaluated for TNBC patients treated in the prospectively-maintained databases of academic cancer programs in two metropolitan cities of the Northeast and Midwest, 1998–2018. ResultsOf 756 TNBC cases, 301 (39.8%) were mammographically screen-detected. 46% of 189 AA and 38.5% of 460 WA patients had screen-detected TNBC (p = 0.16). 25.3% of 257 TNBC cases ≤50 years old had screen-detected disease compared to 47.3% of 499 TNBC cases >50 years old (p < 0.0001).220/301 (73.1%) screen-detected TNBC cases were T1 lesions versus 118/359 (32.9%) non-screen-detected cases (p < 0.0001). Screen-detected TNBC was more likely to be node-negative (51.9% v. 40.4%; p < 0.0001).Five-year overall survival was better in screen-detected TNBC compared to nonscreen-detected TNBC (92.8% v. 81.5%; p < 0.0001) in the entire cohort. The magnitude of this effect was most significant among AA patients (Fig. 1). Screening-related survival patterns were similar among AA and WA patients in both cities. ConclusionData from two different cities demonstrates the value of screening mammography to mitigate breast cancer disparities in AA women through the early detection of TNBC.

Utilization of Palliative Care Among Patients with Hematologic Malignancies: An Extensive National Analysis to Define Trends and Patterns

Background: There is growing recognition of palliative care (PAL) as an integral aspect of cancer treatment. Several guidelines recommend universal access and early utilization of PAL as a goal for patient care but no data exists defining current trends and practice patterns for PAL use, especially in hematologic malignancies.Methods: The 2016 National Cancer Database (NCDB) was utilized for patients with non-Hodgkin lymphoma (NHL), multiple myeloma (MM), chronic lymphocytic leukemia (CLL), acute myeloid leukemia (AML) and Hodgkin disease (HD) diagnosed between 2004-2013. Deceased patients who received PAL as part of initial therapy for these diagnoses were stratified by survival duration (<6, 6-24, 24-60 and 60+ months). These strata were then utilized to determine associations between PAL usage and socio-demographic, disease and facility characteristics using multivariate logistic regression analysis.Results: A total of 293518 patients were present in NCDB for the identified diagnoses (AML: 55827, CLL: 20634, HD: 9871, NHL: 147614, MM: 59572). Of these 15352 (5.2%) received PAL as part of initial therapy. Compared to patients diagnosed in 2004-2005, patients diagnosed in 2012-2013 had significantly higher odds of PAL use in those surviving <6 months (OR 1.28, 95% CI 1.17, 1.39), while not for those with longer survival. Type of PAL used included surgery/radiation/chemotherapy (S/R/C) in 68%, pain management only in 14.5%, both S/R/C/ and pain management in 5% and unknown modality in 12.5%. There was a significant decrease in overall PAL use as duration of patient survival increased, from 7.2% in <6 month to 2.9% in 60+ month group (p<.001). Among the selected diagnoses, PAL use was highest for MM patients for all survival groups (OR 2.65-59.56, ref=AML) and lowest for CLL (OR 0.51-2.94, ref=AML). PAL use increased significantly for the <6 month and 6-24 month survival groups with increasing age (p<.001) but not for those with longer follow up. There was no difference in PAL use by gender for any survival group. PAL utilization increased significantly for patients with higher Charlson-comorbidity index but only for those with <6 month survival (p<.001), not for those with longer survival. PAL use was significantly different by race-ethnicity in those who survived <6 month with lesser use in non-Hispanic Blacks (OR 0.90, 95% CI 0.82, 0.98) than non-Hispanic Whites while not different in those with longer survival. Within a racial-ethnic group, Hispanics had an increased utilization of PAL for those with improving survival (60+ month group OR 1.7, 95% CI 1.09, 2.63). There was no difference in PAL use by urban/rural location of patient residence or distance from the treating facility for any survival duration group. The only influence of geographic region was that for patients with <6 month survival, PAL utilization was higher in Mountain (OR 1.44, 95% CI 1.27, 1.64) and Pacific (OR 1.19, 95% CI 1.09, 1.32) regions (ref=East Coast). Socioeconomic factors affecting PAL use included insurance status but only for those surviving 6-24 months where patients with “other government” payer were most likely to get PAL (OR 1.82, 95% CI 1.32, 2.5, ref=private insurance). There was a significant interaction of median patient income and PAL use across survival groups (p=0.011) but no clear trend within any specific subgroup by income or survival category. Higher PAL use was noted with increasing literacy level (p<.001) only in those with <6 month survival and not for any other survival group. Compared to non-academic cancer programs, academic/research programs were less likely to utilize PAL in those surviving 24-60 months (OR 0.85, 95% CI 0.76, 0.94) and 60+ months (OR 0.74, 95% CI 0.61, 0.89), while there was no significant difference in those surviving <6 months (OR 1.06, 95 % CI 1, 1.12) or 6-24 months (OR 1, 95% CI 0.92, 1.08).Conclusions: We present the largest analysis so far of utilization of PAL in patients with hematologic malignancies. Despite national guidelines and near universal recommendations, overall utilization of PAL was dismal and lesser so in academic cancer programs including NCI-designated centers. There was no clear subgroup showing uniform utilization, suggesting sporadic use at best. We noted significant heterogeneity in practice patterns by all characteristics studied underscoring the need for standardized implementation with public, healthcare provider, institutional and political will. DisclosuresAilawadhi:Novartis: Consultancy, Honoraria; Pharmacyclics: Research Funding; Takeda: Consultancy, Honoraria; Amgen: Consultancy, Honoraria. Sher:LAM Therapeutics, Inc: Research Funding.

