Charlson-Deyo Comorbidity Score Research Articles

Fetal adenocarcinoma: An NCDB analysis of socioeconomic and demographic factors.

e20076 Background: Fetal adenocarcinoma (FA) is a rare subtype of lung neoplasia whose structure is similar to a developing fetal lung. Chest x-ray is valuable for diagnosis as 25 - 40% of patients with FA are asymptomatic. FA is classified into low-grade and high-grade, predominantly occurring in children and older males with a smoking history. The rarity of FA suggests that evaluating its diagnostic patterns could expand awareness of its epidemiology. Impactful demographic factors of FA were established through analysis of the National Cancer Database (NCDB). Methods: The 2004 - 2020 National Cancer Database (NCDB) was utilized to perform a retrospective analysis of all 120 patients with a histologically confirmed diagnosis of FA (ICD-O-3 Code 8333). Descriptive statistics were employed to examine demographic factors, including sex, age, race, Hispanic ethnicity, urban/rural residence, Charlson-Deyo comorbidity score (CDCS), and treatment facility type. Additionally, regression analysis was utilized to demonstrate incidence trends. Exclusion criteria included missing values. Results: The NCDB identified 120 patients from 2004 - 2020. Over this time period, there was a slightly increasing incidence of patients diagnosed per year (R2 = 0.4461). Represented age at diagnosis featured negative skewness (-0.8), and the mean age was 54.4 years (95% CI = 51.2 - 57.6, SD = 17.6). Most patients were female (57%), White (76%), and non-Hispanic (95%). The vast majority of patients (85%) resided in metropolitan areas, with a slight majority of patients (53%) hailing from areas of 1 million population or more. Regions of the United States were well-represented, with a plurality of patients from the South Atlantic (21%). Most patients were diagnosed at Stage I (56%) and had a CDCS of 0 (61%). The primary tumor site was the upper lung lobes, and most (83%) patients underwent surgery as primary treatment. Multiple facility types were utilized in the care of patients, including research programs (42%), comprehensive community cancer center programs (30%), and integrated network cancer programs (25%). The 30-day mortality rate was 1%, comparable to the 90-day mortality rate of 3%. Five years after diagnosis, 60% of patients were alive. Conclusions: To the best of our knowledge, this is the first NCDB analysis to examine the sociodemographic factors concerning prognosis in patients with FA. Our results are consistent with previous studies finding that patients with low-stage FA tend to have favorable outcomes. Our study is the first documentation of location demographics of patients with FA: Most patients live in metropolitan counties along the Atlantic Coast. Future investigations on the prognostic significance of demographic and socioeconomic factors should be performed to optimize treatment approaches for improved mortality rates of diverse patients with FA.

Periosteal osteosarcoma: A study of demographic and socioeconomic factors.

e23506 Background: Periosteal Osteosarcoma (PO) is a rare primary malignant bone cancer that typically affects the tibia or femur of young adults in their second and third decades of life. This soft-tissue mass causes extrinsic erosion of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into soft-tissue components. Despite the rarity of PO, 29% of diagnosed patients do not survive past 10 years following treatment. Further investigation into the diagnostic trends of PO may produce valuable information about its epidemiology. The National Cancer Database (NCDB) was analyzed to identify the demographic factors of patients diagnosed with PO. Methods: A retrospective cohort analysis that utilized data from the 2004–2020 NCDB included 138 patients with a histologically-confirmed diagnosis of PO (ICD-9193-3). Demographic factors (age, sex, race, Hispanic status, educational attainment, insurance status, facility type, distance from facility, and Charlson/Deyo score were analyzed by descriptive statistics, and incidence trends were interpreted via regression analysis. Results: A total of 138 individuals had a confirmed diagnosis of PO between the years 2004-2020 with a relatively constant rate of diagnosis each year (R2 = 0.1749). The average age of diagnosis was 29.7 (SD = 17.5, range = 6-86 years). Males and females were affected at rates of 58% and 42%, respectively. The majority of patients diagnosed with PO identified as White (73%) and non-Spanish/non-Hispanic (86%). The primary sites of diagnosis were the long bones of the lower limb (77%), with an average tumor size of 94.4 mm (SD = 54.2). Most patients (73%) utilized surgical treatment options such as radical excision or resection of the lesion with limb salvage. A higher percentage of patients were privately insured (62%), lived in a metropolitan area (75%), and were treated at an academic/research program (59%). Many individuals (91%) had no concurrent comorbidities (Charlson-Deyo comorbidity score = 0). Following treatment, the survival rates of patients were 91% at 2 years, 78% at 5 years, and 71% at 10 years. Conclusions: To our knowledge, this is the first NCDB analysis concentrating on PO, addressing a substantial gap in our understanding. In congruence with earlier descriptions of PO in case reports, a majority of patients are White and of non-Spanish/non-Hispanic origin and the primary site of diagnosis presents on the lower limbs. This is the first instance in the literature where the socioeconomic factors of PO patients have been clarified: PO patients are more likely to live in densely populated metropolitan areas, receive treatment in academic programs, and have private insurance. Further research is needed to elucidate the influence of demographic and socioeconomic factors on the diagnosis, treatment approaches, and survival outcomes of individuals with PO.

Impact of racial disparities in adjuvant treatment of triple negative breast cancer (TNBC) among American Indians/Alaskan Natives (AI/AN) and non-Hispanic Whites (NHW) on overall survival (OS).

