Comprehensive Community Cancer Center Research Articles

Epidemiology and clinical management of primary penile melanoma: A review of the National Cancer Database.

e21570 Background: Primary penile melanoma (PPM) is an exceedingly rare variant of skin cancer, estimated to account for less than 0.18% of all melanomas. As the incidence of melanoma is projected to increase, it is crucial to further understand subtypes of melanoma like PPM. We sought to use the National Cancer Database (NCDB) to describe the epidemiology, clinical features, and treatment modalities of PPM. Methods: We conducted a retrospective review of adults diagnosed with malignant PPM between 2004 and 2021 using the NCDB. Demographic factors analyzed included age, year of diagnosis, insurance status, and facility type. Clinical features studied included regional lymph node examination and treatments. SPSS was utilized to calculate descriptive statistics and chi-square tests for differences between categorical variables. Results: A total of 137 patients met inclusion criteria. The median age at diagnosis was 73 years. The majority of patients were insured by Medicare (n = 86, 63%) or private insurance (n = 46, 34%). About 50% (n = 69) of patients received care at an academic institution with other popular care centers being comprehensive community cancer centers (n = 33, 24%) and integrated network cancer programs (n = 28, 20%). Of the 91 (66%) patients examined for regional lymph node metastasis, 46% (n = 42/91) tested positive. The treatments of choice were partial amputation (n = 70, 51%), excisional biopsy (n = 30, 22%), total amputation (n = 15, 11%), and local excision (n = 10, 7%). After surgical intervention, 74% of patients (n = 101) showed no residual margins. Immunotherapy treatment, which was typically used as an adjuvant (n = 21,15%), increased from 7% (n = 5) of 68 cases diagnosed between 2004 and 2012 to 32% (n = 22) of 69 cases diagnosed between 2013 and 2021 (p < 0.001). Only 7% (n = 9) of patients underwent chemotherapy. Conclusions: To our knowledge, we present the largest study of PPM. Most patients were of older age, covered by Medicare, and examined for regional lymph node metastasis. In line with existing literature that demonstrates increased adoption of organ-sparing procedures over more aggressive approaches for PPM, partial amputation and excisional biopsy were the most common treatments. We observed a rise in the utilization of immunotherapy in the last decade, which is consistent with the timeline of FDA approval of several immune-based therapies for advanced melanoma. Current literature regarding immunotherapy in penile melanoma is scarce. Further research should investigate patient survival and the impact of different treatment modalities on outcomes.

Socioeconomic disparities in survival outcomes of patients with NSCLC with brain metastases: A real-world analysis.

8569 Background: Racial and ethnic disparities have been previously reported in outcomes of metastatic cancer patients. While novel therapies have improved outcomes of NSCLC patients with brain metastases (BM), however, barriers to therapy persist, warranting updated evaluations of socioeconomic disparities in clinical outcomes. Methods: A retrospective cohort study was conducted on patients diagnosed with NSCLC BM in 2018-2020 in the National Cancer Database. Patients were classified as White, Black, American Indian, Aleutian or Pacific Islander (AAPI), or Asian. Sociodemographic and clinical outcomes were analyzed and reported using median overall survival (mOS) (95% CI). Multivariate analyses were performed using Cox proportional hazard models adjusting for sex, race, facility type, and income and reported using hazard ratios for death (HR) (95% CI). Results: 13850 patients with NSCLC BM were included: 81% (N=11123) were White, 14% (N=1914) Black, 0.5% (N=73) AAPI, 3.7% (N=508) Asian. 8% were treated in community cancer centers (CCC) and 39% in comprehensive CCCs (CCCC). 55% were Medicare-insured and 30% had annual income >$74063. Compared to White, Asian patients had significantly better mOS of 29.1 months (24.57-36.5). Compared to non-Hispanic, Hispanic patients had significantly better mOS at 18.1 months (14.5-24.3). Medicaid and Medicare-insured had significantly worse outcomes vs. private-insured patients – mOS of 14.62 months (12.75-16.49) and 8.84 months (8.41-9.36) vs. 21.72 months (20.37-23.29). In multivariate analyses, compared to White, Asians had an HR of 0.61 (0.53-0.70). Hispanic had a HR of 0.77 (0.67-0.88) compared to non-Hispanic patients (P<0.05). Compared to academic centers, patients treated at CCC (HR 1.42 (1.29-1.57)) and CCCC (HR 1.25 (1.19, 1.32)) had worse outcomes. Patients with higher annual income (>$74063) had better outcomes compared to those with low income (<$46277) (HR 0.83 (0.78-0.89), P<0.002). Conclusions: Asian and Hispanic patients with NSCLC BM had better 3-year survival compared to White and non-Hispanic patients, respectively. Patients at community centers had worse outcomes than those at academic centers. Medicare-insured and Medicaid-insured patients had unfavorable outcomes. Targeted efforts are warranted to improve disparities in outcomes across racial and ethnic groups. [Table: see text]

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.

Trends in utilization of MSI testing and reporting among patients with gastrointestinal cancers: A review of NCDB Database.