Racial disparities in genetic testing of breast cancer patients.

10591 Background: TNBC is disproportionately prevalent in African American (AA) populations and in women with BRCA-1 germline mutations. BRCA mutation carriers are candidates for targeted therapy with PARP-inhibitors, and testing results may influence risk-reducing surgery choice. Methods: We evaluated genetic testing patterns and outcomes for TNBC patients treated in the prospectively maintained databases of academic cancer programs in two metropolitan cities in the Northeast (New York City, NYC) and Midwest (Detroit, Det), 1998-2018. Median follow up was 3.73 years. Testing patterns were also analyzed by time, comparing pts diagnosed before versus after the mid-2013 Supreme Court ruling that expanded testing availability by banning gene patenting. Results: Of 810 pts, 600 were from NYC and 200 from Det; 202 were AA and 488 WA. Pts undergoing genetic testing were younger (median age 50 vs 62; p &lt; 0.0001). Compared to WA, AA pts were less likely to undergo genetic testing overall (23.8% vs 42.0%; p &lt; 0.0001) and within site (NYC: 25.6% vs 42.8%, p = 0.008; Det: 22.3% vs 38.6%, p = 0.025). No significant differences were seen in frequency of pathogenic BRCA mutations (AA-14.6%; WA-29.3%) or VUSs (AA-6.3%; WA- 4.9%); p = 0.20. Genetic testing disparities were reduced among pts diagnosed after mid-2013 (AA-31.4% vs WA-44.0%; p = 0.01) compared to pre-mid-2013 (AA-18.3% vs WA-40.7%; p &lt; 0.0001). No differences were seen in local or distant recurrence free survival between patients with BRCA, BRCA variants of uncertain significance, non-BRCA mutations, and patients without genetic mutations (local recurrence p = 0.827; distant recurrence p = 0.574). This outcome equivalence was consistent when stratified by WA vs AA identity. Conclusions: Genetic testing has increased for TNBC pts following the mid-2013 Supreme Court ban on gene patenting, but race-associated disparities persist. Pts undergoing genetic testing are more likely to undergo risk-reducing mastectomy, but testing results do not affect survival outcomes, regardless of race. Addressing genetic testing disparities will become increasingly important as mutation-associated targeted therapies are identified through advances in precision medicine.

Transarterial radioembolization versus systemic treatment for hepatocellular carcinoma with macrovascular invasion: Analysis of the US National Cancer Database.