e13736 Background: There are significant differences in patient and tumor characteristics among AI/AN and NHW breast cancers (BC) which adversely impact overall survival in AI/AN. Prior studies have also shown higher Mortality: Incidence ratio for BCs in AI/AN as compared to NHW. The aims of this study are to 1) investigate disparities in adjuvant treatment of TNBC between the two races adjusting for age, stage, and year of diagnosis; and 2) Assess differences in OS. Methods: This was a hospital based, retrospective cohort study using the National Cancer Database. AI/AN and NHW women with TNBC, greater than or equal to 18 years of age, diagnosed with BC between the years 2010 through 2019, stages I, II, and III were included. Propensity score matching in a 1:3 ratio was used for age, year, and analytical stage at diagnosis. Primary endpoint was time to first treatment and compliance with recommended treatment. Secondary endpoint was OS. Results: A total of 489 AI/AN and 1465 matched NHW women with TNBC were identified. AI/AN women traveled longer distances for cancer care (p<.01), resided in lower median income zip codes at the time of diagnosis (p<.001), had a higher Charlson-Deyo (CD) comorbidity score (p<.001), and were less likely to have private insurance (p<.001). There was no difference in the rates of chemotherapy, surgery, and radiation therapies that were recommended and received by the two races. Time to first treatment was significantly longer for AI/AN as compared to NHW women (Mean ± SD: 35 ± 27 days vs. 39 ±27 days; p=.005). Multivariable analysis revealed that longer time to first treatment was associated with only higher CD score (p=.013) and non-private insurance (p=.027), but no longer associated with race (p=.324). Compliance with recommended treatment was similar between AI/AN and NHW women (93.5% vs 92.9%, p=.096). Compliance was significantly associated with only insurance status (p < .001) with Medicare/Medicaid having the lowest compliance. OS did not differ by race (p=.299, HR=1.132; 95% CI: 0.90-1.43). Cancer stage, CD score, insurance status, and treatment compliance were associated with worse OS. Conclusions: In patients with TNBC, there was no difference in time to treatment, compliance with recommended treatment or OS among AI/AN in comparison to White women when matched for age, stage, and year of diagnosis. Medicare/Medicaid insurance was associated with prolonged time to treatment, lower compliance with recommended treatment and decreased survival when compared with other insurances. Higher comorbidities adversely impacted time to treatment and overall survival. In order to improve BC mortality, it is important to manage comorbid conditions and improve detection of cancer at earlier stages. Prospective studies comparing outcomes by race are needed to confirm these findings.

Factors associated with benefit of adjuvant chemotherapy in patients with T1b/T1c HR-positive/HER2-negative breast cancer and high multigene recurrence score.

e12540 Background: Patients diagnosed with early-stage HR-positive/HER2-negative Breast Cancer (BC) and high Oncotype DX Recurrence Score (RS ≥26) are offered adjuvant chemotherapy and endocrine therapy compared (CET) to endocrine therapy alone (ET). We sought to investigate if additional clinical factors that could further determine benefit from chemotherapy in patients with T1b/T1c and N0 tumors with high Oncotype DX to help deescalate treatment by avoiding chemotherapy induced toxicity. Methods: The purpose of this study is to determine the clinical factors associated with a survival difference from CET compared to ET alone in T1b/T1c and N0 BC. We analyzed the record of patients diagnosed with T1b/T1cN0M0 HR-positive/HER2-negativeBC and RS ≥26 between 2006 and 2020 from the National Cancer Database. Patients were separated into two groups based on their treatment: CET or ET and the following characteristics were assessed: age, grade, histology, and RS (26-30, 31-40, 41-100) to determine overall survival differences among the two groups. Chi-square was performed to evaluate the association between baseline categorical characteristic variable and chemotherapy treatment. Survival analysis of treatment modalities using Kaplan Meier curves and univariate Cox regression. Multivariate Cox regression with backwards elimination was performed for subgroup analyses. Results: A total of N=19,373 eligible patients were identified, n=14,422 (74.4%) received CET and the rest ET alone. The mean age at diagnosis was 59.6 years (SD=10.3); 86.6% presented with invasive ductal carcinoma and 83.3% had a Charlson-Deyo Comorbidity Score of 0. In the overall group, patients who received CET had a higher median overall survival than endocrine therapy alone (65.7 versus 52.1 months, log-rank p-value<.0001). However, further analysis noted that treatment with CET showed better outcome compared to ET alone in the following subgroups of patients: invasive ductal histology (95% OS 65.5 versus 52.7 months, log-rank p-value<.0001) and RS >30 (95% OS 63.6 versus 40.5 months, log-rank p-value<.0001). Importantly, multivariable cox regression subgroup analysis revealed no significant overall survival difference among the subgroup of patients with T1b/T1c and low grade (p=0.286) or RS 26-30 (p=0.200) with CET compared to ET alone. Conclusions: This large database confirms the heterogeneity of BC in patients with low burden disease despite high Oncotype.While patients diagnosed with T1b/T1cN0M0 and high RS (>30) could benefit from CET compared to ET alone as per standard practice, additional criteria could be considered in this group including low grade or RS 26-30 to better determine which population of patients do not benefit from the addition of chemotherapy and accordingly individualized chemotherapy decision might be made to minimize toxicity.

Pulmonary blastoma: An NCDB analysis of demographic and socioeconomic factors.

e20069 Background: Pulmonary blastoma (PB) is a rare sarcomatoid carcinoma classified as a non-small cell lung cancer with a poor prognosis and no standard treatment. This malignancy exhibits glandular proliferation with a morular component resembling embryonic development. Leading PB treatment favors surgical resection with concurrent chemotherapy. However, radiation is recommended for inoperable tumors. Further analysis of diagnostic trends may provide information about the epidemiology of PB. The National Cancer Database (NCDB) was analyzed to establish the demographic factors in diagnosed patients. Methods: A retrospective cohort study from 2004 to 2020 was conducted using the NCDB. 146 patients were identified with a histologically confirmed diagnosis of PB (ICD-O-3 code 8972). Race, gender, Hispanic origin, urban/rural residence, insurance coverage, treatment approaches, and mean survival rates were analyzed via descriptive statistics. Regression analysis was performed to examine incidence trends. Results: 146 patients diagnosed with PB were identified in the NCDB, where the incidence rate of diagnoses strongly declined annually (R² = 0.079). The average age of diagnosis was 50 years (SD = 26, range = 1-90 years), with women (56%) more likely to be affected than men (44%). The majority of patients identified as White (80%) and non-Hispanic (88%), lived in metropolitan counties with a population greater than 1 million (58%), and were privately insured (45%). The top primary sites of diagnoses were the upper (38%) and lower (28%) lobe of the bronchus or lung. For patients who did not receive palliative care (93%), many received surgery (75%) as their primary treatment. Within this group, chemotherapy and radiation therapy were also chosen as treatment options (48% and 27%, respectively). The majority of individuals (66%) had a Charlson-Deyo comorbidity score of 0. The survival rates were 58% at two years, 49% at five years, and 34% at ten years. The mean survival was also found to be 86 months. Conclusions: To the best of our knowledge, this is the first NCDB analysis on pulmonary blastoma and helps provide insight on a previously understudied topic. Results demonstrated that the majority of PB patients are non-Hispanic White females, who were primarily diagnosed at the upper lobe of the bronchus or lung. These findings confirmed similar descriptions from other databases and earlier case reports. This is the first time the socioeconomic factors of PB patients have been described in the literature: PB patients typically do not receive palliative care and choose to undergo surgery as their primary treatment. Further research is indicated to provide a greater insight on the effects of demographic/socioeconomic factors on diagnostic criteria, chosen treatments, and overall survival rates of patients with PB.