221 Background: MSI-H tumors have a different disease biology and clinical outcomes compared to MSS/MSI-low tumors. The frequency and pattern for MSI testing and reporting is unknown. The aim of this study was to characterize the trends of MSI testing and reporting among GI cancers. Methods: From the National Cancer Database, we identified all GI cancer patients from 2010 to 2016 to determine the number of patients where MSS/MSI low or MSI-H data were available. We describe the basic tumor and disease characteristics and treatment utilization for the two groups. Results: Between 2010-2016, MSI testing was done in 140,602 patients in colon, small intestine and rectal cancers among all GI cancers. MSI testing increased significantly during this study period (11,400 in 2010; 15,021 in 2011; 17,968 in 2012; 20,810 in 2013; 21,973 in 2014; 25,012 in 2015; 28,418 in 2016). We identified a total of 120,349 patients with MSI status reported, among these three tumor types, most commonly among colon followed by rectal and then small intestinal cancers. Overall 111,694 (92.8%) were MSS/MSI-low and 8,655 were MSI-H (7.2%). Among patients with reported MSI status, 52.1% were males and 47.9% were females. The mean age was 64.4 years. Most patients were whites (87.6%) and had insurance (96.8%), no existing comorbidities (70.4%), and grade 2 (70.8%) and AJCC Clinical Stage 4 (26.1%) GI cancer. A higher proportion of GI cancer patients with MSS/MSI-low utilized chemotherapy as first course compared to those with MSI high (48.2% vs 34.0%) whereas a lower proportion of GI cancer patients with MSS/MSI-low underwent a surgical procedure compared to those with MSI high (94.7% vs 97.1%). MSI status was reported most frequently in comprehensive community cancer program (40.3%) and academic center (34.8%), followed by integrated network cancer program (16.8%) and Community Cancer program (8.1%). Conclusions: The utilization of MSI testing has increased significantly between 2010 and 2016. Among all GI cancer patients, MSI status was most frequently reported in colon, rectum and small intestinal cancers. Comprehensive community cancer centers and academic centers reported MSI status more frequently than Integrated Network Cancer program and Community Cancer program.

Is Breast Involvement in Marginal Zone Lymphoma Associated with Worse Outcomes? a Nationwide Analysis

Background Marginal zone lymphoma (MZL) is the second most common indolent non-Hodgkin's lymphoma (NHL). It accounts for 6% of all B-cell lymphomas. Several MZL subtypes are recognized in the World Health Organization classification with the following rates :70% Extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT lymphoma), 10% splenic MZL and 20% nodal MZL. MZL involving the breast, is a rare occurrence, it constitutes 1.7-2.2% of all extranodal NHLs and 0.04-0.5% of all malignant neoplasms of the breast (P L Cohen, 1991) and (M Vasei, 1997). Involvement of the breast by a primary lymphoma like DLBCL portends a more aggressive behavior but data is lacking in indolent lymphomas like MZL. We assume that patients with EMZL involving the breast will require earlier treatment compared with nodal MZL. In this population-based analysis we intend to examine this theory and investigate predictors of breast involvement in MZL and its outcomes. Methods We conducted a retrospective cohort analysis using de-identified data accessed from NCDB. The NCDB provided records of 17,198 patients diagnosed with nodal MZL and 1250 patients diagnosed with EMZL involving the breast between 2004 and 2016. We excluded patients without histologic or cytologic confirmation of the diagnosis. We also excluded patients who received treatment outside the reporting facility and patients missing survival data. Exploratory analysis of the patient groups was performed. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Chi square test was used to compare categorical variables and t-test was used to compare means. Multivariate regression models were used to analyze the predictors of breast involvement and survival. Results We identified 11,130 patients with nodal MZL and 769 patients with EMZL involving the breast. The median age was 68 (IQR 58-77), there were 56.5% females. Majority of the patients were non-Hispanic whites (85.9%), had a government insurance (58.5%), had comorbidity score of 0 (78.6%), belonged to a metropolitan area (86.2%), and were treated at a comprehensive community cancer centers or academic programs (79.1% combined). Black race, receiving treatment in a comprehensive community cancer center, and having insurance were associated with more breast involvement of MZL. While younger age was associated with less breast involvement. Median follow up was 9.1 years (IQR 8.8-9.5). Black race was associated with worse survival (HR 1.1, 95CI 1.0-1.3, p 0.004). Receiving treatment in a comprehensive community cancer center (HR 0.84, 95CI 0.76-0.93, p ≤ 0.01), older age (HR 0.996, 95CI 0.993-0.999, p 0.003), and living in an urban area (HR 0.92, 95CI 0.84-0.99, p 0.03) were associated with better survival. Breast involvement did not affect survival (HR 1.02, 95CI 0.93-1.12, p 0.71). The average days to start treatment in patients with EMZL involving the breast was 48 compared with 37 in nodal MZL (p ≤0.01). Conclusion Our study highlights clinical and socioeconomic predictors of breast involvement in MZL. Breast involvement in the whole cohort was not associated with worse clinical outcomes and our data does not suggest a different treatment approach for this patient population. Although, African American patients tend to have more breast involvement in MZL and it was associated with decreased survival. Our study is limited by its retrospective nature and its inherent selection bias, adjustment for baseline characteristics using univariate and multivariate analyses was used to mitigate this bias.