Background and Aims: Systemic therapy remains the recommended first-line treatment for hepatocellular carcinoma (HCC) with macrovascular invasion (MVI). Transarterial radioembolization (TARE) is a promising alternative treatment given superior quality of life. The aims of this study were to 1) characterize trends and correlates for TARE as first-line treatment of HCC patients with MVI in the US and 2) compare survival after TARE versus systemic therapy. Methods: We used the US National Cancer Database to identify patients with T3BN0M0 HCC during 2010-2017. We performed multivariable logistic regression to identify factors associated with use of TARE vs. systemic therapy and Cox proportional hazards regression to identify factors associated with overall survival. Results: Of 11,259 patients with T3BN0M0 HCC, 1454 (12.9%) and 3915 (34.7%) patients were treated with TARE and systemic therapy, respectively. The proportion of patients who received TARE increased from 13.0% in 2010 to 37.0% in 2017. Older age, White race, and receiving care at an academic cancer program were associated with receipt of TARE, while lack of insurance, higher MELD score, Charlson comorbidity Index ≥3, and Northeast region were associated with receipt of systemic therapy. TARE was associated with reduced mortality compared to systemic therapy (adjusted hazard ratio: 0.74, 95%CI: 0.68-0.80), with consistent results observed in propensity weighted analysis and across all examined subgroups. Conclusion: Use of TARE as first-line therapy for HCC with MVI has increased in the US. Patient characteristics, region, and medical center type affected the use of TARE. TARE was associated with reduced mortality compared to systemic therapy for HCC patients with MVI.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC. How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival? We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact. Of 169,775 patients, 7%, 46%, 10%, 24%, and 12%underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60%and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95%CI, 1.41-1.53), 1.29 (95%CI, 1.25-1.33), 1.18 (95%CI, 1.14-1.23), and 1.20 (95%CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95%CI, 1.28-1.42), 1.22 (95%CI, 1.17-1.26), 1.16 (95%CI, 1.11-1.22), and 1.17 (95%CI, 1.12-1.21), respectively (P< .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11%to 26%of the interinstitutional survival disparities. Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Abstract 2350: Transarterial radioembolization versus systemic treatment for the management of hepatocellular carcinoma with vascular invasion: Analysis of the US National Cancer Database

Abstract Background and Aims: For hepatocellular carcinoma (HCC) with vascular invasion, systemic treatment is recommended but transarterial radioembolization (TARE) is often used in clinical practice. The aim of this study was to investigate the current usage of TARE vs. systemic therapy as a first-line treatment for HCC with vascular invasion in the United States (US). Method: We performed a retrospective cohort study using the National Cancer Database (NCDB), which represents more than 70 percent of newly diagnosed cancer cases nationwide. All HCC patients diagnosed between 2010 and 2015 with the tumor stage of T3BN0M0 according to the 7th edition of the American Joint Committee on Cancer TNM staging system (tumor involving a major branch of a large vein of the liver without lymph nodes or extrahepatic metastasis) and received TARE or systemic treatment as a first-line treatment were included. Multivariable logistic regression was used to estimate factors associated with the utilization of TARE vs. systemic therapy. Results: A total of 1979 patients who received systemic treatment and 524 patients who received TARE were included. The proportion of patients receiving TARE increased from 15.7% in 2010 to 31.4% in 2015 (P&amp;lt;0.01). The median tumor size of the largest lesion was comparable (7.0cm for TARE vs. 7.1 cm for systemic treatment, P=0.43). Factors independently associated with increased likelihood of receiving TARE over systemic treatment were: advanced age (Odds Ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01 - 1.03, p=0.005), insurance status: private (OR: 3.06, 95% CI: 1.61 - 5.65, p&amp;lt;0.001), Medicaid/Medicare (OR: 2.91, 95% CI: 1.52 - 5.31, p&amp;lt;0.001), others (OR: 4.85, 95% CI: 1.90 - 11.62, p&amp;lt;0.001) vs. no insurance, and receiving care in the Midwest vs. Northeast region of the US (OR: 1.89, 95% CI: 1.38 - 2.53, p&amp;lt;0.001). Patients were significantly less likely to receive TARE if receiving treatment at community cancer program (OR: 0.24, 95% CI: 0.098 - 0.49, p&amp;lt;0.001) or comprehensive community cancer program (OR: 0.62, 95% CI: 0.48 - 0.82, p&amp;lt;0.001) vs. academic cancer program. Larger tumor size (OR per 1cm: 0.97, 95% CI: 0.95 - 1.00, p=0.03) and higher Charlson comorbidity index of ≥3 vs. 0 (OR: 0.53, 95% CI: 0.38 - 0.73, p&amp;lt;0.001) were inversely associated with receiving TARE. Recent HCC diagnosis year was associated with an increased likelihood of receiving TARE (OR: 1.23, 95% CI:1.16 - 1.32, p&amp;lt;0.001). Conclusion: The proportion of patients receiving TARE as a first-line treatment for HCC with macrovascular invasion has been increasing in the US. Age, comorbidities, insurance status, tumor size, and the type and location of cancer centers are associated with the usage of TARE vs. systemic treatment in HCC patients with vascular invasion. Citation Format: Joseph C. Ahn, Michael Luu, Walid Ayoub, Alexander Kuo, Andrew Hendifar, Jun Gong, Kambiz Kosari, Shelly Lu, Nicholas Nissen, Ju Dong Yang. Transarterial radioembolization versus systemic treatment for the management of hepatocellular carcinoma with vascular invasion: Analysis of the US National Cancer Database [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2350.

