Community Cancer Programs Research Articles

Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socioeconomic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707-0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102-1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452-0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806-0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210-1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.

A Practice-Based Evaluation of Distress Screening Protocol Adherence and Medical Service Utilization.

Background: This study examined the extent to which cancer programs demonstrated adherence to their own prescribed screening protocol, and whether adherence to that protocol was associated with medical service utilization. The hypothesis is that higher rates of service utilization are associated with lower rates of adherence to screening protocols. Methods: Oncology social workers at Commission on Cancer-accredited cancer programs reviewed electronic health records (EHRs) in their respective cancer programs during a 2-month period in 2014. Rates of overall adherence to a prescribed distress screening protocol were calculated based on documentation in the EHR that screening adherence and an appropriate clinical response had occurred. We examined documentation of emergency department (ED) use and hospitalization within 2 months after the screening visit. Results: Review of 8,409 EHRs across 55 cancer centers indicated that the overall adherence rate to screening protocols was 62.7%. The highest rates of adherence were observed in Community Cancer Programs (76.3%) and the lowest rates were in NCI-designated Cancer Centers (43.3%). Rates of medical service utilization were significantly higher than expected when overall protocol adherence was lacking. After controlling for patient and institutional characteristics, risk ratios for ED use (0.82) and hospitalization (0.81) suggest that when overall protocol adherence was documented, 18% to 19% fewer patients used these medical services. Conclusions: The observed associations between a mandated psychosocial care protocol and medical service utilization suggest opportunities for operational efficiencies and costs savings. Further investigations of protocol integrity, as well as the clinical care models by which psychosocial care is delivered, are warranted.

Early mortality and overall survival of acute myeloid leukemia based on facility type.

Cancer health disparities may exist based on the facility type. We aimed to determine the association between the academic status of centers and outcomes of patients with acute myeloid leukemia (AML). Using the National Cancer Data Base, we compared 1-month mortality and long-term overall survival (OS) of 60 738 patients with AML, who received first course treatment between 2003 and 2011 at academic or nonacademic centers (community cancer program, comprehensive community cancer program, and others). Multivariate analysis was done using logistic regression for one-month mortality and Cox regression with backward elimination approach for OS. Patients treated at academic centers differed from those at nonacademic centers in that they were younger with a median age of 62 versus 70 years (P < .0001), more often an ethnic minority (P < .0001), had lower education level (P = .005), lower co-morbidity score (P < .0001), a different income (P < .0001), and insurance profile (P < .0001), and more often received chemotherapy (P < .0001) and transplant (P < .0001). Receipt of care at nonacademic centers was associated with worse 1-month mortality (29% vs. 16%, P < .0001) and 5-year OS (15% vs. 25%; P < .0001). After adjusting for prognostic covariates, the 1-month mortality (odds ratio, 1.52; 95% confidence interval, CI 1.46-1.59; P < .0001) and OS were significantly worse in nonacademic centers, compared to academic centers. Our large database study suggests that the receipt of initial therapy at academic centers is associated with lower 1-month mortality and higher long-term OS. Investigation of the underlying reasons may allow reducing this disparity.

Self-reported financial stress among patients evaluated at a community cancer program.

6553 Background: Cancer related financial stress has been linked to a multitude of factors including socio-economic status, but its impact on the quality of life (QOL) for underserved populations is less well characterized. We evaluated patient reported financial stress, QOL, and quality of health (QOH) at an outreach cancer program located in a federally qualified health center. Methods: Study participants were interviewed at initial clinic visit for financial stress, QOH and QOL between January 2012 and December 2016. Demographic information, insurance coverage, clinical parameters, and comorbidities were abstracted from participants’ medical records. Responses to the financial stress index question “how difficult is it for you or your family to meet monthly payment of your/your family bills?” and overall QOL and QOH of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 were analyzed. Proportional odds logistic regression models were constructed for 5-point quality of life measures and three levels of financial toxicity. Results: Of the 288 participants analyzed, 52% and 12% reported somewhat and extreme financial stress. In an adjusted analysis, patients who reported financial stress were more likely to be younger in age (OR = 4.03, p &lt; 0.001) unemployed (OR = 3.24, p = 0.002), have less than bachelor’s degree (OR = 0.035, p = 0.018), insured by Medicaid (OR = 3.22, p &lt; 0.011), and were more likely to rate their QOL (OR = 3.76, p = 0.031) as poor, compared to those without financial stress. Race, gender, presence of cancer diagnosis and comorbidities were not associated with financial distress. Independent predictors of poor QOL were disability (OR = 3.12, p = 0.005), depression (OR = 2.12, p = 0.007) and extreme financial difficulty (OR = 2.57, p = 0.011). There was a nearly perfect positive correlation between overall QOL and QOH (r = 0.984, p &lt; 0.001). Conclusions: There is a high prevalence of financial burden among underserved minority patients seeking cancer related care, and this is closely associated with poor quality of life. Interventions targeting cancer disparities need to assess financial stress in order to address this issue.