Hodgkin’s lymphoma, lymphocyte-depleted, reticular: An NCDB analysis of demographic and socioeconomic factors of diagnosed patients.

e19033 Background: Lymphocyte-depleted Hodgkin's lymphoma (LDHL) is an aggressive, rare form of Hodgkin’s lymphoma (HL). The LDHL reticular subtype (LDHL-R) is characterized by a scant invasion of lymphocytes without an increase in collagen fibers by fibroblasts. Patient demographics and clinical features of LDHL-R are poorly understood, causing it to frequently be misdiagnosed as other variants of HL. At diagnosis, patients have often already progressed to late disease staging. The demographic and socioeconomic factors of patients diagnosed with LDHL-R within the National Cancer Database (NCDB) were analyzed to better understand its epidemiology. Methods: A retrospective cohort analysis was performed using data from the 2004-2020 NCDB of the 51 cases of LDHL-R (ICD-O-3 9655). Demographic and socioeconomic factors such as age, sex, race, Hispanic status, treatment facility type, Charles-Deyo score, and 90-day mortality were examined using descriptive statistics. Diagnostic trends were quantified through regression analysis. Results: A total of 51 patients were diagnosed with Hodgkin lymphoma, lymphocyte depletion, reticular subtype within the NCDB. The most common primary site of diagnosis was within lymph nodes of multiple regions (41%). The majority of patients were males (65%), White (72%), and non-Hispanic (74%). Patients tended to have residence in metropolitan counties with populations greater than 1 million (71%) and were enrolled in academic/research programs (36%). Most of the patients were privately insured (41%) followed by those insured by Medicare (29%). A higher percentage of patients were in the top quartile of income earners (31%) than those in the second, third, or fourth quartiles. The incidence rate of diagnosis remained constant from 2004 to 2020 (R² = 0.02). The mean age of diagnosis was 51 years (SD=21, Range=14–90). Using the AJCC System, patients tended to be classified as Stage IV (41%) at diagnosis and had a Charlson-Deyo comorbidity score of 0 (71%). Primary treatment methods involved chemotherapy (84%) and radiation therapy (20%). Surgical intervention was given to 14 patients, and post-surgery survival rates were 93% after 90 days. Conclusions: To the best of our knowledge, this is the first NCDB analysis of the demographic factors of patients diagnosed with LDHL-R. Consistent with previous studies about the aggressiveness of this subtype of Hodgkin’s Lymphoma, most patients received a Stage IV diagnosis. Understanding LDHL-R’s epidemiology could result in significantly earlier diagnoses and improved prognosis. Patients tended to be male, White, and non-Hispanic with a residence in metropolitan counties. To improve understanding of the impact of demographic and socioeconomic factors of the diagnosis, treatment, and survival of patients with LDHL-R, more research is recommended.

Malignant chondroblastoma: NCDB analysis of demographic and socioeconomic factors.

e23500 Background: Malignant chondroblastomas are atypical forms of the rare benign chondroid-producing neoplasm known as a chondroblastoma. Chondroblastomas account for less than 1% of all bone tumors and arise in the epiphyses of long bones in young adults. Unlike conventional chondroblastoma, the majority of patients diagnosed with malignant chondroblastomas tend to be older and tumors present at atypical body sites. Therefore investigating trends in diagnosis may yield important insight into its epidemiology. The National Cancer Database (NCDB) was explored to analyze the demographic factors in patients diagnosed with malignant chondroblastoma. Methods: A retrospective cohort analysis utilizing the 2004–2020 National Cancer Database (NCDB) included 67 patients with a histologically-confirmed diagnosis of malignant chondroblastoma (ICD-O-3 Code 9230). Demographic factors (age, sex, race, Hispanic status, insurance status, facility type, distance from facility, and Charlson-Deyo score) were analyzed by descriptive statistics, and incidence trends were interpreted using regression analysis. Results: Between 2004 – 2020, the NCDB identified 67 patients with a confirmed malignant chondroblastoma diagnosis. There was a slightly increasing incidence of patients diagnosed per year (R² = 0.471). The most common primary site was the frontal lobe (60%). Males and females were affected equally (49% and 51%, respectively) with a mean age at diagnosis of 46.5 years (SD = 15.3, Range = 21 – 74 years). The majority of patients were White (90%), non-Hispanic (87%), lived in metropolitan areas (82%), and were privately insured (63%). Treatment facilities primarily consisted of academic programs (48%). Patients lived an average of 27 miles away from the facility (SD = 49, Range = 356.3 miles). Most individuals (76%) had Charlson-Deyo comorbidity scores of 0. Primary treatment methods involved administering radiation therapy (52%). 60 patients (90%) underwent surgical intervention. For valid data, post-surgery survival rates were 100% after 30 days and 93% after 90 days. About half of the patients (57%) survived 5 years after their initial diagnosis. Conclusions: Malignant chondroblastoma is locally aggressive and has metastatic potential. Surgical intervention was the most common treatment (90%), which is consistent with the previous literature. In this study, AJCC staging was not applicable to almost all of the patients (99%). To the best of our knowledge, this is the first NCDB analysis of malignant chondroblastoma patient demographic and socioeconomic factors which addresses a significant gap in knowledge. Most patients were White, non-Hispanic, lived in metropolitan areas and were privately insured. Additional investigation is required to enhance our understanding of how demographic and socioeconomic factors influence the diagnosis, staging, and treatment of individuals with malignant chondroblastoma.

