American Cancer Society National Research Articles

P2.04B.04 Harnessing EHR/IT to Accelerate Lung Cancer Screening - An American Cancer Society National Lung Cancer Roundtable Initiative

P2.04B.04 Harnessing EHR/IT to Accelerate Lung Cancer Screening - An American Cancer Society National Lung Cancer Roundtable Initiative

Getting a colonoscopy at The Valley Hospital.

71 Background: Colorectal cancer (CRC) is the 3rd most common cancer in the U.S., yet it is preventable with evidence-based strategies such as early screening. The Valley Hospital (TVH) located in Bergen County NJ, is recognized for its high insured payer mix and median household income. According to the 2016 TVH Community Health Needs Assessment, only 71.4% of patients in TVH service area have had a CRC screening. The American Cancer Society National Colorectal Cancer Roundtable (NCCRT) campaigned to reach CRC screening rates of 80% and higher in communities across the nation. The Fast Track Screening Colonoscopy Program (FTSCP) at TVH was created to streamline the process of obtaining a screening colonoscopy and reach the NCCRT’s goal. Through the FTSCP, patients can omit the initial consultation with a gastroenterologist or colorectal surgeon. Patients are instead screened via a telephone call by a Physician Assistant (PA) or Advanced Practice Nurse (APN). The FTSCP is cost effective for patients as it potentially eliminates the initial consultation copayment and/or coinsurance. Methods: The purpose of the FTSCP is to achieve the NCCRT’s 80% goal of CRC screenings in TVH service area. An interdisciplinary team of gastroenterologists, colorectal surgeons, oncologists, anesthesiologists, and administration collaborated to create the FTSCP. A screening questionnaire was developed using the Lincoln Hospital in NYC’s existing criteria for patients who are eligible for a direct endoscopy referral. The questionnaire criteria ensures patients are safe to eliminate the initial consultation. A PA or APN determines the patients’ eligibility for the FTSCP over a screening telephone call. To qualify, patients cannot have significant medical comorbidities or exhibit signs or symptoms of CRC. If deemed eligible, the PA or APN sends a bowel preparation prescription to the patient’s pharmacy, reviews the instructions with them, and meets with them on the day of the procedure at TVH to perform a pre-procedural physical exam. To promote awareness and education of the FTSCP, multiple ongoing outreach events are held in the community. Patients also learn about the FTSCP through primary and specialty care referrals. Results: Since the inception of FTSCP in 2018, over 1300 patients have been screened for CRC. Additionally, adenocarcinomas, carcinoid tumors and tubular adenomas with high grade dysplasia have been detected. 394 tubular adenomas (30%) were identified and removed. In 2018, 59 patients were screened. The number of patients increased by 500% to 296 in 2023. The 2022 TVH Community Health Needs Assessment showed an increase to 79.6% of patients in TVH service area who have undergone CRC screening. Conclusions: The FTSCP at TVH is maximizing patient’s access to the prevention and timely screening for CRC. Additionally, TVH’s relocation from Ridgewood, NJ to Paramus, NJ offers further opportunities to educate a new community on CRC prevention.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Optimizing strategies for lung nodule evaluation and management.

Lung nodules are frequently detected on low-dose computed tomography scans performed for lung cancer screening and incidentally detected on imaging performed for other reasons. There is wide variability in how lung nodules are managed by general practitioners and subspecialists, with high rates of guideline-discordant care. This may be due in part to the level of evidence underlying current practice guideline recommendations (primarily based on findings from uncontrolled studies of diagnostic accuracy). The primary aims of lung nodule management are to minimize harms of diagnostic evaluations while expediting the evaluation, diagnosis, and treatment of lung cancer. Potentially useful tools such as lung cancer probability calculators, automated methods to identify patients with nodules in the electronic health record, and multidisciplinary team evaluation are often underused due to limited availability, accessibility, and/or provider knowledge. Finally, relatively little attention has been paid to identifying and reducing disparities among individuals with screening-detected or incidentally detected lung nodules. This contribution to the American Cancer Society National Lung Cancer Roundtable Strategic Plan aims to identify and describe these knowledge gaps in lung nodule management and propose recommendations to advance clinical practice and research. Major themes that are addressed include improving the quality of evidence supporting lung nodule evaluation guidelines, strategically leveraging information technology, and placing emphasis on equitable approaches to nodule management. The recommendations outlined in this strategic plan, when carried out through interdisciplinary efforts with a focus on health equity, ultimately aim to improve early detection and reduce the morbidity and mortality of lung cancer. PLAIN LANGUAGE SUMMARY: Lung nodules may be identified on chest scans of individuals who undergo lung cancer screening (screening-detected nodules) or among patients for whom a scan was performed for another reason (incidental nodules). Although the vast majority of lung nodules are not lung cancer, it is important to have evidence-based, standardized approaches to the evaluation and management of a lung nodule. The primary aims of lung nodule management are to diagnose lung cancer while it is still in an early stage and to avoid unnecessary procedures and other harms.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Promoting guideline-concordant lung cancer staging.