Variation in Locoregional Prostate Cancer Care and Treatment Trends at Commission on Cancer Designated Facilities: A National Cancer Data Base Analysis 2004 to 2013.

Contemporary treatment trends for prostate cancer show increased rates of active surveillance. However, nationwide applicability of these reports is limited. Additionally, the effect of Commission on Cancer facility type on prostate cancer treatment patterns is unknown. We used the National Cancer Data Base to identify men diagnosed with prostate cancer, between 2004 and 2013. Our cohort was stratified on the basis of the National Comprehensive Cancer Network prostate cancer risk classes. Cochran-Armitage tests were used to evaluate temporal trends. Random effects hierarchical logit models were used to assess treatment variation at Commission on Cancer facility and institution level. In 825,707 men, utilization of radiation therapy declined and utilization of radical prostatectomy increased for all prostate cancer risk groups between 2004 and 2013 (P< .0001). Observation for low-risk prostate cancer increased from 16.3% in 2004 to 2005 to 32.0% in 2012 to 2013 (P< .0001). Significant treatment variation was observed on the basis of Commission on Cancer facility type. Across all risk groups, the lowest rates of radical prostatectomy and highest rates of external beam radiation therapy were observed in community cancer programs. The highest rates of observation for low-risk disease were observed in academic centers. Treatment variation according to institution ranged from 14% (95% confidence interval, 0.12-0.15) for androgen deprivation therapy up to 59% (95% confidence interval, 0.45-0.73) for cryotherapy. The increased utilization of observation in low-risk prostate cancer is an encouraging finding, which appears to be mainly derived by a decrease in radiotherapy utilization in this risk group. Regardless of tumor characteristics, significant variations in treatment modality exist among different facility types and institutions.

Patterns of Care for Patients With Early-Stage Glottic Cancer Undergoing Definitive Radiation Therapy: A National Cancer Database Analysis

To characterize practice patterns, including temporal trends, in fractionation schedules among patients in the United States undergoing definitive radiation therapy for early-stage glottic cancer and to compare overall survival outcomes between fractionation schedules. We queried the National Cancer Database for patients with TisN0M0, T1N0M0, or T2N0M0 squamous cell carcinoma of the glottic larynx diagnosed between 2004 and 2012 and undergoing definitive radiation therapy. Dose per fraction was calculated to define cohorts undergoing conventional fractionation (CFxn) and hypofractionation (HFxn). Logistic regression was performed to identify predictors of receiving HFxn, and Cox regression was used to determine predictors of death. One-to-one propensity score matching was then used to compare survival between fractionation schedules. The study included 10,539 patients, with 6576 undergoing CFxn and 3963 undergoing HFxn. Patients with T1 disease comprised a majority of each cohort. Use of HFxn increased significantly over the period studied (P<.001), but even in the final year, nearly one-half of patients continued to receive CFxn. Receipt of HFxn was also independently associated with higher income and facility types other than community cancer programs on logistic regression. On multivariate Cox regression, HFxn was associated with improved survival (hazard ratio [HR] for death, 0.90; 95% confidence interval [CI], 0.83-0.97; P=.008), a finding redemonstrated on univariate Cox regression among a well-matched cohort after propensity score matching (HR, 0.88; 95% CI, 0.80-0.96; P=.003). Subgroup Cox multivariate analysis demonstrated a significant survival advantage with HFxn among patients with T1 disease (HR, 0.90; 95% CI, 0.81-0.99; P=.042) but a nonsignificant benefit among those with Tis (HR, 0.86; 95% CI, 0.57-1.30; P=.472) or T2 (HR, 0.88; 95% CI, 0.76-1.02; P=.099) disease. Use of HFxn is increasing and is associated with improved survival over CFxn. Our findings support the broadened use of HFxn for patients with early-stage glottic cancer undergoing definitive radiation therapy.

MP67-15 SURGICAL TREATMENT FOR STAGE I RENAL CELL CARCINOMA: DOES TREATMENT FACILITY MATTER?