Small Bowel Adenocarcinomas: Impact of Location on Survival

BackgroundProximal (duodenal) small bowel adenocarcinomas have a worse prognosis than distal (jejuno-ileal) tumors, but differences in patient, tumor, and treatment factors between locations remain unclear. MethodsPatients in the National Cancer Database with surgically resected pathologic stage I-IV small bowel adenocarcinomas between 2004 and 2015 were analyzed. Clinical stage IV patients were excluded. ResultsProximal tumors (n = 3767) were more likely to be higher grade (OR 1.52, CI 1.22-1.85 for moderately; OR 1.83, CI 1.49-2.33 for poorly differentiated, P < 0.01 for both) and have positive lymph nodes (OR 2.04, CI 1.30-3.23, P < 0.01), while distal tumors (n = 3252) were likely to be larger (OR 1.31, CI 1.07-1.60 for size > 5 cm, P < 0.01). Proximal tumors were associated with worse overall survival (OS) and stage-specific survival compared with distal tumors (all P < 0.01). Cox regression analysis of the entire cohort showed worse survival with community versus academic cancer programs, higher comorbidity scores, pathologic stage IV, poorly differentiated histology, positive nodal or margin status, and proximal location, while female gender, larger tumor size, and chemotherapy predicted better survival. On separate Cox regression analyses of each location, neoadjuvant chemotherapy was associated with better OS in the proximal cohort (HR 0.70, CI 0.55-0.88, P < 0.01), while adjuvant chemotherapy was associated with better OS for both proximal (HR 0.49, CI 0.42-0.57, P < 0.01) and distal tumors (HR 0.68, CI 0.57-0.81, P < 0.01). ConclusionsProximal small bowel adenocarcinomas are associated with worse overall and stage-specific survival. This may be due to tumor biologic differences as proximal tumors were more likely to have higher grade. Future studies should further investigate differences between proximal and distal tumors to guide targeted treatment algorithms.

An intersectional investigation of race and sex on receipt of adjuvant chemotherapy in stage III colon cancer.

86 Background: Race and sex disparities exist for receipt of adjuvant chemotherapy (AC) for stage III colon cancer. However, most studies have not used an intersectional approach, which assesses the cumulative effects of different identities (e.g., Black women) instead of treating each as distinct, independent variables. Using this approach, we assessed the summative impact of these identities on receipt of AC for stage III colon cancer. Methods: The National Cancer Database was queried from 2004 to 2015 for patients who underwent surgery for stage III colon cancer and were healthy enough for AC. Receipt of AC was assessed chi-squared and multivariable logistic regression analyses. Results: 92,696 patients were identified. White patients had higher rates of care at community cancer centers. Black patients had higher rates of treatment at academic cancer programs (p &lt; 0.001). Overall 83.5% received AC. Black males and females had higher rates of AC (86.5% and 86.2%, respectively) compared to White males and females (85.3% and 80.5%), respectively (p &lt; 0.001). In adjusted analysis, Black males had the lowest odds of AC (OR 0.73), followed by Black females (OR 0.89) and White females (OR 0.91). When evaluated by age &lt; 65 years and adjusting for potential confounders, Black men remained the least likely group to receive AC (OR 0.70). Black females had similar odds of receipt of AC (OR 0.99) and White females had increased odds (OR 1.22) relative to White males. Conclusions: Despite higher rates of treatment at academic centers, Black males and females had lower odds of receipt of AC after adjusting for confounders. Younger Black males persisted with the lowest odds of AC, although younger Black females had odds similar to younger White males. Additional research is necessary to identify drivers of these disparities and interventions to ameliorate them. [Table: see text]

Normalizing the use of patient-provider agreement for opioid treatment within a cancer institute.