Accurate staging improves lung cancer survival by increasing the chances of delivering stage-appropriate therapy. However, there is underutilization of, and variability in, the use of guideline-recommended diagnostic tests used to stage lung cancer. Consequently, the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT) convened the Triage for Appropriate Treatment Task Group-a multidisciplinary expert and stakeholder panel-to identify knowledge and/or resource gaps contributing to guideline-discordant staging and make recommendations to overcome these gaps. The task group determined the following: Gap 1: facilitators of and barriers to guideline-concordant staging are incompletely understood; Recommendation 1: identify facilitators of and barriers to guideline-concordant lung cancer staging; Gap 2: the level of evidence supporting staging algorithms is low-to-moderate; Recommendation 2: prioritize comparative-effectiveness studies evaluating lung cancer staging; Gap 3: guideline recommendations vary across professional societies; Recommendation 3: harmonize guideline recommendations across professional societies; Gap 4: existing databases do not contain sufficient information to measure guideline-concordant staging; Recommendation 4: augment existing databases with the information required to measure guideline-concordant staging; Gap 5: health systems do not have a performance feedback mechanism for lung cancer staging; Recommendation 5: develop and implement a performance feedback mechanism for lung cancer staging; Gap 6: patients rarely self-advocate for guideline-concordant staging; Recommendation 6: increase opportunities for patient self-advocacy for guideline-concordant staging; and Gap 7: current health policies do not motivate guideline-concordant lung cancer staging; Recommendation 7: organize a representative working group under the ACS NLCRT that promotes policies that motivate guideline-concordant lung cancer staging. PLAIN LANGUAGE SUMMARY: Staging-determining the degree of cancer spread-is important because it helps clinicians choose the best cancer treatment. Receiving the best cancer treatment leads to the best possible patient outcomes. Practice guidelines are intended to help clinicians stage patients with lung cancer. However, lung cancer staging in the United States often varies from practice guideline recommendations. This report identifies seven opportunities to improve lung cancer staging.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Methods for improving turnaround time of comprehensive biomarker testing in non-small cell lung cancer.

Comprehensive biomarker testing for patients with non-small cell lung cancer is critical for selecting appropriate targeted therapy or immunotherapy. Ensuring timely ordering, processing, and reporting is key to optimizing patient outcomes. However, various factors can prevent or delay patients from being offered the option of treatment selection based on comprehensive biomarker testing. These factors include problems with access to testing, tissue adequacy, turnaround time, and health insurance coverage and billing practices. Turnaround time depends on several logistical and tissue handling factors, which involve institutional policies, processes, resources, testing methodology, and testing algorithms that vary across different practices. In this article, the authors identify key factors that prolong biomarker testing turnaround time, propose strategies to reduce it, and present a process map to aid physicians and key organizational stakeholders in improving testing efficiency.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Advancing comprehensive biomarker testing in non-small cell lung cancer.