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging II1 Apr 2017MP67-15 SURGICAL TREATMENT FOR STAGE I RENAL CELL CARCINOMA: DOES TREATMENT FACILITY MATTER? Kyle plante, Telisa Stewart, Dongliang Wang, Thomas Schwaab, Gennady Bratslavsky, and Margaret Formica Kyle planteKyle plante More articles by this author , Telisa StewartTelisa Stewart More articles by this author , Dongliang WangDongliang Wang More articles by this author , Thomas SchwaabThomas Schwaab More articles by this author , Gennady BratslavskyGennady Bratslavsky More articles by this author , and Margaret FormicaMargaret Formica More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2051AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While the use of partial nephrectomy (PN) has increased over the last decade, it is unclear if the shift has been uniform across the different types of cancer treatment facilities. This study seeks to compare the use of RN across types of Commission on Cancer (CoC)-accredited cancer programs in the United States from 2004-2013. METHODS Cases of RCC were identified from the Commission on Cancer's (CoC) National Cancer Data Base (NCDB) Participant User File (PUF) from 2004-2013. Patients with clinical stage I RCC who received either RN or PN as the primary surgical treatment at a CoC-accredited facility were included. Facility types were grouped by case volume (HV= high volume; LV=low volume) and multivariable logistic regression was used to estimate odds ratios for RN overall and stratified by tumor size across types of CoC-accredited cancer programs. Kaplan-Meier curves, Cox regression, and log-rank tests were used to characterize patient survival. RESULTS The study population consisted of 114,057 cases (PN=52,654; RN=61,403). Academic/Research Cancer programs (ACAD) performed the most PNs (52.0%), while Comprehensive Community Cancer Programs (CCCP) performed the most RNs (50.1%). Multivariable analysis indicated that when compared to ACAD-HV facilities, cases were more likely to be treated with RN if they received care at a Community Cancer Program (CCP) (OR= 3.082, 95%CI: 2.916-3.257), Integrated Network Cancer Program (INCP) (OR= 1.629, 95%CI: 1.542-1.722), CCCP-LV (OR=3.241, 95%CI: 3.084-3.405), CCCP-HV (OR=2.115, 95%CI: 2.047-2.185), or ACAD-LV (0R= 1.771, 95%CI: 1.682-1.865). The survival curves indicate that the overall risk of death was higher for RN compared to PN across all treatment facility types. CONCLUSIONS Stage I RCC patients receiving surgical treatment at CoC-accredited cancer programs are more likely to have a RN when receiving care at facilities that are not ACAD-HV. Survival analysis indicates that the benefits associated with PN still remain, regardless of the different treatment facility types. These findings indicate variability in how stage I RCC is surgically treated across CoC-accredited treatment facilities within the United States. Research is required to further explore these differences. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e877 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Kyle plante More articles by this author Telisa Stewart More articles by this author Dongliang Wang More articles by this author Thomas Schwaab More articles by this author Gennady Bratslavsky More articles by this author Margaret Formica More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Disparity between pre-existing management of penile cancer and NCCN guidelines

ObjectiveTo determine the locoregional management of penile cancer before the introduction of NCCN guidelines and how much shift in practice patterns is required to meet the guidelines. MethodsThe National Cancer Data Base was queried to identify 6,396 patients with squamous cell carcinoma of the penis diagnosed between 2004 and 2013. The cohort was divided into management groups based on the NCCN guidelines: cTa and cTis (cTa/is), pT1 low grade (T1LG), pT1 high grade (T1HG), and pT2 or greater (T234). These groups were analyzed to determine if management of locoregional disease complies with the 2016 NCCN guidelines and logistic regression analyses were performed to determine factors associated with adherence. ResultsNationwide management of the primary tumor closely follows the NCCN guidelines, with 96.9% adherence for cTa/is, 91.4% for T1LG, and 94.2% for T234. Management of regional lymph nodes (LNs) was inadequate with only 62.9% of patients with clinical N1 or N2 disease undergoing regional LN dissection (LND). The percentage of patients with known LN metastases who received regional LND increased over time (46.2% in 2004 to 69.4% in 2013, P = 0.034). Patients treated at community cancer programs (odds ratio [OR] = 0.26, 95% CI: 0.19–0.35), comprehensive community cancer programs (OR = 0.34, 95% CI: 0.29–0.41), and integrated network cancer programs (OR = 0.36, 95% CI: 0.25–0.52) were significantly less likely to receive LND compared with patients treated at academic comprehensive cancer programs. ConclusionsBefore the introduction of NCCN guidelines, national practice patterns for the management of the primary tumor were consistent with the recommendations. However, the management of regional LNs deviated from the guidelines, reflecting an area for improvement.

National Trends and Predictors of Androgen Deprivation Therapy Use in Low-Risk Prostate Cancer

Androgen deprivation therapy (ADT) is not recommended for low-risk prostate cancer because of its lack of benefit and potential for harm. We evaluated the incidence and predictors of ADT use in low-risk disease. Using the National Cancer Database, we identified 197,957 patients with low-risk prostate cancer (Gleason score of 3+3=6, prostate-specific antigen level <10ng/mL, and cT1-T2a) diagnosed from 2004 to 2012 with complete demographic and treatment information.We used multiple logistic regression to evaluate predictors of ADT use and Cox regression to examine its association with all-cause mortality. Overall ADT use decreased from 17.6% in 2004 to 3.5% in 2012. In 2012, 11.5% of low-risk brachytherapy patients and 7.6% of external beam radiation therapy patients received ADT. Among 82,352 irradiation-managed patients, predictors of ADT use included treatment in a community versus academic cancer program (adjusted odds ratio [AOR], 1.60; 95% confidence interval [CI], 1.50-1.71; P<.001; incidence, 14.0% vs 6.0% in 2012); treatment in the South (AOR, 1.51), Midwest (AOR, 1.81), or Northeast (AOR, 1.90) versus West (P<.001); and brachytherapy use versus external beam radiation therapy (AOR, 1.32; 95% CI, 1.27-1.37; P<.001). Among 25,196 patients who did not receive local therapy, predictors of primary ADT use included a Charlson-Deyo comorbidity score of ≥2 versus 0 (AOR, 1.42; 95% CI, 1.06-1.91; P=.018); treatment in a community versus academic cancer program (AOR, 1.61; 95% CI, 1.37-1.90; P<.001); and treatment in the South (AOR, 1.26), Midwest (AOR, 1.52), or Northeast (AOR, 1.28) versus West (P≤.008). Primary ADT use was associated with increased all-cause mortality in patients who did not receive local therapy (adjusted hazard ratio, 1.28; 95% CI, 1.14-1.43; P<.001) after adjustment for age and comorbidity. ADT use in low-risk prostate cancer has declined nationally but may remain an issue of concern in certain populations and regions.

