Comprehensive Community Cancer Center Research Articles

Abstract P4-19-05: Efficacy of screening and treatment of breast cancer patients reporting high level of distress

Abstract Background: Cancer patients (pts) are burdened by symptoms related to the disease itself or to the toxicities of treatment. A recent meta-analysis has shown that anxiety is the most common mental health issue among cancer survivors [Mitchell AJ, 2013]. The ASCO clinical oncology guideline adaptation recommends all health care providers routinely screen for the presence of emotional distress and symptoms of anxiety from the point of diagnosis onward [Andersen BL, 2014]. Consensus-based recommendations have been published to help cancer centers meet the American College of Surgeons Commission on Cancer's accreditation requirement to screen for distress [Pirl, 2014] At our comprehensive community cancer center we perform distress screening using the M.D. Anderson Symptom Inventory (MDASI), composed of 27 questions. Pts who report moderate and severe levels of distress (≥5) on the MDASI are identified and referred for therapeutic interventions offered by the facility's integrative oncology services. Materials and Methods: The MDASI is an assessment tool that captures pts' perceived symptom burden for real-time clinical intervention, taken at the point of no intervention (baseline) and every 21 days or greater. The 27-question MDASI is comprised of the M.D. Anderson Symptom Inventory (MDASI), a validated 19-item assessment instrument, with a Symptom Inventory Tool (SIT) added by our center of 8 questions and a free-text box. Symptoms are rated “at the worst” on an 11-point numeric scale ranging from 0 (“none present”) to 10 (“as bad as you can imagine”), as experienced by the patient in the past 24 hours. Results: Over a ten-month period (9/1/2014 to 6/30/2015), 247 breast cancer (BC) pts completed the MDASI at intake and again ≥ 21 days after. Analysis of their initial surveys identified 69 pts (27.9%) who rated their distress as ≥ 5 (1st MDASI mean = 6.83), scores which would have initiated a support system response with referrals to integrative medicine services for intervention. Second MDASI results from these 69 BC pts revealed an average 2.29 distress score reduction (2nd MDASI mean = 4.48), with 51 pts (73.9%) reporting a decrease in distress, 7 pts (10.1%) having no change, and 11 pts (15.9%) reporting increased distress. More specifically, the group with decreased distress levels documented a mean distress score of 3 on their 2nd MDASI, averaging a significant 4-point diminution of distress for three-fourths of the BC pts heavily burdened by this symptom. The integrative services most utilized by these pts were Nutrition Therapy (100%), Spiritual Care (96.1%), Mind-Body Counseling (82.4%), Rehabilitation Therapy (41.2%), Acupuncture (35.3%), and Massage Therapy (35.3%). Conclusions: Distress is a relevant symptom reported by cancer pts. This study demonstrates that early intervention in BC pts using integrative oncology approaches reduced distress in 74% of cases. Citation Format: Daneker SR, Bendinger GM, Thomas JW, Smith E, Kendrick D, Hartman S, Gordon C, Barber K, Langlois C, Pabbathi H, McKnight JE, Johnson AT, Lammersfeld C, Denny D, Markman M, Alvarez RH. Efficacy of screening and treatment of breast cancer patients reporting high level of distress [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-19-05.

Impact of timing of adjuvant chemotherapy initiation on survival in pancreatic adenocarcinoma.

355 Background: Pancreatic adenocarcinoma (PDAC) is now the third leading cause of cancer death. Surgical resection followed by adjuvant chemotherapy has been the standard of care. Due to the significant risk of morbidity following pancreatic surgery, initiation of adjuvant chemotherapy is often delayed. Prior prospective adjuvant trials have suggested that adjuvant therapy can be initiated as late as 12 weeks without detriment, but data regarding the effectiveness of beginning adjuvant therapy beyond that time remains unknown. Methods: We retrospectivelyreviewed data from the National Cancer Data Base (2004-2014) and included adult patients (pts) with PDAC with pathologic stage I-IIB who underwent surgical resection with curative intent. The primary outcome was overall survival (OS) based on time to adjuvant chemotherapy post-surgery as defined by postoperative weeks. Data were analyzed using Cox proportional hazard model and Kaplan-Meier survival curves. Results: 5279 pts. had surgery alone and 4,537 pts. received adjuvant chemotherapy. The median age was 64 years. 52% were male, 88% were white, 46% were treated at comprehensive community cancer centers. The primary surgical approach was whipple procedure in 61% of pts. 63% pts. received single agent chemotherapy and the mean time from surgery to chemotherapy was 61 days. Adjuvant chemotherapy was associated with improved OS irrespective of disease stage compared to those undergoing surgery alone (median OS for surgery alone 14 months vs adjuvant chemotherapy 21 months, p < 0.001). Cox proportional hazard model controlling for stage, surgical technique, lymph node dissection and margin status revealed improved OS in pts. receiving adjuvant chemotherapy. No significant differences in OS were seen for pts. starting adjuvant chemotherapy at 3, 6, 9, 12, 16, 20 or 24 weeks after surgical resection. Conclusions: Current guidelines recommend initiation of adjuvant chemotherapy prior to 12 weeks after pancreatic resection. Initiating adjuvant chemotherapy even up to six months post-operatively improves OS compared to those undergoing surgery alone. Our data supports the use of adjuvant chemotherapy if indicated regardless of time of surgery.