Comprehensive biomarker testing is a crucial requirement for the optimal treatment of advanced-stage non-small cell lung cancer (NSCLC), with emerging relevance in the adjuvant treatment setting. To advance its goal of ensuring optimal therapy for persons diagnosed with lung cancer, the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT) held The Summit on Optimizing Lung Cancer Biomarkers in Practice in September 2020 to align its partners toward the goal of ensuring comprehensive biomarker testing for all eligible patients with NSCLC. The ACS NLCRT's Strategic Plan for Advancing Comprehensive Biomarker Testing in NSCLC, a product of the summit, comprises actions to promote comprehensive biomarker testing for all eligible patients. The approach is multifaceted, including policy-level advocacy and the development and dissemination of targeted educational materials, clinical decision tools, and guides to patients, physicians, and payers aimed at ameliorating barriers to testing experienced by each of these groups. PLAIN LANGUAGE SUMMARY: The ACS NLCRT works to improve care for patients with lung cancer. The ACS NLCRT supports comprehensive biomarker testing as essential to determine treatment options for all eligible patients with non-small cell lung cancer. Many factors lead to some patients not receiving optimal biomarker testing. The ACS NLCRT held a collaborative summit and developed a strategic plan to achieve and promote comprehensive biomarker testing for all patients. These plans include developing educational materials and physician tools and advocating for national policies in support of biomarker testing.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Provider engagement and outreach

The American Cancer Society National Lung Cancer Roundtable strategic plan: Provider engagement and outreach

The American Cancer Society National Lung Cancer Roundtable strategic plan: Lung cancer in women

The American Cancer Society National Lung Cancer Roundtable strategic plan: Lung cancer in women

The American Cancer Society National Lung Cancer Roundtable strategic plan: Implementation of high‐quality lung cancer screening

The American Cancer Society National Lung Cancer Roundtable strategic plan: Implementation of high‐quality lung cancer screening

The American Cancer Society National Lung Cancer Roundtable strategic plan: Current challenges and future directions for shared decision making for lung cancer screening.

Shared decision making (SDM) between health care professionals and patients is essential to help patients make well informed choices about lung cancer screening (LCS). Patients who participate in SDM have greater LCS knowledge, reduced decisional conflict, and improved adherence to annual screening compared with patients who do not participate in SDM. SDM tools are acceptable to patients and clinicians. The importance of SDM in LCS is emphasized in recommendations from professional organizations and highlighted as a priority in the 2022 President's Cancer Panel Report. The updated 2022 national coverage determination from the Centers for Medicare & Medicaid Services reaffirms the value of SDM in offering LCS to eligible beneficiaries. The Shared Decision-Making Task Group of the American Cancer Society National Lung Cancer Roundtable undertook a group consensus process to identify priorities for research and implementation related to SDM for LCS and then evaluated current knowledge in these areas. Priority areas included: (1) developing feasible, adaptable SDM training programs for health care professionals; (2) understanding the impact of alternative health system LCS models on SDM practice and outcomes; (3) developing and evaluating new patient decision aids for use with diverse populations and in varied settings; (4) offering conceptual clarity about what constitutes a high-quality decision and developing appropriate quality measures; and (5) studying the use of prediction-augmented screening to support SDM in practice. Gaps in current research in all areas were observed. The authors conclude with a research and implementation agenda to advance the quality and implementation of SDM for persons who might benefit from LCS.

Abstract PO4-11-02: Accelerating Progress and Achieving Health Equity: The American Cancer Society National Breast Cancer Roundtable