Disparities in Breast-Conserving Therapy vs. Mastectomy among Asian American and Pacific Islander Women

Multiple randomized trials support the use of breast-conserving therapy (BCT), defined as lumpectomy followed by adjuvant radiotherapy, as an alternative to mastectomy for definitive treatment of early-stage (T1-2N0) breast cancer. However, data suggest that Asian American, Native Hawaiian, and Pacific Islander (AANHPI) may undergo mastectomy at higher rates than BCT and may experience barriers to receipt of BCT. The purpose of this study was to examine BCT utilization by disaggregated AANHPI groups to identify differences in receipt of mastectomy versus BCT. The 2004-2017 National Cancer Database was queried to identify women age ≥18 years old diagnosed with cT1-2N0M0 breast cancer treated with either BCT or mastectomy without post-mastectomy radiation therapy. Women were classified based on self-reported race. Multivariable logistic regression defined adjusted odds ratios (OR) assessing the association between race and receipt of BCT versus mastectomy for all patients and separately by cT1-2 stage. All models were adjusted for relevant sociodemographic and clinical factors. Of 794,403 women with cT1-2N0M0 breast cancer, 239,801 (30%) received mastectomy and 554,602 (70%) received BCT. After adjusting for clinical and sociodemographic factors, AANHPI women had greater odds of receiving mastectomy over BCT, compared to White women (OR [95% CI], 1.35 [1.30-1.39]; p<0.001). In contrast, Black women were less likely than White women to receive mastectomy (0.86 [0.84-0.87]; p<0.001). Upon disaggregation, Chinese, Japanese, Filipino, Korean, Vietnamese, and Asian Indian & Pakistani women were more likely to receive mastectomy over BCT compared to White women (p<0.001 for all). Treatment at academic (1.30 [1.27-1.32]), integrated (1.24 [1.21-1.27]), and comprehensive community cancer centers (1.15 [1.13-1.17]) were all associated with greater odds of mastectomy compared to treatment at community cancer programs (all p<0.001). Greater distance from treatment facility (≥50 mi. vs. 0 to <10 mi. [reference], OR 1.50 [1.47-1.53]) and cT2 disease (1.85 [1.82-1.87]) were also associated with greater odds of receiving mastectomy (all p<0.001). In this evaluation of women with early-stage breast cancer, women from several AANHPI groups were more likely to receive mastectomy (as opposed to BCT) compared to White women. While sociocultural preferences, differences in access to and interest in reconstruction, as well as prevalent tumor-to-breast ratios may partially explain the disparities, collectively our data suggest an ongoing need for greater patient involvement in shared-decision making, particularly in vulnerable and understudied Asian populations.

Hospital facility characteristics and socioeconomic factors on outcomes and treatment in patients with multiple myeloma: National Cancer Database analysis.

Previous studies have shown that socioeconomic factors play an important role in multiple myeloma (MM) health outcomes. We postulated that the type of treatment facilities and their volume of cases also affect overall survival, utilization of various therapies including palliative care services in newly diagnosed MM. Using the National Cancer Database (NCDB), we analyzed 174,551 newly diagnosed MM participants from across the country. We found that at high volume facility centers (over 90th percentile of new patient volume from 2004 to 2016), the median overall survival (OS) was 62.3 months versus 35.3 months at lower volume facilities (p <0.001). Similarly, high volume academic cancer centers had an improved median OS of 66.4 months (65.3-67.4 CI) versus 39.2 months (37.9-40.4 months CI) in lower volume academic centers (p <0.001). The odds of utilizing chemotherapy, immunotherapy, and autologous transplants were higher in academic cancer centers compared to community cancer centers, after adjusting for demographic and socioeconomic factors (OR 1.10, 1.23, and 2.06 respectively, all with p<0.001). There was significantly decreased odds of receiving palliative care (OR 0.89, 95% CI 0.85-0.93) in high volume facilities compared to low volume. Palliative care services were more frequently utilized at integrated network cancers and comprehensive community cancer centers compared to community cancer centers, with similar odds of receiving palliative care between community and academic facility types. Our results likely reflect increased provider experience and resources in higher volume and academic facilities. This highlights the need to integrate resources and improve access to community programs.

Predicting Survivorship Appointment Nonattendance in a Community Cancer Center: A Machine-Learning Approach.

Understanding and predicting cancer survivors' health care utilization is critical to promote quality care. The consultative system of survivorship care uses a onetime consultative appointment to transition patients from active treatment into survivorship follow-up care. Knowledge of attributes associated with nonattendance at this essential appointment is needed. An ability to predict patients with a likelihood of nonattendance would be of value to practitioners. Unfortunately, traditional data modeling techniques may not be useful in working with large numbers of variables from electronic medical record platforms. A variety of machine-learning algorithms were used to develop a model for predicting 843 survivors' nonattendance at a comprehensive community cancer center in the southeastern United States. A parsimonious model resulted in a k-fold classification accuracy of 67.3% and included three variables. Practitioners may be able to increase utilization of follow-up care among survivors by knowing which patient groups are more likely to be survivorship appointment nonattenders.