Disparities in standard of care treatment and associated survival decrement in patients with locally advanced cervical cancer

PurposeStandard of care (SOC) treatment for locally advanced cervical cancer includes pelvic external beam radiation (EBRT) with chemotherapy and interdigitated brachytherapy. We evaluated national utilization trends and factors associated with receiving SOC therapy. Materials and methodsWe utilized the National Cancer Database (NCDB) to identify women with locally advanced cervical cancer treated with definitive radiation or chemoradiation therapy and stratified these patients by treatment received. ResultsWe identified 15,194 patients. Only 44.3% of patients received SOC treatment and this group had significantly improved OS. High volume centers, academic centers, comprehensive community cancer centers, private insurance, and higher income, were all associated with an increased likelihood of receiving SOC, whereas Black patients were less likely to receive SOC. We found 26.8% of patients received no radiation boost, 23.8% received an EBRT boost only, and 49.5% of patients received EBRT with brachytherapy. Although an EBRT boost was advantageous over no boost at all (HR 0.720, p<0.001), OS was superior in patients who received brachytherapy (HR 0.554, p<0.001). Patients were more likely to receive no radiotherapy boost if they had lower incomes, Medicaid, were treated at low volume centers, or were treated at non-comprehensive community cancer centers. ConclusionsSOC for locally advanced cervical cancer offers superior outcomes, yet less than half of patients receive SOC and there are disparities in which patients receive SOC treatment. No additional treatment, including sophisticated EBRT techniques including IMRT or SBRT, can make up for the survival decrement from lack of brachytherapy as a component of definitive care.

Patterns of Care and Comparative Effectiveness of Intensified Adjuvant Therapy for Resected Oropharyngeal Squamous Cell Carcinoma in the Human Papillomavirus Era.

There is a growing debate on the relative benefits of adjuvant chemoradiotherapy (CRT) and boost doses of postoperative radiotherapy (B-PORT) in oropharyngeal squamous cell carcinoma (OPSCC) treated with primary surgery, especially for patients with human papillomavirus (HPV)-driven disease. To characterize the recent patterns of care in and overall survival (OS) outcomes following the use of adjuvant CRT and B-PORT after primary surgery for OPSCC. Retrospective analysis of patients in the National Cancer Database with stage III to IVA-B OPSCC treated with surgery and adjuvant radiotherapy between 2010 and 2012 at Commission on Cancer-accredited facilities. The data analysis was performed between June 15, 2015, and May 4, 2016. The primary outcomes were prevalence of CRT and B-PORT, and OS. The primary predictors were HPV positivity and high-risk pathologic features (HRPFs) (extracapsular extension and positive surgical margins). Of the 1409 patients (1153 [82%] male; median age, 57 [interquartile range {IQR}, 51-63] years), 873 (62%) and 789 (56%) patients received CRT and B-PORT, respectively; most patients (n = 583 [79%]) with HRPFs received CRT, and many patients (n = 227 [40%]) without HRPFs received CRT. Multivariable predictors of CRT included adverse pathologic features (extracapsular extension [OR, 6.99; 95% CI, 5.22-9.35], positive surgical margins [OR, 2.07; 95% CI, 1.50-2.87], ≥6 involved nodes [OR, 2.34; 95% CI, 1.39-3.92], or low-neck disease [OR, 1.52; 95% CI, 1.01-2.28]), and treatment at a nonacademic institution (OR, 1.59 [95% CI, 1.21-2.10] for comprehensive community cancer center vs academic program). Patients with HPV-positive disease (OR, 0.47; 95% CI, 0.33-0.68) were less likely to receive CRT; this decrease was limited to absent HRPF treated at academic institutions (n = 173, 44 [25%] received CRT). With a median follow-up of surviving patients of 27 (IQR, 21-33) months, the 2-year OS probability was 92% (95% CI, 90%-94%). Multivariable analysis including age, sex, pathologic T stage, 6 or more positive nodes, and educational status confirmed the prognostic impact of HPV positivity (hazard ratio [HR], 0.41; 95% CI, 0.21-0.80) and HRPFs (positive surgical margins [HR, 2.15; 95% CI, 1.27-3.66] and ≥6 involved nodes [HR, 2.11; 95% CI, 1.13-3.93]), but neither CRT (HR, 1.27; 95% CI, 0.70-2.30) nor B-PORT (HR, 1.04; 95% CI, 0.63-1.73) was associated with improved OS. Postoperative CRT and B-PORT following resection of OPSCC were dependent on factors beyond HRPFs, including HPV status and treatment at an academic institution. No benefit was seen with intensified adjuvant therapy, supporting enrollment of the HPV-positive population into deintensification trials.