Radiation Therapy is Independently Associated with Worse Survival After R0-Resection for Stage I-II Non-small Cell Lung Cancer: An Analysis of the National Cancer Data Base.

The 1998 post-operative radiotherapy meta-analysis for lung cancer showed a survival detriment associated with radiation for stage I-II resected non-small cell lung cancer (NSCLC), but has been criticized for including antiquated radiation techniques. We analyzed the National Cancer Database (NCDB) to determine the impact of radiation after margin-negative (R0) resection for stage I-II NSCLCon survival. Adult patients from 2004 to 2014 were analyzed from the NCDB with respect to receiving radiation as part of their first course of treatment for resected stage I-II NSCLC; the primary outcome measure was overall survival. A total of 197,969 patients underwent R0 resection for stage I-II NSCLC, and 4613 received radiation. Median radiation dose was 55Gy with a 50-60Gy interquartile range. On adjusted analysis, treatment at a community cancer program, sublobectomy, tumor size (3-7cm), and pN1/Nx were associated with receiving radiation (odds ratio>1, p<0.05). The irradiated group had shorter median survival (45.8 vs. 77.5months, p<0.001), and radiation was independently associated with worse overall survival (hazard ratio (HR) 1.339, 95% confidence interval (CI) 1.282-1.399). After propensity score matching, radiation remained associated with worse overall survival (HR 1.313, 95% CI 1.237-1.394, p<0.001). Radiotherapy was independently associated with worse survival after R0 resection of stage I-II NSCLC in the NCDB and was more likely to be delivered in community cancer programs.

Abstract C52: Clinic utilization and smoking cessation practices among ethnic minority patients referred for paired lung cancer screening and tobacco treatment services at a community cancer program

Abstract Background: Studies on outcomes of lung cancer screening and smoking cessation programs among underserved and ethnic minority populations are scarce. These patients, however, have the greatest potential to benefit from these services. African Americans have the highest incidence and mortality rates for lung cancer, often as a result of multiple factors including factors related to disparities in access to quality care. The aim of this study was to determine clinic utilization rates and smoking cessation practices among underserved and ethnic minority patients referred for paired lung cancer screening and smoking cessation services at a community cancer program. Methods: The Dana-Farber Cancer Institute (DFCI)'s Cancer Care Equity Program (CCEP) added lung cancer screening to the established tobacco treatment arm of its community cancer program, housed in a neighborhood Federally Qualified Community Health Center (FQHC) in 2014. Nearly half (46%) of patients, aged 55 to 77 years who received care at the center in 2015 did not have a recorded smoking history. The paired intervention was offered at no cost to patients. Prospective data approved by the IRB was collected on a secured REDcap database that was designed for the CCEP. Patients referred by primary care providers at the health center had a low-dose computed tomography (LDCT) scan scheduled if they met the U.S. Preventive Services Task Force (USPSTF) criteria for lung cancer screening at their first visit. Concurrently, and at subsequent follow-up visits to review results of LDCT scans, patients who had not quit smoking were encouraged to enroll in the tobacco treatment program (TTP), which is individualized, one-on-one and available in both English and Spanish. A yearly surveillance LDCT plan was established for all participants who had negative scans while those with positive scans (based on American College of Radiology Lung-RADs risk stratification system) received further care at DFCI's main campus. Study outcomes include clinic show rates, smoking status, recommendations for LDCT, attendance at LDCT appointments, willingness to enroll in the TTP, and TTP participation rates. Descriptive statistical analysis on data collected between September 2014 and May 2016 was performed using JMP Pro (version 11, SAS Institute Inc., Cary, NC). Results: Fifty two out of 70 patients referred for lung cancer screening and tobacco treatment presented to the clinic, indicating a no show rate of 26%. Of the 52, 46 (88%) were current smokers. Among 47 (90%) participants who consented to research, mean age was 59.8 years (SD±5.8), 49 % were men, 74% were African American/Black, and 89% were current smokers. Most participants (87%) met the USPSTF criteria and were recommended for LDCT. Of these, 93% attended their appointments and were screened. None of the participants had a positive screen. While 83% of current smokers were screened and 87% initially expressed willingness to enroll in the TTP, only a third (33%) participated in the TTP. Conclusion: Compared to a high percentage of attendance at LDCT screenings, study participants had a low attendance at the TTP despite having expressed willingness to participate in the program. Further studies are needed to elucidate the causative factors for this difference. Additionally, the impressive utilization of a free LDCT service by patients who were referred when compared to the much larger number of patients who would fit into the criteria who were not referred, underscores the importance of mitigating health disparities by improving access to care. Efforts should be made to improve smoking-history taking in order to identify and appropriately refer eligible underserved candidates who might benefit from lung cancer screening and tobacco treatment. Citation Format: Ruth N. Akindele, Ludmila A. Svoboda, Sabrina G. Gonzalez, Christopher S. Lathan. Clinic utilization and smoking cessation practices among ethnic minority patients referred for paired lung cancer screening and tobacco treatment services at a community cancer program. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C52.