A National Cancer Disparities Analysis of Pacific Islanders Who Decline Radiation Therapy and Impacts on Overall Survival

<h3>Purpose/Objective(s)</h3> Native Hawaiians and Other Pacific Islanders (NHPI) face significant cancer health disparities. Declining cancer treatment is complex and associated with inferior outcomes. Understanding populations that decline radiation therapy (RT) may provide insight into improving cancer disparities. We investigated 1) whether NHPI decline RT at higher rates than other races, 2) the impact of declining RT on overall survival (OS), and 3) the factors associated with declining RT. <h3>Materials/Methods</h3> A retrospective cohort study of the National Cancer Database was conducted using a US hospital-based population including patients ≥18 years old with diagnostically confirmed lung, breast, prostate, rectal, liver, or endometrial cancer, diagnosed between 2004-2017. All patients were offered cancer RT. Declining treatment was defined as RT "recommended by the patient's physician, but was refused by the patient, the patient's family member, or the patient's guardian." Binomial logistic regression compared patients who declined RT versus accepted RT reported as odds ratios (OR) with 95% confidence intervals (95%CI). Cox proportional hazard models assessed OS with hazards ratios (HR). Analyses were adjusted for patient factors (age, urban/rural, income, education, comorbidities) and cancer characteristics (stage, pathology, treatment facility). A P<.05 threshold was used for co-variable selection into multivariable models. <h3>Results</h3> Of 5,229,314 patients eligible, 2,441,471 patients had a documented recommendation for RT. Median follow-up was 55 months. Patients were most often female (67%), white (84%), from metropolitan areas (84%), and insured by Medicare/Medicaid (52%). Cancer types included breast (53%), lung (19%), prostate (18%), rectal (5%), endometrial (4%), and liver (<1%) cancers, of which most (72%) were early-stage disease. 120,291 patients (5%) were documented as declining RT. Compared to white patients, the racial group with the highest risk for declining RT was NHPI (adjusted OR [aOR]=1.52, 95%CI=1.35-1.72), Table. Declining RT among NHPI was associated with poor OS (adjusted HR [aHR]=1.58, 95%CI=1.28-1.95), compared to NHPI patients who accepted RT. Factors associated with NHPI declining RT included patient age (aOR=1.04 per year, 95%CI=1.02-1.05), having any co-morbidities (aOR=1.62, 95%CI=1.28-2.05), breast cancer (aOR=1.82, 95%CI=1.2-2.85), and treatment at either a comprehensive community cancer center (aOR=1.55, 95%CI=1.20-2.01) or an integrated cancer center (aOR=1.89, 95%CI=1.30-2.72). <h3>Conclusion</h3> NHPI patients who decline RT have poor survival outcomes. Understanding NHPI patient perspectives and perceptions may elucidate interventions to mitigate these disparities. Investigating the intersection of culture and healthcare perceptions among NHPI patients is warranted.

Trends in IMRT Utilization for Definitive Treatment of Cervical Cancer, 2004-2018

<h3>Purpose/Objective(s)</h3> Intensity-modulated radiation therapy (IMRT) is an advanced radiotherapy technique that delivers conformal radiation to desired targets while minimizing dose to surrounding organs at risk. In the post-operative setting, IMRT is associated with reduced acute and late genitourinary and gastrointestinal side effects for patients with cervical cancer. However, no prospective randomized data exist for the use of IMRT in the setting of definitive treatment of intact cervical cancer. The objective of this study was to identify trends in IMRT use for this population. <h3>Materials/Methods</h3> Patients with stage IB2-IVA cervical cancer diagnosed from 2004-2018 who were treated with curative intent chemoradiation were identified in the National Cancer Database. Patients who underwent primary surgical management, did not receive external beam radiation to the pelvis or received radiation outside the pelvis, or received an unspecified technique or target of radiation were excluded. The primary outcome of interest was utilization of IMRT vs 3D conformal radiotherapy (3D-CRT) over time. A Cochrane-Armitage test was performed to assess trends over time. T-tests, chi-square tests, and multivariable logistic regression with propensity score matching were used to identify factors associated with receipt of IMRT. <h3>Results</h3> Overall, 13,974 patients met inclusion criteria; 4,590 (33%) received IMRT, and 9,384 (67%) received 3DCRT. In this cohort, 65% were non-Hispanic White, 45% were early stage (I-II), 80% were squamous histology, 62% received brachytherapy, and 28% had lymph node involvement. The utilization of IMRT increased from 30% in 2004 to 71% in 2018 (p<0.001). After adjustment for clinical and demographic variables, factors associated with IMRT use were: Hispanic ethnicity (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.0-1.5), treatment in the Western U.S. (aOR 1.4, CI 1.2-1.7) and the Southern U.S. (aOR 1.3, CI 1.1-1.5), living more than 50 miles from the treatment facility (aOR 1.2, CI 1.0-1.5), stage III disease (aOR 1.3, CI 1.1-1.5), and lymph node involvement (aOR 1.4, CI 1.3-1.6). Compared to an academic medical center, patients receiving care at a comprehensive community cancer center were less likely to receive IMRT (aOR 0.66, CI 0.59-0.72). There were no differences in IMRT use by age, insurance, or medical comorbidities. <h3>Conclusion</h3> Despite the lack of prospective efficacy data supporting the use of IMRT in patients with intact cervical cancer, IMRT has dramatically increased over the last fifteen years especially for patients with advanced-stage disease or lymph node involvement. More data on the optimal use of IMRT, including appropriate target volume margins and on-board imaging, are needed.

Oncology Nurse Navigator Effect on Emergency Department Visits and Hospital Admissions of Adults With Cancer Post-Outpatient Chemotherapy.