Malignant mesenchymoma: A demographic analysis of the National Cancer Database.

e23556 Background: Malignant mesenchymoma is a rare, aggressive soft tissue tumor characterized by the presence of two or more histologic subtypes of sarcoma. As a result of these characteristics, this cancer has a poor prognosis and a lack of proven treatment options. It may be epidemiologically beneficial to analyze the diagnostic trends to further understand the factors contributing to the disease. This study examines the demographic factors of malignant mesenchymoma, ICD-O-3 Code 8990, through the National Cancer Database (NCDB). Methods: The 2004-2020 NCDB was used for retrospective analysis. 72 patients were identified and their demographic factors such as age, sex, race, Hispanic status, educational attainment, insurance status, facility type and location, distance from facility, and Charlson-Deyo score were analyzed using descriptive statistics. Regression analysis was used to interpret incidence trends. Results: The NCDB contains 72 recorded cases of malignant mesenchymoma from 2004-2020 with an average age at diagnosis of 49.9 ± 21.3 years, with the incidence rate exhibiting variability (R2= 0.1028). Women had a considerably higher diagnosis rate (67%) compared to men (33%). The majority of patients were White (75%), and 11% of patients were Black. Most patients were of non-Hispanic origin (81%). A higher percentage of patients fell into the fourth quartile of income earners (32%) compared to the top three quartiles. A significant portion of patients (26%) did not have a high school degree. The sites with the highest cancer prevalence were the retroperitoneum (10%) and endometrium (10%). A majority of individuals (78%) had Charlson-Deyo comorbidity scores of 0. The size of the tumors ranged from 10.0 to 250.0 mm with an average size of 61.6 ± 67.4 mm. A majority of the patients (72%) underwent surgery at the primary site. Most (96%) patients survived at least thirty days following their primary surgery, with 94% surviving for ninety or more days. The mean survival time was 91.0 months. The cancer’s 2-year, 5-year, and 10-year survival rates were 61.5%, 45.5%, and 43.1% respectively. Conclusions: Based on our searches, this is the first NCDB study on malignant mesenchymoma to address epidemiological gaps in the literature. Most malignant mesenchymoma patients identified as non-Hispanic and White with a primary site of either the retroperitoneum or endometrium. The majority of patients fell into the fourth income quartile, and a significant amount did not have a high school degree. Due to this cancer’s rarity, recent literature exploring the factors contributing to the disease course is scarce. Additional research is necessary to understand how demographics influence the diagnosis, treatment, and long-term outcomes of individuals diagnosed with malignant mesenchymoma.

Juxtacortical chondrosarcoma: An NCDB analysis of demographics and socioeconomic factors.

e23505 Background: Juxtacortical chondrosarcoma (JCC) is a rare cartilaginous tumor—accounting for less than 2% of all chondrosarcomas—and typically appears on the external surfaces of long bones. The prognosis of JCC is relatively promising compared to other chondrosarcomas, with the current therapy of choice being en-bloc resection. However, a significant amount of information regarding JCC remains unknown. Therefore, exploring diagnostic trends may provide greater insight into this cancer’s epidemiology and potential forms of treatment. The National Cancer Database (NCDB) was assessed to uncover the demographic factors in patients diagnosed with JCC. Methods: A retrospective cohort analysis utilizing the 2004–2020 National Cancer Database (NCDB) included 131 subjects with a histologically-confirmed diagnosis of JCC (ICD-0-3 code 9221). Demographic factors (age, sex, race, Hispanic status, insurance status, facility type, distance from facility, and Charleson-Deyo comorbidity score) were analyzed by descriptive statistics and incidence trends were interpreted in regression analysis. Results: Between 2004 and 2020, the NCDB reported a total of 131 patients with a confirmed diagnosis of JCC. This data indicated a rising incidence of patients diagnosed per year (R² = 0.0855), with an average age of diagnosis of 45 years (SD = 18, range = 8-88). Patients with JCC were more likely to be White (82%), of non-Hispanic origin (86%), and male (63%). The tumor was most commonly found in the long bones of the lower limbs (35%). Surgical removal was the primary treatment for the majority of patients (95%), while others received radiation (7%) or chemotherapy (4%). Most patients (83%) had a Charlson-Deyo comorbidity score of 0. Patients were commonly treated at academic and research facilities (61%), and no patients received palliative care. More than half of individuals were privately insured (57%) and resided in a metropolitan area with a population size of at least 1 million (59%). The mean distance between patient residence and treatment site was 104.1 miles (SD = 221, range = 11-1194 miles). Conclusions: To the best of our knowledge, this is the first study on juxtacortical chondrosarcoma utilizing NCDB data to address the significant lack of research on this subject. The majority of JCC patients are non-Hispanic, White, and have a primary site of diagnosis at the long bones of the lower limbs. This paper is the first to describe the socioeconomic factors of patients diagnosed with JCC: patients tend to be privately insured, live in large metropolitan areas, and are mostly treated in academic research facilities. Additional research is necessary to comprehend how socioeconomic and demographic factors influence the manner in which JCC patients are diagnosed and treated.

Pagetic osteosarcoma: An analysis of the National Cancer Database.

e23503 Background: Pagetic osteosarcoma (Pagetic OS) is a rare cancer typically originating at bones affected by Paget disease. Pagetic OS may present as metachronous multifocal lesions primarily affecting the pelvis, proximal femur, and proximal humerus. There are currently no available sociodemographic descriptions of patients with Pagetic OS. Analyzing sociodemographic factors through the National Cancer Database may unveil important information about its epidemiology and guide future treatment. Methods: A retrospective cohort analysis utilizing the 2004–2020 National Cancer Database (NCDB) included patients with a histologically-confirmed diagnosis of Pagetic osteosarcoma (N = 128) using ICD-O-3 code 9184. Demographic factors (age, sex, race, Hispanic status, educational attainment, insurance status, facility type, distance from facility, and Charles/Deyo score) were analyzed by descriptive statistics. Incidence trends were interpreted in regression analysis. Results: In the NCDB, 128 patients were identified with a confirmed diagnosis of Pagetic osteosarcoma (Pagetic OS) between 2004 and 2020, with a steady incidence of diagnoses per year (R2 = 0.0). The average age of diagnosis was 68.9 years (SD = 13.4, range = 11-90 years). Men were more likely to be diagnosed than women (57% and 43%, respectively). Most patients were non-Hispanic White (71%), insured by Medicare (56%), and lived in a metropolitan area (85%). When compared individually, more patients were in the top median household income quartile (31%). The top two primary sites were the long bones of the lower limb including their associated joints (27%) and the pelvic bones excluding the sacrum, coccyx, and symphysis pubis (27%). Within the cohort, 31 patients received chemotherapy as primary treatment (24%) while 28 patients received primary radiation therapy (22%). Most patients (63%) did not undergo primary site surgery while 39 patients (31%) did receive surgery as primary treatment. The 90-day mortality included 15% of patients, who died 90 or fewer days after surgery was performed. The 2-year survival was 82% while the 5-year survival was 53% and the 10-year survival was significantly lower at approximately 11%. Most individuals (76%) had Charlson-Deyo comorbidity scores of 0. Conclusions: To the best of our knowledge, this NCDB analysis on Pagetic osteosarcoma (Pagetic OS) is the first of its kind on this specific subset of osteosarcoma. Previous research suggests the broader osteosarcoma occurs most frequently in adolescents. This data reveals that Pagetic OS is primarily diagnosed later in life (68.9 years), while still affecting a significantly wide age range (range = 11-90 years). Most patients were non-Hispanic White (71.1%), lived in a metropolitan area (85.2%), and belonged to the top median household income quartile (31.3%). Further research could unveil additional guidance on best practice in diagnosing and treating this cancer.