251 Background: Addressing the opioid epidemic can be challenging in a large academic cancer program and necessitates the need for a multidisciplinary approach for implementation of a successful program. The oncologist has a challenging role caring for patients with preexisting pain conditions, acute cancer-related pain, pain at the end of life and cancer survivors who live with cancer as a chronic condition after treatment. Methods: A structured program was developed to address the mounting pressure from many fronts related to the opioid epidemic including insurance companies, pharmacies, and the Department of Health. In April 2018, the Lifespan Cancer Institute implemented a system wide opioid program including patient education, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. The intent of the program is to implement safe processes to safe guard the patient and their family along with the providers. The patient-provider treatment agreement clearly describes the roles and responsibilities of both groups with a goal of reducing risks by improving education. Our responsibility is to provide optimal management while addressing patient concerns and maintaining patient safety. Results: The opioid program has been well received by both caregivers, patients and families. All are engaged in the embedded education process and fully appreciate the need to use opioids safely. The program has been helpful in managing patient expectations and focusing difficult conversations in cases of potential abuse. In April 2018, only 13% of patients prescribed an opioid had a signed patient-provider treatment agreement. As of April 2019, 75% of patients have a signed agreement. Conclusions: The transitioning of care for the patient with chronic pain after completion of active cancer treatment continues to be a focus of future initiatives. Patient satisfaction remains a top priority as the patient-provider agreement becomes a standard of care for all patients receiving opioids. As oncology healthcare providers, our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.

Patterns of care for anal cancer in the United States - a comparison between academic and community cancer centers

BackgroundManagement of squamous cell carcinoma of the anus (SCCA) is becoming more relevant, as its incidence increases. The purpose of this study was to investigate possible differences in patient population and care delivery for SCCA between academic and community cancer programs in the United States.MethodsA review of available data from the American College of Surgeons Committee on Cancer National Cancer DataBase focused on gender, age, race, type of health insurance, comorbidity score, distance traveled for care, stage at diagnosis, and therapy utilization (surgery, chemotherapy, and radiation therapy) as first course of treatment (FCT). The analysis included 38,766 patients treated for SCCA. Of them, 14,422 patients received treatment at Academic Cancer Programs (ACPs), while 24,344 were treated at Community Cancer Programs (CCPs) between the years 2003 and 2013.ResultsOver the 11-year study period, ACPs had significantly more male patients, of younger age, a greater non-white race population, with more Medicaid or no insurance coverage, who traveled farther for cancer center care (p < 0.001). There was no difference between ACPs and CCPs with respect to Charlson co-morbidity score and stage of SCCA at diagnosis. For stage 0 patients, use of chemotherapy was 8% for ACPs, 9% for CCPs, and use of radiotherapy was 10% for ACPs and 14% for CCPs. The incidence of stage unknown was identical at both ACPs and CCPs (11.5%). CCPs had a greater overall utilization of radiation therapy as FCT for stage 0, I, II and IV patients (p < 0.001).ConclusionsOur study indicates that gender, demographic and socio-economic differences exist in the patient population with SCCA accessing different cancer programs in the US. The high incidence of stage unknown patients reflects ongoing challenges in the pre-treatment phase. A significant percentage of stage 0 patients received systemic chemotherapy and/or radiotherapy, rather than surgery alone. Despite comparable stage at diagnosis and comorbidity scores between ACPs and CCPs, there appear to be variations in treatment choices, especially with the use of radiotherapy, with associated cost and toxicity risks. Further analysis and monitoring of SCCA management in the US may lead to improved compliance with NCCN guidelines.

Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer

In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy. National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n=17,924) and no adjuvant chemotherapy (n=12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence. There was a statistical difference in age (adjuvant therapy 64.86±9.89 vs. no therapy 67.78±11.22, p<0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59days following surgery, and at academic cancer programs (52%). Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.