To examine the effect of oncology nurse navigators (ONNs) on the number of emergency department (ED) visits and hospital admissions (HAs) of adults with cancer post-outpatient chemotherapy. 1,370 patients with cancer between January 1, 2018, and December 31, 2019, in a comprehensive community cancer center in southern California. A descriptive cross-sectional study was conducted using retrospective electronic health records. Primary analysis included bivariate and multiple linear regression to identify correlates of ED visits and HAs in terms of ONN involvement. About 35% of patients had an ED visit or HA. Anemia, dehydration, and pain were common diagnoses. No significant differences were found in ED visits and HAs by ONN group. Medicare and chemotherapy administration location contributed to the likelihood of ED visits; nausea, pain, and pneumonia contributed to the likelihood of HAs. ED visits and HAs are not appropriate clinical outcomes to measure ONNs' efficacy. Further research is needed to understand the long-term fiscal and operational outcomes of ONNs.

Trends in palliative care interventions for stage IV esophageal cancer: An analysis of the NCDB.

e24104 Background: Palliative care (PC) addresses patient quality of life and satisfaction with care. Oncological PC can be manifested through surgery, radiation, chemotherapy, and pain management. These treatments do not cure disease but improve quality of life. The survival rate for stage IV esophageal cancer is 15-20%, making it an excellent candidate for PC. This study will analyze patterns in who received each type of PC. Methods: This study looked at 8808 patients with stage IV esophageal cancer who received PC interventions from 2004-2018 in the National Cancer Database (NCDB). The NCDB listed 4 types of PC: surgical, radiation, chemotherapy/hormone therapy, and pain management. All modalities were to “alleviate symptoms, but no attempt to diagnose, stage, or treat the primary tumor is made.” Exclusion criteria was concurrent tumors and missing data. Histology subgroups were divided into adenocarcinoma, squamous cell carcinoma, and other, based on ICD-O-3 coding. Cross tabulation analysis was performed using Pearson chi-square and ANOVA tests. Kaplan Meyer curves with log-rank analysis were used to determine survival probabilities. Results: Of PC interventions, 9.0% were surgical, 42.5% radiation, 41.1% chemotherapy, and 7.4% pain management with no other treatment. From 2004-2018 pain management increased 380% and chemotherapy increased 250%. Radiation increased 32%, and surgical decreased 39%. Surgical patients were more often male (79.9%), white (87.4%), non-Hispanic (97.3%), treated at an academic/research program (39.6%), and have a mean survival of 8.6 months. The most common surgical interventions were photodynamic therapy and esophagectomy with partial gastrectomy. Radiation patients more often male (82.3%), white (83.9%), non-Hispanic (96.5%), treated at a comprehensive community cancer center (39.7%), and have a mean survival of 9.1 months. Most common phase I radiation treatments were external beams (photons) and external beams NOS. Chemotherapy patients were more likely to be male (84.5%), white (88.2%), non-Hispanic (96.8%), treated at a comprehensive community cancer program (39.4%), and have a mean survival of 13.9 months. Chemotherapy patients most often received multiagent chemotherapy and single agent chemotherapy. Pain management patients were more often male (80.2%), white (88.0%), non-Hispanic (96.5%), treated at an academic/research program (38.8%), and have a mean survival of 4.1 months. Chemotherapy patients had average age of 62, while all other interventions had an average age of 65 (p &lt; 0.001). Conclusions: Major differences between subtypes of PC interventions included location of treatment, average age at diagnosis, and mean survival. Chemotherapy patients were diagnosed younger and had a longer mean survival time. Pain management patients had the lowest mean survival time. This data can be utilized as PC utilization increases in the United States.

Off study utilization of an unpublished trial regimen: A real-world analysis of GOG258-eligible cohorts.

e18763 Background: Practice patterns in the management of advanced endometrial cancer are widely variable and treatment paradigms are rapidly changing given the evolving clinical trial landscape. Prior studies have demonstrated “medical reversals” where clinicians favor or utilize the experimental approach only to find inferiority on publication of results. The objective of this study was to examine the utilization of the GOG 258 arms-- (adjuvant chemotherapy (CT) vs chemoradiotherapy (CRT)-- for patients with advanced or high-risk endometrial cancer. Methods: Patients 18 years or older who underwent staging surgery with stage III/IVA endometrial carcinoma of any histology or stage I/II clear cell or serous histologies with positive washings diagnosed between 2004 and 2018 were identified in the National Cancer Database. Utilization of adjuvant CT and CRT were examined in the pre-GOG 258 era (before 2009), during GOG 258 enrollment (2010-2017), and after publication of results (2018). Two-sided Cochrane-Armitage test assessed trends over time. T-test and chi-square tests assessed differences in groups receiving CT alone vs CRT. Multivariable logistic regression assessed factors associated with receipt of CRT. Propensity score matching accounted for baseline differences in groups receiving CT vs CRT. Results: 40,028 patients were included. 16,342 (41%) received adjuvant CT and 23,686 (59%) received adjuvant CRT. The majority of patients (39,185, 98%) were advanced stage and 19,616 (49%) were endometrioid histology. 90% of patients receiving both CT and CRT received multiagent therapy. Utilization of CRT was 54% before GOG 258 opening, 60% during GOG 258 enrollment, and 67% after publication of results (p &lt; 0.001). Factors associated with receipt of CT alone were age greater than 70 (adjusted odds ratio [aOR] 0.68, 95% confidence interval [CI] 0.46-0.99), non-Hispanic Black race (aOR 0.84, CI 0.77-0.92), serous and clear cell histologies (aOR 0.68, CI 0.59-0.77; aOR 0.74, CI 0.57-0.95), living greater than 50 miles from treatment facility (aOR 0.84, CI 0.77-0.92), and receiving care in the Midwest, South, and West regions (aOR 0.84, CI 0.78-0.90; aOR 0.69, CI 0.64-0.76; aOR 0.72, CI 0.66-0.78). Compared to an academic medical center, receiving care at a comprehensive community cancer center was associated with receipt of CRT (aOR 1.2, CI 1.2-1.3). Compared to pre-GOG 258 opening in 2009, patients were more likely to receive CRT during GOG 258 enrollment (aOR 1.2, CI 1.1-1.3) and immediately after results announcement in 2018 (aOR 1.7, CI 1.5-1.8), despite results showing that CRT was not associated with longer relapse-free or overall survival. Conclusions: For patients with advanced endometrial cancer, there was significant use of both study arms with increases in CRT use during the study enrollment period and immediately after reporting of GOG 258 results, despite lack of benefit in the CRT arm.