Surgical intervention in early-stage pancreatic adenocarcinoma.

443 Background: Bilimoria et al (2007) reviewed 9,559 patients from the 1995-2004 National Cancer Database (NCDB) showing that 38.2% of patients with early-stage pancreatic cancer without any identifiable contraindications failed to undergo pancreactomy. We used the 2004-2013 NCDB to look at the role of surgery in initial care plans of patients with stage I pancreatic adenocarcinoma. We also assessed differences in practice in this regard at different types of cancer centers. Methods: We analyzed 12,927 patients diagnosed with stage I pancreatic adenocarcinoma between 2004-2013 from the NCDB. Survival differences between patients who received surgery at the primary site versus patients not offered surgery were estimated by the Kaplan-Meier method. Differences in surgery were compared using chi-squared analysis. Results: Of the stage I patients, 27.3% had surgery, 52.8% were not offered surgery, 9.3% were not offered surgery due to risk factors, 4.4% refused surgery. Patients who received surgery had an increased median survival time compared to patients who were not offered surgery (30.2 months versus 7.1 months, p &lt; 0.05). Patients at academic/research programs were most likely to have surgery compared to those at community cancer programs who were least likely to have surgery (39.8% versus 22.9%, p &lt; 0.05). Conclusions: Patients who had surgery of the primary site had a significantly longer median survival time than those that were not offered surgery. Patients were most likely to be offered surgery if they were at an academic/research facility. Future studies should examine other factors that could possibly influence whether a patient is offered surgery or not for early-stage pancreatic adenocarcinoma. [Table: see text]

Utilization of minimally invasive versus open colectomy for colon cancer and perioperative/short-term oncologic outcomes: Are we there yet?

733 Background: Randomized controlled trials (RCTs) in highly-selected patient populations demonstrated equivalent outcomes following minimally invasive colectomy (MIC) versus (vs) open colectomy (OC) for colon cancer. The purpose of this study was to evaluate utilization of MIC and compare perioperative/short-term oncologic outcomes after MIC vs OC in a large, generalizable, national sample. Methods: We identified adult patients with invasive colon adenocarcinoma who underwent elective surgical resection between 2010 and 2012 using the National Cancer Data Base. Univariate associations between patient/tumor/facility/treatment characteristics and surgical approach were analyzed using chi-square tests. Multivariable logistic regression was used to identify independent predictors of receipt of MIC, as well as to evaluate independent associations between surgical approach and outcomes. Results: Among 111,372 patients identified, 48,393 (43.5%) underwent MIC; the proportion who underwent MIC increased between 2010 (37.8%) and 2012 (49%; p &lt; 0.001). High education level (adjusted odds ratio [aOR] 1.13) and increasing income level (aOR 1.09-1.36) were independently associated with receipt of MIC, whereas black race (aOR 0.85), Medicare (aOR 0.86)/Medicaid (aOR 0.67)/uninsured status (aOR 0.57), non-metropolitan residence (aOR 0.92), and community (aOR 0.63) or other (aOR 0.58) cancer programs were independently associated with potential underuse. Mean length of stay was shorter following MIC vs OC (6.07 vs 7.68 days; p &lt; 0.001). Use of MIC was independently associated with reduced 30-day (aOR 0.6) and 90-day (aOR 0.62) mortality, as well as lower rate of positive surgical margins (aOR 0.69) and higher rate of regional lymph nodes examined &gt; = 12 (aOR 1.14). Conclusions: This study confirms that MIC is associated with favorable perioperative/short-term oncologic outcomes (compared to OC), as demonstrated in RCTs. Although utilization of MIC for colon cancer continues to rise, implementation studies are warranted to enhance access to optimal surgical care and eradicate persistent disparities in receipt of MIC among historically underserved populations.