Analysis of demographic and socioeconomic factors in adamantinoma using data from the National Cancer Database (NCDB).

e23501 Background: Adamantinoma is a rare low-grade primary malignant bone tumor accounting for less than 1% of all malignant bone tumors. It largely presents in the tibia of young adults, is locally aggressive, and can metastasize. Definitive diagnosis is primarily established by histopathological examination. This rare tumor with uncertain histogenesis remains under-studied. Therefore, exploring trends in diagnoses may provide insight into its epidemiology. The National Cancer Database (NCDB) was examined to reveal the demographic factors in patients diagnosed with Adamantinoma. Methods: A retrospective cohort analysis utilizing the 2004–2020 NCDB included 206 patients with a histologically-confirmed diagnosis of adamantinoma (ICD-O-3 Code 9261). Demographic factors such as age, sex, race, Hispanic status, insurance status, facility type, distance from facility, and Charlson-Deyo score were analyzed via descriptive statistics. Trends in incidence were interpreted using regression analysis. Results: A total of 206 patients were identified in the NCDB with a confirmed diagnosis of adamantinoma of long bones between 2004-2020. Incidence remained relatively stable over this time period (R² = 0.009). The most common primary site of diagnosis were the long bones of lower limb and associative joints (97%). Most individuals (88%) had a Charlson-Deyo comorbidity score of 0. The majority of patients (66%) were classified as Stage 1 AJCC staging. Men were more likely to be diagnosed (56%) compared to women (44%). Most patients were White (78%) and non-Hispanic (85%). A higher percentage of patients were privately insured (67%) and lived in metropolitan areas (87%). Treatment facilities primarily were academic programs (74%). Almost all of the patients were treated surgically (92%) with the most common approach being lymph node dissection (61%) more so than local tumor excision or removal of adjacent organs. Following surgery, the patients observed had a very good prognosis, with a 99% ninety-day survival, a 93% five-year survival, and an 89% ten-year survival. Conclusions: Adamantinoma has a risk for recurrent and metastatic disease. This first NCDB analysis on adamantinoma’s demographics addresses a significant knowledge gap on this topic. The primary site of diagnosis were lower extremity long bones, most commonly treated with surgical intervention, and had a high survival rate which is consistent with earlier studies. The majority of patients included in this study tend to be White, non-Hispanic, and privately insured. This may suggest a demographic and socioeconomic factor that plays a part in diagnosis, prognosis, and treatment of individuals with adamantinoma. Future research should focus on the understanding of factors that impact the course of one’s health and the etiology of this rare pathology.

High-grade surface osteosarcoma: A National Cancer Database study of demographic characteristics.

e23508 Background: High-grade surface osteosarcoma (HGSO) is an extremely rare malignant subtype of osteosarcoma. HGSO often affects long bones, particularly the femur, and is the rarest subtype of surface osteosarcomas. Though data is limited, current information suggests this cancer presents with a poor prognosis, generally affecting adults aged 20 to 40. Current treatment standards involve wide resection and chemotherapy. The National Cancer Database (NCDB) was examined to establish the demographic factors among HGSO patients and identify diagnostic and treatment trends. Methods: A retrospective cohort study from 2005-2020 was conducted using the NCDB. A total of 99 patients were found with a histologically confirmed diagnosis of high-grade surface osteosarcoma (ICD-9194-3). Factors such as gender, age, race, insurance status, rural/urban residence, treatments, mortality rates, and Charles/Deyo scores were analyzed using descriptive statistics, and trends in incidence were interpreted via regression analysis. Results: Yearly HGSO incidence rates increased from 2005 to 2020 (R2 = 0.19). The average age of diagnosis was 41 years (SD = 24.9, range = 10-90) with men diagnosed (54%) slightly more than women. The majority of patients were non-Hispanic white (73%), had private insurance (55%), and lived in a metropolitan area with over 250,000 in population (89%). The average patient was diagnosed at a hospital 40.4 miles away from their home (SD = 84.9, range 0.4-648.4 miles). Most patients (55%) were in stage II at diagnosis, and 86% of patients had a Charlson-Deyo comorbidity score of 0. The most common primary site of this malignancy was the long bones of the lower limb and associated joints (67%), while the upper extremities (8%) and pelvic bone (8%) served as less common primary sites. Surgery was the most common primary treatment (62%). Data from 69 patients revealed the 90-day mortality post-surgery was 3%. The mean survival rate was 70% at two years and 52% at five years. Conclusions: To the best of our knowledge, this study represents the first NCDB analysis of HGSO. Our analysis demonstrated that HGSO occurs most often, but not exclusively, within the lower extremity long bones, which may be an important diagnostic distinction. It was previously indicated that the average age at HGSO diagnosis is 20-40 years, but our analysis suggested it is closer to 40. Our analysis revealed a five-year survival rate of 52% which is worse than prior studies have indicated. Demographic data has revealed the majority of patients were non-Hispanic white, privately insured, and living within a metropolitan area. This trend may suggest access to healthcare resources is influencing this cancer’s diagnosis and treatment. Further research is warranted to explore whether the demographic patterns seen in HGSO are indicative of biological causes or socioeconomic factors that are significantly influencing diagnosis.