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study

ObjectiveTo determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.MethodsA retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31,...

Safe and Appropriate Minimally Invasive and Robotic Esophagectomy in a Community Cancer Center.

Minimally invasive esophagectomy is a technically challenging procedure that been associated with better outcomes at high-volume tertiary care centers. Louisiana is one of the most impoverished states, and travel to a "destination center" is not an option for many patients. We hypothesize that patients can obtain excellent surgical outcomes following MIE in a comprehensive community cancer center. We identified all patients who underwent totally robotic MIE by a single surgeon at our center from July 2018 to November 2020. All cases were performed using totally robotic Ivor Lewis technique with intrathoracic isoperistaltic esophagogastrostomy. Incidence, demographics, treatment, and outcomes were compared before and after first 10 cases using Student's t-test. We identified 21 patients: 16 male and 5 female. Mean age 65 (49-85). 19 patients underwent MIE for malignancy; 18 of these received neoadjuvant therapy. OR time decreased following the first 10 cases (502 vs. 408 minutes, P = 0.0127). Average lymph node harvest was 14 (4-23 nodes). Positive margin rate was 0%. Mean length of stay trended towards a decrease after the first 10 cases (11 vs. 9days, P = NS). There were no leaks or strictures. Thirty-day readmission was five patients. Ninety-day mortality was 0%. These outcomes rival those of high-volume referral centers and demonstrate that totally robotic MIE can be performed with excellent outcomes in community center. These data call into question the need for all patients to travel to "destination centers" to receive complex oncologic surgery.

Poor Outcomes of Older Adults with Acute Promyelocytic Leukemia (APL) Regardless of Insurance Types

IntroductionPrior studies report multiple factors, including insurance status, as significant barriers to healthcare access in the United States. Barriers to healthcare access may lead to worse outcomes in APL, which requires timely diagnosis and prompt treatment. We performed a large database analysis to examine the effects of insurance type and other factors on one-month mortality and overall survival (OS) in patients ≥65 years of age with APL.MethodsWe aimed to compare one-month mortality and OS of patients on private insurance with patients on non-private insurance, which included Medicare, Medicaid, and other government insurance. Patients ≥65 years of age who were diagnosed with APL between 2004-2015 were identified from the National Cancer Database (NCDB). Multiple regression analysis was used to evaluate the effects of insurance type on the probability of one-month mortality. The Kaplan-Meier method estimated overall survival (OS), which was defined as the time from APL diagnosis to last contact or death from any cause. We used Cox regression model to determine the effects of insurance type on mortality risk adjusting for the other covariates of interest.ResultsWe analyzed a total of 1520 patients- either private (12%) or non-private (88%), which included Medicare (85%), Medicaid (2%), and other government insurance (1%). Among total patients, 60% were 65-74 years of age, 46% were female, 87% were white, 84% had Charlson-Deyo comorbidity index (CCI) of 0 or 1, and 52% were treated at academic centers.One-month mortality was 18% for patients with private insurance and 23% for patients with non-private insurance. In a multivariate regression analysis, insurance type did not affect one-month mortality (Table 1). One-month mortality was higher for older patients; patients ≥75 years of age were more likely to die at one month compared to patients 65-74 years (Odds ratio [OR] 1.98, 95% confidence interval [CI] 1.53-2.57, p<0.0001). Compared to patients with CCI of 0, patients with CCI of 1 (OR 1.91, 95% CI 1.43-2.55, p<0.0001), CCI 2 (OR 1.68, 95% CI 1.10-2.56, p=0.01), and CCI ≥3 (OR 2.88, 95% CI 1.75-4.73, p<0.0001) had worse one-month mortality. One-month mortality was higher for patients treated at comprehensive community cancer center compared to those treated at academic cancer center.Median follow-up for surviving patients was 4.5 years (0.03-13.72). Three-year OS was 56% for private insurance and 50% for non-private insurance (Table 2, Figure 1). In Cox proportional hazard model, there was no statistically significant difference in OS based on insurance type. (Table 3). OS did decrease with increasing age. Compared to patients 65-74 years of age, the likelihood of death was higher for patients ≥75 years (Hazard ratio [HR] 1.80, 95% CI 1.57-2.07, p><0.001). OS decreased with increasing comorbidities: HR 1.31 (95% CI 1.12-1.54, p=0.0007) for CCI 1, HR 1.60 (95% CI 1.28-1.99, p<0.0001) for CCI 2, and HR 1.80 (95% CI 1.37-2.37, p<0.0001) for CCI ≥3 compared to patients with CCI of 0. OS was lower for patients treated at comprehensive community cancer center compared to those treated at academic cancer center. Higher income status and diagnosis after 2009 were associated with improved OS.ConclusionIn our large database analysis, while insurance types were not associated with mortality in patients ≥65 years of age with APL, one-month mortality (about 20%) still remains high and only half of older adults are alive at 3 years. Our study highlights a significant effect of increasing age on mortality even among older adults, with approximately 2-fold higher risk of mortality among patients ≥75 years versus those 65-74 years. Other factors associated with higher mortality included treatment outside of academic centers and lower income status. Unlike younger adults, APL in older adults still has significant unmet need. [Display omitted] DisclosuresGundabolu: Bristol-Myers Squibb Company: Consultancy; Blueprint Medicines: Consultancy; Pfizer: Research Funding; Samus Therapeutics: Research Funding; BioMarin Pharmaceuticals: Consultancy. Bhatt: Servier Pharmaceuticals LLC: Consultancy; Partnership for health analytic research, LLC: Consultancy; Abbvie: Consultancy, Research Funding; Jazz: Research Funding; Incyte: Consultancy, Research Funding; Pfizer: Research Funding; Tolero Pharmaceuticals, Inc: Research Funding; National Marrow Donor Program: Research Funding; Abbvie: Consultancy, Research Funding; Genentech: Consultancy; Rigel: Consultancy.