OA01.01 Institutional-Based Differences in the Quality and Outcomes of US Lung Cancer Resections

Institutional-level differences in NSCLC survival are associated with differences in the quality of oncologic care. We examined stage-stratified and overall survival of patients in different categories of US Commission-on-Cancer (CoC)-accredited institutions, to quantify inter-institutional differences in survival-impactful quality measures and estimate their relative survival impact, in order to identify the most impactful targets for improvement efforts. National Cancer Data Base (NCDB) institutions were grouped according to CoC category into: Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), Teaching Research Program (TRP), and NCI Program/Network (NCIP). Resections for stage I-IIIA NSCLC in the National Cancer Data Base from 2004-2013 performed within each category of institution were examined for specific quality parameters. Survival was estimated by the Kaplan-Meier method and compared with the log-rank test. Of 125,408 NSCLC eligible patients, 8% received surgery at CCP, 52% at CCCP, 28% at TRP, and 12% at NCIP. The pNX rate was 8%, 5.7%, 5.5%, and 3.2% respectively (p<.0001); the median (IQR) nodal count for pN0/1 patients was 6 (7), 7 (7), 8 (9), and 10 (10) respectively, and the CoC quality criterion attainment rate (examination of >10 nodes for stage I/II patents) was 25.5%, 30.2%, 38.7%, and 51.4% (p<.0001). The nodal upstaging rate from clinical (c) N0 to pathologic N-positive was 10.4%, 10.8%, 10.7% and 13.1% (p<.0001); for cN1, nodal upstaging rate was 9.4%, 10.5%, 10.4% and 15.5% (p<.0001). There was no significant inter-institutional difference in 5-year OS for stage I/II patients with pNX resections: 0.47 v 0.50 v 0.51 v 0.54 (log-rank p=.27), whereas stage I/II patients with resections meeting or failing the CoC quality standard had persistent inter-institutional survival differences. For those with <10 nodes, 5-year survival was 0.59 v 0.63 v 0.65 v 0.69 (log-rank p<.0001) and for those with >10 nodes, it was 0.62 v 0.64 v 0.67 v 0.69 (log-rank p<.0001). Striking differences in the quality and accuracy of NSCLC pathologic nodal staging exist between the different categories of CoC-accredited facilities. Institutions with higher quality staging have significantly better stage-stratified OS. This inter-institutional survival difference disappears in the patients without examination of any lymph nodes, who arguably have similarly bad quality pathologic nodal staging. However, adjustment for other measures of pathologic nodal staging quality failed to eliminate the inter-institutional survival disparity. Further investigation of inter-institutional practice differences is needed to understand the institutional-level difference in survival after lung cancer surgery.

P1.07-046 Uptake of Recommended Treatment in Small Cell Lung Cancer: Trend over the Last 15 Years and Risk Factors

Despite the dismal outcomes of small-cell lung cancer (SCLC), the fact that SCLC patients are generally responsive to treatment emphasizes the importance of adherence to recommended treatment. This study analyzed the trend in treatment provision in SCLC over the last 15 years and its associated factors. A total of 207,375 adult patients diagnosed with SCLC between 1998 and 2012 in the United States were identified from the National Cancer Data Base. In this study, recommended treatment was defined as surgery and/or chemoradiation for the limited stage (LS-SCLC), regardless of sequence; and chemotherapy for the extensive stage (ES-SCLC). We excluded patients who did not receive treatment due to a contraindication. Logistic regression was used to analyze the risk of not receiving recommended treatment, adjusted for socio-demographics, facility type, and clinical factors. Kaplan-Meier estimator was used to estimate patients’ survival. Between 1998 and 2012, the proportion of patients receiving recommended treatment increased among LS-SCLC patients (63% to 73.4%), but was unchanged in ES-SCLC (75.7% to 76.6%). Nevertheless, a significant proportion of patients did not receive recommended treatments. Older age, low income, use of non-private insurance or no insurance, higher comorbidity score, and diagnosis and/or treatment at a community cancer program were independent predictors of inadequate treatment for both LS-SCLC and ES-SCLC, while Black race was a predictor only in LS-SCLC. For instance, compared to patients with private insurance, the odd ratios of uninsured patients not receiving recommended treatment or no treatment was 1.7 (95% CI 1.543-1.932) in LS-SCLC and 1.9 (95% CI 1.751-2.060) in ES-SCLC patients. Both LS-SCLC and ES-SCLC patients aged 65-74 years had 1.5 (95% CI for LS-SCLC: 1.402-1.587; 95% CI for ES-SCLC: 1.454-1.613) times higher odds of not receiving recommended treatment or no treatment, compared to younger patients. In both groups, patients who received recommended treatment had better survival than those who did not receive recommended treatment or any treatment (median survival time of 18.4 vs. 6 months in LS-SCLC; 8.3 vs. 1.2 months in ES-SCLC). This study demonstrated an increase in the uptake of recommended treatment in LS-SCLC, but relatively no change in ES-SCLC. Reasons for not receiving recommended treatment warrant further investigation. The survival benefit among patients with recommended treatment highlights the need to alleviate any system-based barriers that may impact more patients receiving recommended treatment.