Extra-adrenal paraganglioma demographic data: A NCDB study.

e16293 Background: Extra-adrenal paragangliomas are rare neuroendocrine tumors that form near blood vessels and nerves outside of adrenal glands. Despite their rare occurrence, these tumors have higher rates of malignancy and varying survival rates compared to other paragangliomas. To better understand its epidemiology, there may be clinical value in analyzing the diagnostic trends of these tumors. This study utilized information provided by the National Cancer Database (NCDB) to examine the demographic factors of patient populations diagnosed with extra-adrenal paragangliomas. Methods: A retrospective cohort analysis using the 2004–2020 National Cancer Database (NCDB) included 133 patients with a histologically-confirmed diagnosis of extra-adrenal paraganglioma (ICD-O-3 code 8693). Demographic factors (age, sex, race, Hispanic status, educational attainment, insurance status, facility type, distance from facility, and Charles/Deyo score) were analyzed by descriptive statistics. Incidence trends were interpreted via regression analysis. Results: In the NCDB, 133 patients were identified with a confirmed diagnosis of extra-adrenal paraganglioma between 2004 and 2020. This database suggested a relatively stable number of patients diagnosed per year (R² = 0.022). Men (67%) were more likely to be diagnosed than women (35%), with an average age at diagnosis of 45.7 years (SD = 17.7, range = 11-83). Patients were most commonly non-Hispanic (88%), White (68%), and had a primary site of diagnosis in the retroperitoneum (35%). Treatment was primarily surgical resection (84%) followed by radiation (17%) and chemotherapy (8%). Most patients did not receive palliative care (98%). A majority of patients (77%) had a Charlson-Deyo comorbidity score of 0, with a 2 year survival rate of 92%, a 5 year survival rate of 79%, and a 10 year survival rate of 50%. Most patients were privately insured (65%) and received treatment in an academic research facility (56%). Many individuals lived in large metropolitan counties with a population larger than 1 million (56%), and resided a mean distance of 41.6 miles (SD = 74.4, range = 0.8 - 559.3) from the treatment facility. Conclusions: To the best of our knowledge, this is the first analysis of extra-adrenal paragangliomas utilizing the NCDB, and thus addresses a significant lack of knowledge on the subject. The majority of patients are non-Hispanic White men, with a primary site of diagnosis in the retroperitoneum. This is the first time that the socioeconomic factors of extra-adrenal paraganglioma patients have been described in the literature: patients tend to be privately insured, live in large metropolitan counties, and have 10 survival rate of 50%. Continued research is necessary to gain a deeper insight on the impact of socioeconomic and demographic factors that influence the diagnosis, treatment, and survivability of extra-adrenal paraganglioma patients.

The impact of treatment approach on survival among patients with clinical stage T2N0 and T3N0 rectal cancer.

e15637 Background: Treatment of early stage rectal cancer requires a multi-disciplinary approach and is often treated with curative intent surgery with use of total neoadjuvant treatment (TNT) or neoadjuvant chemoradiotherapy (nCRT) in select cases pre-operatively. In this study, we determine the various clinicopathologic factors associated with the use of these different approaches (Surgery upfront vs nCRT vs TNT) and their effect on patient survival. Methods: The National Cancer Database (NCDB) was queried for patients with clinical T2N0M0 and T3N0M0 rectal cancer between 2004-2019. Results: 36,869 patients were identified, of which about half had nCRT only while < 15% had received TNT. Patients who underwent nCRT had the highest median OS compared to those who underwent surgery only (106.8 vs 126.5 months, p < 0.001). The surgery upfront cohort had the highest proportion of patients who were seen at a facility with high/very high case volume per year quartiles (surgery: 52.5%, nCRT: 47.3%, and TNT: 48.3%, p < 0.001). The highest median age was among the surgery cohort at 69 years followed by the nCRT cohort at 64 years and TNT cohort at 61 years (p < 0.001). Amongst patients with a Charlson-Deyo co-morbidity score of 2 or more, the surgery upfront cohort had the highest proportion while the TNT cohort had the lowest (p < 0.001). Low anterior resection (LAR) was the most common procedure among all three cohorts. A multivariate logistic regression model revealed that when compared to surgery only, the nCRT (Adjusted Odds Ratio (AOR) = 1.51, p < 0.001) and TNT (AOR = 1.62, p < 0.001) were both associated with an increased likelihood of 5-year long-term survival (LTS), with TNT having a stronger association. Among the various pre-operative characteristics, patients 70 years and older, patient with normal CEA and presence of LVI were less likely to have LTS with TNT as compared to surgery upfront. On the other hand, patients with clinical T3 stage who received TNT were much more likely to have improved LTS as compared to T2 stage (Relative Risk Ratio (RRR) 16.19, p < 0.001). Conclusions: Results of our study show that patients with early stage T2N0 and T3N0 rectal cancer who underwent neoadjuvant treatment had an improved median OS compared to patients who received surgery upfront. Both nCRT and TNT were associated with an increased likelihood of long-term survival, with TNT having a stronger association particularly in the T3N0 cohort.

Declination of Treatment, Racial and Ethnic Disparity, and Overall Survival in US Patients With Breast Cancer

Declining treatment negatively affects health outcomes among patients with cancer. Limited research has investigated national trends of and factors associated with treatment declination or its association with overall survival (OS) among patients with breast cancer. To examine trends and racial and ethnic disparities in treatment declination and racial and ethnic OS differences stratified by treatment decision in US patients with breast cancer. This retrospective cross-sectional study used data for patients with breast cancer from the 2004 to 2020 National Cancer Database. Four treatment modalities were assessed: chemotherapy, hormone therapy (HT), radiotherapy, and surgery. The chemotherapy cohort included patients with stage I to IV disease. The HT cohort included patients with stage I to IV hormone receptor-positive disease. The radiotherapy and surgery cohorts included patients with stage I to III disease. Data were analyzed from March to November 2023. Race and ethnicity and other sociodemographic and clinicopathologic characteristics. Treatment decision, categorized as received or declined, was modeled using logistic regression. OS was modeled using Cox regression. Models were controlled for year of initial diagnosis, age, sex, health insurance, median household income, facility type, Charlson-Deyo comorbidity score, histology, American Joint Committee on Cancer stage, molecular subtype, and tumor grade. The study included 2 837 446 patients (mean [SD] age, 61.6 [13.4] years; 99.1% female), with 1.7% American Indian, Alaska Native, or other patients; 3.5% Asian or Pacific Islander patients; 11.2% Black patients; 5.6% Hispanic patients; and 78.0% White patients. Of 1 296 488 patients who were offered chemotherapy, 124 721 (9.6%) declined; 99 276 of 1 635 916 patients (6.1%) declined radiotherapy; 94 363 of 1 893 339 patients (5.0%) declined HT; and 15 846 of 2 590 963 patients (0.6%) declined surgery. Compared with White patients, American Indian, Alaska Native, or other patients (adjusted odds ratio [AOR], 1.47; 95% CI, 1.26-1.72), Asian or Pacific Islander patients (AOR, 1.29; 95% CI, 1.15-1.44), and Black patients (AOR, 2.01; 95% CI, 1.89-2.14) were more likely to decline surgery; American Indian, Alaska Native, or other patients (AOR, 1.13; 95% CI, 1.05-1.21) and Asian or Pacific Islander patients (AOR, 1.21; 95% CI, 1.16-1.27) were more likely to decline chemotherapy; and Black patients were more likely to decline radiotherapy (AOR, 1.05; 95% CI, 1.02-1.08). Asian or Pacific Islander patients (AOR, 0.81; 95% CI, 0.77-0.85), Black patients (AOR, 0.86; 95% CI, 0.83-0.89), and Hispanic patients (AOR, 0.66; 95% CI, 0.63-0.69) were less likely to decline HT. Furthermore, Black patients who declined chemotherapy had a higher mortality risk than White patients (adjusted hazard ratio [AHR], 1.07; 95% CI, 1.02-1.13), while there were no OS differences between Black and White patients who declined HT (AHR, 1.05; 95% CI, 0.97-1.13) or radiotherapy (AHR, 0.98; 95% CI, 0.92-1.04). This cross-sectional study highlights racial and ethnic disparities in treatment declination and OS, suggesting the need for equity-focused interventions, such as patient education on treatment benefits and improved patient-clinician communication and shared decision-making, to reduce disparities and improve patient survival.