Disparity in Utilization of Multiagent Therapy for Acute Promyelocytic Leukemia in the United States

BackgroundDespite high rate of cure in acute promyelocytic leukemia (APL) in clinical trials, outcomes in real-world practice are dismal. We utilized National Cancer Database (NCDB) to explore utilization of multiagent therapy in APL and identify any disparities in treatment in real-world practices. Patients and MethodsNCDB categorizes use of systemic chemotherapy into single agent versus multiagent therapy. Some patients received hormonal therapy, immunotherapy, and unknown therapy; details of these treatments could not be ascertained. We therefore used multiple logistic regression analysis to evaluate effects of covariates on the probability of multiagent therapy use in 6678 patients. ResultsCompared to patients >60 years, patients aged 0 to 18 years (hazard ratio[HR] 3.2, 95% confidence interval [CI] 1.8-5.5, P< .0001), 19 to 40 years (HR 1.6, 95% CI 1.03-2.54, P= .03), and 41 to 60 years (HR 1.6, 95% CI 1.3-1.9, P< .0001) were more likely to receive multiagent therapy. Patients with Charlson comorbidity index (CCI) of 0 (HR 1.6, 95% CI 1.2-2.3, P= .001) and CCI of 1 (HR 1.4, 95% CI 1.0-1.9, P= .04) had a higher likelihood of receiving multiagent therapy than patients with CCI ≥ 3. Patients treated at academic cancer centers, compared to those treated at community cancer center (HR 0.5, 95% CI 0.3-0.7, P= .001), comprehensive community cancer center (HR 0.7, 95% CI 0.6-0.8, P< .0001), and integrated network cancer center (HR 0.8, 95% CI 0.6-0.9, P= .02) were more likely to be treated with multiagent therapy. Compared to the patients with private insurance, those with Medicaid had increased likelihood (HR 1.2, 95% CI 1.0-1.4, P= .04) whereas uninsured patients had a lower likelihood of receiving multiagent therapy (HR 0.6, 95% CI 0.5-0.8, P= .0005). ConclusionTo our knowledge, this study is the first and the largest scale analysis of treatment practices in APL in real-world practices. Our findings highlight significant disparities in treatment of APL based on age, insurance, and health-system factors.

Distance traveled to glioblastoma treatment: A measure of the impact of socioeconomic status on survival

BackgroundPrevious studies have shown improved post-surgical outcomes in patients who travel farther for glioblastoma treatment. This study investigates socioeconomic and facility factors that may influence this relationship. MethodsOverall survival was calculated and compared by distance to treatment facility using univariate and multivariate survival models. The analysis was stratified by facility type, income quartile and insurance status and the association re-evaluated. Kaplan-Meier survival curves were created to analyze the relationship between overall survival and distance group. ResultsIndividuals who traveled less than 5 miles to treatment had the shortest overall survival (11.8 months), while those who traveled greater than 50 miles had the longest survival (12.9 months). Stratification by income quartile failed to demonstrate an association between distance traveled and survival for those making less than $63,000 (adjusted hazard ratio range: 0.94–1.01). There was no association between survival and distance traveled for patients treated at a community cancer center, comprehensive community cancer center or an integrated network cancer program (adjusted hazard ratio range: 0.86–1.04). ConclusionFinancial strain, rather than distance traveled to treatment, may be associated with glioblastoma survival.

Disparity in utilization of multiagent therapy for acute promyelocytic leukemia (APL): A large National Cancer Database (NCDB) analysis.