An appropriately complex biomechanical model of running

In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy.National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n = 17,924) and no adjuvant chemotherapy (n = 12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence.There was a statistical difference in age (adjuvant therapy 64.86 ± 9.89 vs. no therapy 67.78 ± 11.22, p < 0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59 days following surgery, and at academic cancer programs (52%).Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.

Prevalence and predictors of active surveillance management for black males diagnosed with low risk prostate cancer.

e18019 Background: Consensus guidelines recommend that active surveillance (AS) be considered in the management of men with low risk prostate cancer (LRPC). The evidence supporting this recommendation is largely derived from studies in which men of African descent were underrepresented; thus, the appropriate implementation of AS in this population remains controversial. The objective of our study was to evaluate the prevalence and clinical predictors of an AS approach in black men (BM) diagnosed with LRPC following the 2010 inclusion of AS in LRPC management consensus guidelines. Methods: BM (N = 15,242) and non-Hispanic white men (WM) (N = 86,655) diagnosed with LRPC (as defined by PSA ≤ 10 ng/ml, Gleason score ≤ 6, clinical stage T1 – T2a) between 2010 and 2013 were identified from the National Cancer Database. Logistic regression models were used to assess the likelihood of pursuing an AS strategy over time, as well as to examine associations between sociodemographic characteristics (SDCs) and the receipt of AS. Results: Overall, 9% of BM with LRPC were managed with AS. On univariate analysis, the likelihood of BM undergoing AS increased from 2010 and was statistically significant ( p &lt; 0.001) for all subsequent years (2011: OR = 1.54, 95% CI 1.30-1.82; 2012: OR = 2.19, 95% CI 1.82-2.60; 2013: OR = 2.55, 95% CI 2.15-3.02). Uninsured BM were twice as likely as those with private insurance to pursue AS (OR 1.97, 95% CI 1.51-2.58, p &lt; 0.001). BM seen at academic cancer programs were also more likely to be managed with AS, when compared to those seen at community cancer centers (OR 1.47, 95% CI 1.37-1.60, p &lt; 0.001). BM were less likely than WM to receive AS (OR = 0.82, 95% CI 0.77 to 0.87, p &lt; 0.001). On multivariate analysis adjusted for SDCs, there was no significant difference in AS utilization between the two ethnic groups. Conclusions: The utilization of AS for BM with LRPC appears to be increasing, may be influenced by SDCs, and may not differ from the AS utilization for WM with LRPC. Given the observed elevated rates of post-prostatectomy adverse pathologic features among BM, further evaluation of the determinants of AS utilization and scrutinous consideration of the appropriateness of AS in this population is warranted.

Patterns of Regional Lymphadenectomy for Clinically Node-negative Patients With Penile Carcinoma: Analysis From the National Cancer Database From 1998 to 2012.

Evidence supports upfront regional lymphadenectomy (rND) when primary penile tumors exhibit high-risk features and negative inguinal adenopathy (cN0). We sought to analyze trends in the utilization of early rND as well as assess factors associated with its use and survival outcomes using a nationwide cancer registry database. The National Cancer Database was queried for patients with clinically nonmetastatic penile carcinoma and available nodal status who underwent rND from 1998 to 2012. Temporal trends in the utilization of early rND for those with cN0 disease were analyzed, and a multivariable logistic regression model was used to identify predictors for receiving rND. Survival analysis based on rND status was performed using the Kaplan-Meier method and Cox proportional hazard regression. From 1919 patients with available clinicopathologic variables, performance of early rND was documented in 377 (19.6%) patients with an increase in utilization over time (P= .001). The increase was driven by academic and comprehensive cancer programs compared with community programs (P< .001). Positive predictors were treatment facility, clinical tumor stage, and grade (all P< .05). African American patients (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33-0.86; P= .01) and those aged > 75 years (OR, 0.42; 95% CI, 0.26-0.68; P< .001) were significantly less likely to receive rND. Early rND was associated with improved overall survival (hazard ratio [HR], 0.67; 95% CI, 0.52-0.87; P= .003). There was increased use of early lymphadenectomy for patients with cN0 penile cancer driven by comprehensive and academic cancer programs. The study demonstrated demographic and socioeconomic differences that can help identify barriers to care for patients with penile cancer in the United States.