Abstract Background: Breast cancer continues to be a leading cause of death among women, with disparities in mortality rates persisting, particularly for Black women and under-supported communities. In response to this urgent need, the American Cancer Society (ACS) has launched the American Cancer Society National Breast Cancer Roundtable (ACS NBCRT) to address complex challenges across the breast cancer continuum and improve access to quality care. Methods: The ACS NBCRT is a coalition of organizations committed to eliminating disparities and reducing mortality rates. By leveraging strategic partnerships and using the Collective Impact Model, the ACS NBCRT aims to ensure equitable access to screening, treatment, and comprehensive support services. The roundtable follows the proven ACS Roundtable Model, which brings together diverse contributors to drive progress on breast cancer priorities. Results: The ACS NBCRT, chaired by prominent leaders in the field, has engaged thought leaders, organizations, policymakers, and individuals with lived experiences to identify initial roundtable priorities through a community-informed process. The ACS NBCRT conducted three listening sessions, 8 focus groups, 10 community conversations, and 33 informant interviews and received 700+ responses to a nationwide survey. As a result of this work, the ACS NBCRT leadership was able to interpret the data to inform our roundtable's strategic priorities focused on risk reduction, screening, early detection, access to treatment, clinical trials, and support services. Workgroups will address cross-cutting approaches, including health equity, patient navigation, and education, to develop short- and long-term goals for the roundtable. This approach to addressing health equity through our priority areas is intentional, and it is reflected in our engagement with lived experience experts and diverse community contributors in our early planning, formative research, leadership recruitment, and our member engagement and recruitment. Conclusion: Through its Collective Impact approach, the ACS NBCRT is poised and positioned to accelerate progress, promote health equity, and reduce the burden of breast cancer. The roundtable is uniquely designed to identify and addresses gaps by providing a neutral platform to convene diverse stakeholders to establish national priorities across the cancer continuum, catalyze policy and patient care solutions, promote evidence-based strategies and translate them into practice, and leverage volunteer knowledge and experiences to inform the reduction of health disparities. The roundtable's commitment to strategic partnerships, evidence-based strategies, and health equity will drive change and allow the ACS NBCRT to lead the national dialogue on breast cancer. Implications: The establishment of the ACS NBCRT signifies a crucial step towards achieving health equity in breast cancer care. By addressing disparities and promoting collaborative solutions, the roundtable aims to improve outcomes for all people facing breast cancer. Citation Format: Ashley Dedmon, Theresa Petee, Olufunmilayo Olopade, John Williams, Arif Kamal, Sarah Shafir. Accelerating Progress and Achieving Health Equity: The American Cancer Society National Breast Cancer Roundtable [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 PO4-11-02.

Patient Navigation for Timely, Guideline-Adherent Adjuvant Therapy for Head and Neck Cancer: A National Landscape Analysis.

Aligned with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers, in November 2021 the Commission on Cancer approved initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery for head and neck cancer (HNC) as its first and only HNC quality metric. Unfortunately, >50% of patients do not commence PORT within 6 weeks, and delays disproportionately burden racial and ethnic minority groups. Although patient navigation (PN) is a potential strategy to improve the delivery of timely, equitable, guideline-adherent PORT, the national landscape of PN for this aspect of care is unknown. From September through November 2022, we conducted a survey of health care organizations that participate in the American Cancer Society National Navigation Roundtable to understand the scope of PN for delivering timely, guideline-adherent PORT for patients with HNC. Of the 94 institutions that completed the survey, 89.4% (n=84) reported that at least part of their practice was dedicated to navigating patients with HNC. Sixty-eight percent of the institutions who reported navigating patients with HNC along the continuum (56/83) reported helping them begin PORT. One-third of HNC navigators (32.5%; 27/83) reported tracking the metric for time-to-PORT at their facility. When estimating the timeframe in which the NCCN and Commission on Cancer guidelines recommend commencing PORT, 44.0% (37/84) of HNC navigators correctly stated ≤6 weeks; 71.4% (60/84) reported that they did not know the frequency of delays starting PORT among patients with HNC nationally, and 63.1% (53/84) did not know the frequency of delays at their institution. In this national landscape survey, we identified that PN is already widely used in clinical practice to help patients with HNC start timely, guideline-adherent PORT. To enhance and scale PN within this area and improve the quality and equity of HNC care delivery, organizations could focus on providing better education and support for their navigators as well as specialization in HNC.

MA02.10 A Strategic Plan to Accelerate Lung Cancer Screening - An American Cancer Society National Lung Cancer Roundtable Initiative

MA02.10 A Strategic Plan to Accelerate Lung Cancer Screening - An American Cancer Society National Lung Cancer Roundtable Initiative

P2.08-07 The Campaign to End Lung Cancer Stigma: The ACS National Lung Cancer Roundtable Efforts to Confront and Extinguish Lung Cancer Stigma

Lung cancer stigma is common across the lung cancer care continuum and has a significant psychosocial impact on individuals diagnosed with lung cancer and their families. From hampering efforts to support lung cancer risk reduction to impeding biomarker testing post-diagnosis or restricting access to optimal treatment and survivorship, lung cancer stigma plays a pernicious role, contributing to suboptimal delivery of care and outcomes. Recognizing the need for coordinated and comprehensive efforts to eliminate lung cancer stigma, the American Cancer Society National Lung Cancer Roundtable’s (NLCRT) Survivorship, Stigma, and Nihilism Task Group developed and launched a national initiative, the Campaign to End Lung Cancer Stigma.

Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists.

BackgroundAn ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists’ biomarker ordering and treatment practices for advanced non‐small‐cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions.MethodsWe deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists.ResultsWe analyzed 170 eligible responses. For non‐squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non‐targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience).ConclusionsRespondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.

Physician concern about delaying lung cancer treatment while awaiting biomarker testing: Results of a survey of U.S. oncologists.

9067 Background: With rapid advancements in biomarker testing informing lung cancer treatment decisions, clinicians are challenged to maintain knowledge of who, what and when to test and how to treat based on test results. An ASCO taskforce including representatives from the American Cancer Society National Lung Cancer Roundtable and patient advocates conducted a study to assess biomarker testing and treatment practices for patients with advanced non-small cell lung cancer (aNSCLC) among U.S. oncologists. Methods: A survey was sent to 2374 ASCO members – lung cancer specialists and general oncologists. Eligibility required treating ≥1 lung cancer patient/month. Proportions were estimated across groups and compared using chi-square tests. Results: 170 responses were analyzed. 59% of respondents work at an academic center (i.e., have a fellowship program), while 41% work at a community (non-academic hospital/health system/private practice). Nearly all (98%) believe biomarker results should be received within 1 or 2 weeks of ordering, yet 37% wait an average of 3 or 4 weeks for results. Of respondents who usually wait 3 or 4 weeks, 37% initiate a non-targeted systemic treatment while waiting. Respondents from community practices were more likely to initiate non-targeted systemic treatment if results were not available after 2 weeks (59% compared to 40% of academic respondents; p = 0.013). ). When asked about reasons for not testing, respondents &lt;5 years since training were more likely to report that delaying treatment while waiting for results was always/often a concern compared to those &gt;6 years from training (41% vs 19%). Respondents reported high testing rates in both non-squamous and squamous aNSCLC. Roughly equal representation of generalists/specialists and academic/community respondents helps mitigate potential concerns about external validity. Conclusions: Respondents indicated that treatment decisions are impacted by delays in biomarker test results. Clinicians should be informed about when it is safe and appropriate to defer treatment while biomarker testing is pending. Respondents suggest that diagnostic biomarker testing companies should strive to expedite results.[Table: see text]

Abstract PO-255: A colorectal cancer screening intervention to help increase screening rate within the Harris Health safety-net health care system

Abstract Background: Colorectal Cancer (CRC) is often preventable through regular screening. CRC screening is an evidence-based intervention for early detection and prevention of CRC. However, screening rates are low among medically underserved, minority populations. In collaboration with a local safety-net healthcare system and community clinics, we are implementing a comprehensive, multi-modal CRC prevention program. Our CRC screening program includes community outreach, culturally and linguistically targeted educational point-of-care patient education videos, patient navigation services, and provider and staff training. In 2018, a new component was introduced that includes a CRC survivor led provider-targeted assessment intervention leveraging the American Cancer Society National Colorectal Roundtable’s “80% in Every Community” campaign. Methods: As part of the 80% in Every Community campaign, providers and clinical staff are trained by the CRC survivor staff member to employ strategies from the Roundtable’s toolkit to heighten clinic-level commitment to improving screening rates. Specific strategies include providing tips for evidence-based messaging to reach the unscreened, and training providers to consistently give a strong CRC screening recommendation. A baseline survey was administered ahead of the initial training to assess current clinical practices. Results: Survey data indicated 84.3% (N= 297, 14 clinics) of respondents identified patients not completing and returning FIT as a screening barrier (61.7%-Sometimes and 22.7%-Usually). When asked if they had mechanism to ensure patients given a FIT kit have completed and returned them -75.7 % said Yes and 24.3%-No. In the follow-up question, asking if they had a mechanism to ensure FIT were completed and returned, responses showed: 13.9 % said no mechanism, 43.0% reminder call, 8.1% mail reminder, and 28.6% said a chart reminder to return kit at next visit. 73 respondents wrote in various other mechanisms. Discussion: Respondents believed a systematic mechanism already existed to remind patients to complete their FIT and return it to their clinic. Our next steps are to present these findings to health system leadership and investigate the possibility to strengthen screening patient reminders in various forms of communication to increase FIT completion rate. Citation Format: Allison Rosen, Roshanda Chenier, Jane Montealegre, Maria Jibaja-Weiss. A colorectal cancer screening intervention to help increase screening rate within the Harris Health safety-net health care system [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-255.