Disparities in survival in Asian American, Native Hawaiian, and Pacific Islander patients with gastric adenocarcinoma: An NCDB analysis.

253 Background: Asian American, Native Hawaiian, and Pacific Islander (AANHPI) individuals exhibit stark disparities in gastric cancer mortality rates, with AANHPI men facing a two-fold higher risk of death and AANHPI women encountering a 2.5-fold elevated risk compared to their Non-Hispanic White (NHW) counterparts. However, the AANHPI community is a diverse group, including over 21 ethnic groups. Here, we identify disparities among AANHPI subpopulations with gastric adenocarcinoma. Methods: Using the National Cancer Database, which gathers data from over 1,500 accredited hospitals and facilities across the United States, this retrospective cohort study identified 141,906 patients with gastric adenocarcinoma (ICD code “8140”). Races listed as “unknown/other” or “Other Asian” were excluded. Kaplan Meier and Cox Regression model were performed. Results: This study compared mean overall survival (OS) of NHW (n=111,137), East Asian (EA) (n=3,745), South Asian (SA) (n=760), Southeast Asian (SEA) (n=1,379), and Native Hawaiian or Pacific Islander (NHPI) (n=325) patients with gastric adenocarcinoma. When aggregated, AANHPI had statistically significant improved OS compared to NHW (21.6 months vs 14.1 months, p < 0.001). After disaggregating, the mean OS was 26.9 months for EA; 21.3 months for SA; 14.5 months for SEA; and 14.3 months for NHPI. Only SA and EA had significantly improved OS than NHW (p<0.001 for both). SEA and NHPI had significantly worse outcomes than EA (p<0.001 for both) and SA (p<0.001 for SEA, and p = 0.033 for NHPI). Multivariate analysis accounted for age at diagnosis, insurance status, median income quartile, Charlson-Deyo comorbidity score, facility type, stage at diagnosis, and time to treatment. SA (HR=0.82; 95% CI, 0.726 to 0.925; p<0.001)), EA (HR=0.644; 95% CI, 0.609 to 0.68; p<0.001), and SEA (HR=0.896; 95% CI, 0.821 to 0.978, p=0.014) had lower survival hazard ratios compared to NHW. NHPI (HR=0.931, 95% CI 0.775 to 1.119, p=0.448) did not have a statistically significant relationship compared to NHW. EA (HR = 0.637; 95% CI 0.548 to 0.741, p<0.001) and SA (HR = 0.793; 95% CI 0.667 to 0.943, p=0.007) had significantly lower survival hazard ratios compared to NHPI. Conclusions: Survival disparities exist among AANHPI subgroups with gastric adenocarcinoma. At first glance, OS appeared significantly greater for AANHPI patients compared to NHW. However, disaggregation of AANHPI subpopulations revealed that Southeast Asian and NHPI actually had comparable OS with NHW. After controlling for socioeconomic factors, NHPI had significantly worse hazard ratios compared to South Asian and East Asian. This highlights the need to disaggregate AANHPI data so that disparities among these diverse subpopulations can be identified, investigated and ultimately addressed.

Abstract B108: Racial disparities in survival among oral cavity and pharynx cancer patients treated with immunotherapy: Insights from the US National Cancer Database (NCDB)

Abstract Purpose: Survival rates for oral cavity and oropharynx cancers vary by race, with Non-Hispanic(NH)-Black patients experiencing relatively lower survival rates compared to NH-White patients. While the potential for improving survival with immunotherapy has been demonstrated in clinical trials, it remains unclear whether racial disparities persist in patients treated with this novel approach. We aimed to evaluate the association between race and all-cause mortality among oral and pharynx cancer patients who received immunotherapy. Methods: This study utilized the National Cancer Database (NCDB) to investigate racial disparities in survival after immunotherapy among patients diagnosed with oral cavity and pharynx cancers between 2013 and 2017. Multivariable Cox proportional hazards models were employed to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) by race/ethnicity. Results: The study cohort included 7,714 patients, consisting of 7,011 NH-White patients and 703 NH-Black patients. During the follow-up period, mortality occurred in 45.5% of NH-White patients and 59.5% of NH-Black patients. After adjusting for sociodemographic, clinical, and treatment factors, NH-Black patients had a higher risk of death compared to NH-White patients (HR: 1.24; 95% CI: 1.11, 1.38). Additionally, the study found no significant differences in the interaction between race and Charlson-Deyo comorbidity score or race and area-level median income. Conclusion: This study suggests that urgent action is needed to address these disparities to improve outcomes for NH-Black patients with oral cavity and pharynx cancers. Citation Format: Danting Yang, Shama Karanth. Racial disparities in survival among oral cavity and pharynx cancer patients treated with immunotherapy: Insights from the US National Cancer Database (NCDB) [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B108.

Disparities in Time to Treatment for Skin Cancer.