6587 Background: Clinical trials have demonstrated a high rate of cure in APL with the use of multiagent therapy; however, overall survival in real world practice is significantly lower than that in the trials (Blood 2020; 136 (s 1): 13-14). We performed a large NCDB analysis to determine the appropriateness of treatment as a possible explanation for worse survival outside of the clinical trials. Methods: We included a total of 7190 APL cases reported to NCDB between 2004-2015. Multiple logistic regression analysis was used to evaluate the effect of covariates on probability of multiagent therapy use. Results: Only 64% of total patients received multiagent therapy; 29% received singe agent therapy and 4% received unknown therapy. 3% (n = 207) did not receive any treatment for reasons including early death (n = 8), patient refusal (n = 15), perceived contraindication (n = 12) and unknown reasons (n = 182). Compared to patients &gt; 60 years, younger patients aged 0-18 years (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.8-5.5, p &lt; 0.001), 19-40 years (HR 1.6, 95% CI 1.03-2.54, p = 0.03) and 41-60 years (HR 1.6, 95% CI 1.3-1.9, p &lt; 0.001) were more likely to receive multiagent chemotherapy. Patients with Medicaid were more likely to receive multiagent therapy compared to those with private insurance (HR 1.2, 95% CI 1.01-1.42, p = 0.04), possibly because patients with Medicaid are younger. The likelihood of receiving multiagent therapy decreased in uninsured patients (HR 0.6, 95% CI 0.5-0.8, p &lt; 0.001). Compared to academic cancer centers, patients treated at community cancer center (HR 0.5, 95% CI 0.3-0.7, p = 0.001), comprehensive community cancer center (HR 0.7, 95% CI 0.6-0.8, p &lt; 0.001)) and integrated network cancer center (HR 0.8, 95% CI 0.6-0-0.9, p = 0.01) were less likely to be treated with multiagent therapy. Lower comorbidity index increased the likelihood of receiving multiagent therapy. The likelihood of receiving multiagent therapy was not influenced by sex, race, annual income, distance traveled to treatment facility and high school education. Conclusions: To our knowledge, this is the first large scale analysis of utilization of multiagent therapy in APL in real world practice. In our study, 3% of patients did not receive treatment, a much smaller proportion of patients compared to acute myeloid leukemia, where a quarter to a third of patients do not receive any chemotherapy (Blood Adv; 2018 (2): 1277–1282). However, 29% of APL patients received suboptimal treatment with single agent therapy. The use of single agent therapy was higher in older adults and those with greater comorbidity. About half of the patients were treated outside of academic centers, which was associated with a higher probability of receiving single agent therapy. Uninsured patients were more likely to receive single agent therapy. Our findings highlight disparity based on insurance and health system factors.

Effect of time to surgical intervention in stage 3 cutaneous melanoma.

e21571 Background: Delay in surgical resection has been found to be associated with poorer overall survival (OS) in patients with stage 1 cutaneous melanoma. However, the impact of surgical timing on survival in stage 3 cutaneous melanoma remains unknown, especially in the era of immunotherapy. We sought to evaluate to the effect of time to definitive surgical intervention on OS in stage 3 cutaneous melanoma at Commission on Cancer accredited institutions. Methods: The National Cancer Database (2012-2016) was used to identify patients who underwent biopsy and definitive surgical intervention of cutaneous melanoma. Time to intervention (TTI) was analyzed from the time of initial biopsy to definitive surgical resection and classified into quartiles, (Q1≤22 days; Q2 = 23-33 days; Q3 = 34-49 days; Q4≥50 days) using χ2 and multivariable logistic regression. Survival was analyzed using Kaplan-Meier and Cox proportional hazard models. Results: We analyzed 4560 patients with a median age of 61 years (18-90) and most patients being non-Hispanic white and male (91.6% and 63%, respectively). Median Breslow thickness was 2.8 mm (0-9.8 mm). Median TTI was 33 days (0-352 days) with a mean OS of 52, 49.8, 48.4, 48.3 months for Q1 to Q4 respectively (p = 0.008). Age ≤50 years, treatment at a comprehensive community cancer center and only 1 positive lymph node (LN) were all associated with Q1 TTI (p = 0.002, p &lt; 0.001 and p &lt; 0.001, respectively). Black race, treatment at an academic facility, &gt; 4 LN positive, &gt; 4 mm thickness, and no administration of immunotherapy were all associated with Q4 TTI (p = 0.002, p &lt; 0.0001, p &lt; 0.0001, p &lt; 0.0001 and p &lt; 0.0001 respectively) on univariate analysis. Patients in Q4 TTI were more likely to be older (OR 1.01, 95% CI 1.00-1.02, p = 0.01), have T2-T4 tumors (OR 1.6, 95% CI 1.2-2.2, p &lt; 0.001), and be treated at an academic facility (OR 2.4, 95% CI 1.8-3.5, p &lt; 0.001) on multivariable analysis. In the survival analysis, multiple positive LNs (2, 3-4, &gt; 4 LNs; HR 1.4, 1.6 and 2.9, p &lt; 0.001), lymphovascular invasion (HR 1.4, p &lt; 0.001), Breslow thickness &gt; 4 mm (HR 1.7, p &lt; 0.001), Charlson-Deyo score ≥2 (HR 1.5, p &lt; 0.001), increasing age (HR 1.03, p &lt; 0.001), and longer TTI (Q3-Q4) (HR 1.2, p = 0.001) were all associated with worse OS. There was no difference in survival based on TTI in patients who had received adjuvant immunotherapy in Q1-Q2 vs Q3-Q4 (p = 0.3). Conclusions: In stage 3 cutaneous melanoma, longer TTI ( &gt; 33 days) was associated with worse OS but may be due to older age, higher T stage, and barriers to access. However, adjuvant immunotherapy may offer protection from delays in definitive surgery.