Creating and Implementing a National Public Health Campaign: The American Cancer Society's and National Colorectal Cancer Roundtable's 80% by 2018 Initiative.

Creating and Implementing a National Public Health Campaign: The American Cancer Society's and National Colorectal Cancer Roundtable's 80% by 2018 Initiative.

Minimally invasive surgery for gastric cancer: the American experience.

Minimally invasive surgical techniques are increasingly being implemented in oncologic care. This study assesses the impact of minimally invasive surgery on oncologic and perioperative outcomes in the management of gastric cancer in the USA. From the American College of Surgeons and American Cancer Society National Cancer Data Base, we identified 6427 patients who underwent gastrectomy for cancer from 2010 to 2012. Treatment groups were categorized with an intention-to-treat paradigm as robotic, laparoscopic, and open surgery. Univariate and multivariate analyses were performed to estimate the impact of the surgical approach on oncologic and perioperative outcomes. Of patients undergoing definitive surgical intervention, 3.5% (n=223) underwent robotic gastrectomy, 23.1% (n=1487) underwent laparoscopic gastrectomy, and 73.4% (n=4717) underwent open surgery. Minimally invasive gastrectomy was more frequently performed on white (P=0.018), privately insured patients (P=0.049) treated at academic centers (P<0.0001) in the eastern USA (P<0.0001). After demographics, comorbidities, and tumor-related factors had been controlled for, patients who underwent laparoscopic gastrectomy had the postoperative length of stay decreased by 1.08days (P<0.0001) and greater odds of having at least 15 lymph nodes resected (odds ratio 1.16, P=0.023). Use of robotic surgery did not have a statistically significant effect on the postoperative length of stay relative to open surgery (P=0.222) but the patients so treated had greater odds of having at least 15 lymph nodes resected (odds ratio 1.51, P=0.005). There were no differences in R0 resection rates or perioperative mortality on the basis of the surgical approach alone. These findings suggest that use of minimally invasive surgery for gastric cancer in the USA is impacting the adequacy of oncologic resection but is not yet having a clinically significant impact on perioperative outcomes relative to a conventional open approach.

Cost-effectiveness of Treatment Strategies for Pancreatic Head Adenocarcinoma and Potential Opportunities for Improvement

Generally dismal outcomes have led to a nihilistic attitude toward treating pancreatic cancer, while fiscal constraints have increased scrutiny of treatments costs. Our objective was to compare the cost-effectiveness of various treatment strategies for resectable pancreatic head adenocarcinoma, and to identify opportunities for improved cost effectiveness. A decision model compared 6 strategies: no treatment, radiotherapy only, chemotherapy only, chemotherapy plus radiotherapy, surgery alone, and surgery plus adjuvant therapy. Outcomes and probabilities were identified using the National Cancer Data Base, the American Cancer Society National Surgical Quality Improvement Program, and the literature. Costs were estimated using Medicare payment. Incremental cost-effectiveness ratios (ICERs) were calculated, and sensitivity analyses were performed by varying potentially modifiable parameters of the model. Survival was reported in quality-adjusted life-months (QALMs). Surgery plus adjuvant therapy, chemotherapy alone, and no treatment were the only viable strategies in terms of cost effectiveness. Surgery plus adjuvant therapy versus no treatment demonstrated an incremental cost-effectiveness ratio (ICER) of $7,663/QALM. Theoretically increasing survival in node-negative, margin-negative patients from 14 to 22 QALMs produced the largest reduction in the ICER for surgery plus adjuvant therapy compared to no treatment ($6,386/QALM), whereas reducing the perioperative mortality from 3 to 1% had only a marginal effect. The ICER was significantly lower for high-performing centers ($5,991/QALM) than for low-performing centers ($9,144/QALM). Surgery plus adjuvant therapy for resectable pancreatic head adenocarcinoma extends survival, but at considerable expense. Significant cost reductions could be realized by improving treatment outcomes to levels of high-performing centers and development of increasingly effective adjuvant therapies.