Skin cancer is the most common cancer worldwide. This study aimed to identify factors contributing to the disparities in skin cancer treatment. Data from The National Cancer Database (NCDB) spanning 2004 to 2019 were utilized. Variables including age, sex, race, Hispanic origin, Charlson-Deyo Comorbidity (CDC) score, geographic location, insurance status, income, grade and stage of cancer, and type of treatment facility impacting the time to treatment, surgery, radiation, and chemotherapy were analyzed. Trends of longer time to treatment were seen with older age, non-Hispanic white, uninsured, those with a higher CDC score, and treated at academic facilities. Additionally, annual income and clinicopathology of cancer were also significantly associated with time to treatment. Our findings contribute to the expanding body of evidence pointing to the influence of socioeconomic and demographic factors in treatment disparities across diverse patient populations.

Survival Outcomes of Rural Patients with Mantle Cell Lymphoma

Background Mantle cell lymphoma (MCL) is a rare and aggressive malignancy, representing approximately 6-8% of all non-Hodgkin lymphomas, and is generally associated with poor outcomes. Patients (pts) with MCL often require intensive up-front treatment with consideration for stem cell transplant consolidation. Due to geographic limitations, pts living in rural areas with MCL may not have access to specialized treatment centers experienced in managing this rare disease. There is a paucity of data available evaluating the impact of rurality in MCL, and it is unknown how population density and access to major metropolitan centers and their healthcare systems may impact survival outcomes. Methods The National Cancer Database was used to identify MCL pts diagnosed from 2004-2020. Demographic and treatment characteristics were compared by county level measures of rurality and urban influence, categorized into metropolitan (metro), non-metropolitan urban (urban), and non-metropolitan rural (rural) counties. These data are provided from the 2013 Department of Agriculture Economic Research service data Rural-Urban Continuum Codes which uses population, population density, and commuting distance to determine these codes. Pts without rurality data or who were not treated at the reporting facility were excluded. Kaplan Meier and adjusted Cox regression survival analysis were used to compare overall survival by rural-urban codes. Results Of the 29,464 pts with MCL identified, 83.4% (N= 24,849) resided in metro counties, 14.6% (N=4,356) resided in urban counties, 1.9% (N=573) resided in rural counties. Non-metro pts were more likely to be male (70.7% male metro vs 73.0% and 72.1% for urban and rural counties, respectively), with similar age at diagnosis across county types (median age of 68 for metro pts and 69 for rural pts). Rural pts had a higher burden of comorbidities, as determined by the Charlson-Deyo comorbidity index (11.3% of rural pts with a score of 2 or greater, compared to 8.7% urban, and 7.9% of metro pts). Pts from metro counties were more likely to have private insurance (38.5% metro vs. 32.4% for urban and 28.6% for rural pts), where non-metro pts were more often uninsured (3.3% of rural, vs 2.4% of metro) or Medicare insured (61.6% rural vs 53.4% of metro pts). Notably, pts were less likely to be managed with active surveillance if they were from a rural county (4.8% vs 6.9% of metro pts), and were more likely to receive systemic disease related therapy at diagnosis (90.6% rural vs 85.2% metro). With a median follow up of 42 months, pts from metro counties had a median overall survival (OS) of 70.6 months (95% confidence interval (CI) 68.6-72.7), which was significantly longer than those from urban (61.1 months [95% CI 56.4-65.9], p<0.001) and rural counties (59.8 months [95% CI 54.0-65.6], p<0.001). The survival disparity was persistent for metro, urban, rural pts at 1-year (81%, 80%, and 78% respectively, p<0.001), 5-years (54%, 50%, 50% respectively, p<0.001) and 10-years (36%, 30%, 29% respectively, p=0.066). When referenced to pts from metro counties on Cox regression, non-metro counties had a greater risk of all-cause mortality, with hazard ratio (HR) of 1.13 (95% CI 1.08-1.18; p<0.001) for urban and 1.14 (95% CI 1.02-1.28; p=0.024) for rural pts. When adjusted for age and Charlson-Deyo comorbidity score this survival disparity persisted, with a HR of 1.12 (95% CI 1.07-1.17), p<0.001 for urban pts and HR 1.05 (95% CI 0.94-1.18), p=0.408, for rural pts, when referenced to pts from metro counties. Discussion We demonstrate a population density-based survival disparity in MCL pts, finding that pts living in more rural counties have worse survival outcomes. Rural pts had a higher comorbidity burden and were more likely to be underinsured. Additionally, they received less active surveillance, which may indicate delays in diagnosis and/or consultation with an oncologist. Given the rapidly evolving treatment landscape of MCL, these data support the need for efforts to improve healthcare access for MCL pts, such as earlier referrals to academic centers with expertise in MCL management, expanded access to telehealth, rural partnerships with academic medical centers, and programs that support patient and family travel.

Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer.

Despite recommendations for upfront total laryngectomy (TL), many patients with cT4a laryngeal cancer (LC) instead undergo definitive chemoradiation, which is associated with inferior survival. Sociodemographic and oncologic characteristics associated with TL utilization in this population are understudied. This retrospective cohort study utilized hospital registry data from the National Cancer Database to analyze patients diagnosed with cT4a LC from 2004 to 2017. Patients were stratified by receipt of TL, and patient and facility characteristics were compared between the two groups. Logistic regression analyses and Cox proportional hazards methodology were performed to determine variables associated with receipt of TL and with overall survival (OS), respectively. OS was estimated using the Kaplan-Meier method and compared between treatment groups using log-rank testing. TL usage over time was assessed. There were 11,149 patients identified. TL utilization increased from 36% in 2004 to 55% in 2017. Treatment at an academic/research program (OR 3.06) or integrated network cancer program (OR 1.50), male sex (OR 1.19), and Medicaid insurance (OR 1.31) were associated with increased likelihood of undergoing TL on multivariate analysis (MVA), whereas age > 61 (OR 0.81), Charlson-Deyo comorbidity score ≥ 3 (OR 0.74), and clinically positive regional nodes (OR 0.78 [cN1], OR 0.67 [cN2], OR 0.21 [cN3]) were associated with decreased likelihood. Those undergoing TL with post-operative radiotherapy (+/- chemotherapy) had better survival than those receiving chemoradiation (median OS 121 vs. 97 months; p = 0.003), and TL + PORT was associated with lower risk of death compared to chemoradiation on MVA (HR 0.72; p = 0.024). Usage of TL for cT4a LC is increasing over time but remains below 60%. Patients seeking care at academic/research centers are significantly more likely to undergo TL, highlighting the importance of decreasing barriers to accessing these centers. Increased focus should be placed on understanding and addressing the additional patient-, physician-, and system-level factors that lead to decreased utilization of surgery.