Impact of Facility Type and Surgical Volume on 10-Year Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma

Previous studies have demonstrated improved in-hospital mortality after hepatic resection for hepatocellular carcinoma (HCC) at teaching hospitals. The objective of this study was to evaluate if resection of HCC at academic cancer programs (ACP) is associated with improved 10-year survival. Using the National Cancer Data Base (NCDB) (1998 to 2011), we evaluated patients undergoing hepatic resection for HCC at ACPs, comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). High volume cancer programs (HVCPs) were defined as performing 10 or more hepatectomies per year. Multivariate Cox proportional hazard models by stepwise selection were applied to estimate hazard ratios (HR) of predictors of survival. The Kaplan-Meier method was used to generate survival curves at each facility type, and survival rates were compared using the log-rank test. We identified 12,757 patients undergoing hepatic resection for HCC at ACPs (n= 8,404), CCPs (n= 483), and CCCPs (n= 3,870). Sixty-two percent (n= 5,191) of patients treated at ACPs were at high volume institutions compared with 11.6% (n= 446) and 0% of CCCPs and CCPs, respectively (p < 0.0001). On multivariable analysis, patients undergoing hepatic resection at transplant centers (p < 0.0001) and HVCPs had significantly improved survival (p < 0.0001). Adjusted 10-year survival rates were 28.7% at high volume ACPs, 28.2% at high volume CCCPs, 24.9% at low volume CCCPs, 25.1% at low volume ACPs, and 21.3% at CCPs (p ≤ 0.0001). Patients undergoing hepatic resection for HCC at HVCPs had a significantly improved 10-year survival. Regionalization of HCC treatment to HVCPs may improve long-term survival.

Center Effect and Socioeconomic Determinants of Overall Survival (OS) of Diffuse Large B Cell Lymphoma (DLBCL)

Introduction:DLBCL is a heterogeneous disease with increasingly complex treatment selection. Prior studies demonstrated improved outcomes of hematologic malignancies managed in academic centers and based on socioeconomic factors. We aimed to compare OS of patients with DLBCL based on the type of treatment facility and other factors.Methods:This retrospective study utilized the National Cancer Data Base (NCDB) to identify patients with DLBCL diagnosed between 1998 and 2012. Health care facilities were categorized as either academic (academic/research program) or non-academic (comprehensive community cancer program, community cancer program, and other programs). Patients with complete data for sex, age, race, education, income, distance traveled for health care, hospital type, facility location, urban/rural, insurance, Charlson co-morbidity score, chemotherapy use, time from diagnosis to treatment initiation, use of hematopoietic stem cell transplant, last contact, and vital status were included. OS of patients who received first course treatment at academic centers, was compared to those treated at non-academic centers. Kaplan Meier curves for OS were compared using log-rank test. Multivariate Cox proportional hazard model was performed to identify determinants of OS.Results:Of 264,697 patients with DLBCL, 33% were treated at academic centers. Patients treated at academic centers differed from non-academic centers in mean age (65 vs. 68 years; p <0.0001), gender (45 vs. 47% females, p <0.0001), race (85 vs. 91% whites, p <0.001), income (38 vs. 31% with annual income >$63,000, p <0.001), education (17 vs. 15% residing in locality with ≥21% population without high school graduates, p <0.001), and insurance status (40 vs. 35% with private insurance, p <0.001), Charlson comorbidity score (79 vs. 76% with score 0, p <0.001) and AJCC stage (40 vs. 33% stage IV, p <0.001). Because of missing data, only 167,458 patients were used for OS analysis. Receipt of first course treatment at academic versus non-academic centers was associated with a higher median OS (95 months vs. 78 months, p<0.0001) (Figure 1). After adjusting for other co-variates, treatment at non-academic centers was associated with an increased risk of death (hazard ratio 1.05, 95% confidence interval 1.03-1.07). Other factors associated with improved OS include younger age, female sex, white race, private insurance, higher income and educational status, lower stage, lower comorbidity score, early initiation of chemotherapy, and use of radiation therapy (Table 1).Conclusion:Our study demonstrated differences in the characteristics of patients with DLBCL based on the facility type. Academic centers were more likely to treat patients who were younger, females, of ethnic minorities, with less education, higher income levels, private insurance, less comorbidities and higher stage disease. The receipt of frontline therapy at academic centers was associated with increased OS in patients with DLBCL. Some of the possible reasons for this difference may include provider experience, increased access to resources and clinical trials. Our study also demonstrated cancer health disparities based on other socioeconomic factors such as gender, race, income and insurance status. Further investigations into the factors contributing to such disparities should be a research priority to help standardize care and improve outcomes. [Display omitted] [Display omitted] DisclosuresArmitage:Conatus - IDMC: Consultancy; Roche: Consultancy; Spectrum Pharmaceuticals: Consultancy; GlaxoSmithKline IDMC: Consultancy; ZiopharmOncology: Consultancy; Tesaro bio Inc: Membership on an entity's Board of Directors or advisory committees.

ASCO Quality Care Symposium 2016 Exemplars in Quality and Identifying High-Quality Practice: Delivering Quality in the Community Setting (Bon Secours St Francis Cancer Center).

On the basis of data from the American Cancer Society and the National Cancer Institute, greater than 85% of cancer patients are treated in community cancer centers (CCCs) within the United States. Although there have been avenues for community participation in therapeutic research for decades, the opportunities for contributing to the quality discussion have beenmore restricted. The small size of many community cancer programs and the lack of staff skilled in quality improvement (QI) methodology have limited substantive participation of CCCs in the QI discourse. In addition, there are unique features of CCCs that make the deployment of QI across the spectrum of organizations potentially problematic. These programs constitute a heterogeneous assortment of relationships between hospital and physician practice, including hospital-employed models, private practice, as well as free standing and hospitalaffiliated centers. Nevertheless, despite the potential difficulties associated with developing a standardized QI process for CCCs, there can be no movement toward the triple-aim goals of improved individual and population health care and reduced overall cost without substantive community participation, given the sizable role these organizations play in the provision of cancer care. At the 2016 ASCO Quality Care Symposium (QCS), the Bon Secours Saint Francis Cancer Center (BSSFCC) was honored with the opportunity to present our QI efforts as an exemplar from the community. Much of what I present in this article cannot be elevated to the level of conventionally “scientific” in that there are no clear end points, no inclusion/exclusion criteria, andno consensus-based assessment tools that unequivocally measure the effect of interventions. We have neither the size nor expertise to provide such data. Nevertheless, we at BSSFCCbelieve that CCCs can andshouldbe incubatorsofQI interventions despite these shortcomings. In many ways, the size of programs such as ours maymake us optimal sites to test novel concepts that might resonate with other organizations. Upon arriving at this year’s QCS, I noticed what was an apparent metaphor for this conundrum.Therewas a sign at the breakfast buffet that stated “Bran Muffins, made with gluten, prepared in a nut-free environment.” It was an inexpensive sign, yet it undoubtedly avoided harm to those who might have experienced significant morbidity from the ingestion of the muffins. I haveno ideahowmanypeople, if any,

Time to Treatment: Measuring Quality Breast Cancer Care.

To optimize breast cancer care, several organizations have crafted guidelines to define best practices for treating breast cancer. In addition to recommended therapies, 'timeliness of treatment' has been proposed as a quality metric. Our study evaluates time to surgical treatment and its effect on overall survival (OS). The National Cancer Data Base (NCDB) was used to identify women diagnosed with invasive breast cancer between 2004 and 2012. Time from diagnosis to surgical treatment was calculated and grouped according to predetermined time intervals. Univariate and multivariate Cox proportional hazard models were used to assess patient and treatment factors related to OS. Overall, 420,792 patients initially treated with surgery were identified. Increased time to surgical treatment >12weeks was associated with decreased OS [hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.09-1.20]. When stratified by pathologic stage, stage I patients treated at 8 to <12weeks (HR 1.07, 95% CI 1.02-1.13) and >12weeks (HR 1.19, 95% CI 1.11-1.28), as well as stage II patients treated at >12weeks (HR 1.16, 95% CI 1.08-1.25), had decreased OS compared with patients treated at <4weeks. Other variables associated with decreased survival were treatment at a community cancer program, Medicaid or Medicare insurance, Black race, increasing age, mastectomy, moderately and poorly differentiated tumor grade, increasing T and N stage, and higher Charlson Index Group. The survival benefit of expedited time to initial surgical treatment varies by stage and appears to have the greatest impact in early-stage disease. Prior to establishing standard metrics, further quantification of the impact on patient outcomes is needed.

Positive surgical margins contribute to the survival paradox between patients with stage IIB/C (T4N0) and stage IIIA (T1-2N1, T1N2a) colon cancer

The underlying reasons for the survival paradox between stage IIB/C and stage IIIA colon cancer are elusive. We hypothesized that positive margins contribute to this paradox. We evaluated a cohort of 16,471 patients with stage IIIA and stage IIB/C colon cancer from 709,583 cases diagnosed between 2003-2012 in the National Cancer Data Base. All patients had chemotherapy, and all stage IIB/C patients had ≥12 lymph nodes retrieved. Patients with stage IIIA were subdivided further into those with <12 lymph nodes retrieved and those with ≥12 lymph nodes retrieved. Univariable and multivariable survival analyses were used. The 5-year overall survival rate was 70.8% for stage IIB/C, 81.6% for stage IIIA with <12 lymph nodes, and 85.6% for stage IIIA with ≥12 lymph nodes (P<.0001). The 5-year overall survival rate was 84.3% for stage IIIA with no residual tumor, 74.8% for stage IIIA with residual tumor, 73.3% for stage IIB/C with no residual tumor, and 60.5% for stage IIB/C with residual tumor (P<.0001). Independent predictors (P<.01) of poor overall survival include stage IIB/C, advanced age, African American ethnicity, community cancer program, uninsured and Medicaid, low education level, high comorbidity index, and positive surgical margins. Positive surgical margins may contribute to the survival paradox between stage IIB/C and stage IIIA colon cancer patients.