Early-Stage Classic Hodgkin Lymphoma: The Utilization of Radiation Therapy and Its Impact on Overall Survival

To examine the association between radiation therapy (RT) utilization and overall survival (OS) for patients with early-stage Hodgkin lymphoma (HL). Using the National Cancer Database, we evaluated clinical features and survival outcomes among patients diagnosed with stage I/II HL from 1998 to 2011. The association between RT use, covariables, and outcome was assessed in a Cox proportional hazards regression model. Propensity score matching was performed to balance observed confounding factors. Survival was estimated using the Kaplan-Meier method. Among the 41,943 patients in the National Cancer Database with stage I/II HL, 29,752 patients were analyzed for this study. Radiation therapy use was associated with younger age (≤40 years), favorable insured status, higher socioeconomic status (income, education), and treatment at comprehensive community cancer centers (all P<.05). Five-year OS for patients receiving RT was 94.5%, versus 88.9% for those not receiving RT (P<.01). Radiation therapy use was a significant predictor of OS in the "As-Treated" cohort (hazard ratio 0.53, 95% confidence interval 0.49-0.58, P<.01) and intention-to-treat analysis (P<.01). After propensity score matching based on clinicopathologic characteristics, RT use remained associated with improved OS (hazard ratio 0.46, 95% confidence interval 0.38-0.56, P<.01). Over the study period, RT utilization for this cohort decreased from 55% to 44%, most commonly because it was not part of the planned initial treatment strategy. Consolidation RT was associated with improved OS for patients with early-stage classic HL. We also have identified patient-specific variations in the use of RT that may be targeted to improve patient access to care.

Abstract P1-15-10: Low utilization of hypofractionated radiotherapy for the treatment of early-stage breast cancer in the US

Abstract Background: Large randomized controlled trials have shown that hypofractionated whole breast irradiation (HF-WBI) is not inferior to or more toxic than conventionally fractionated whole breast irradiation (CF-WBI) for the treatment of early-stage breast cancer. Royal Marsden data were published in 2006 (10-yr), the Ontario trial was reported in 2002 (5-yr) and 2010 (10-yr), and the UK START trials were published in 2006 (5-yr) and 2013 (10-yr). We utilized the National Cancer Data Base (NCDB) to evaluate patterns of radiotherapy fractionation for early-stage, node-negative breast cancer in the U.S. We hypothesized that HF-WBI use would increase over time in response to emerging data supporting its use in this population. Methods: We conducted a retrospective, population-based cohort study of women &amp;gt;18 years diagnosed with T1-2N0 invasive breast carcinoma and treated with breast-conserving surgery between 2004 and 2011. Radiotherapy was categorized as accelerated partial breast irradiation (APBI; 38-40 Gy/1-10 fractions), HF-WBI (40-56 Gy/15-24 fractions) or CF-WBI (50-66 Gy/25-40 fractions). Patients treated with alternate fractionation were excluded. Patterns of breast radiotherapy fractionation were compared using the chi-square test. Multivariable logistic regression was performed for patients diagnosed in 2011, the year with the highest levels of HF-WBI utilization. Results: 217,789 patients in the NCDB met inclusion criteria. HF-WBI use increased over time, rising from 2.1% among eligible patients in 2004 to 15.1% in 2011, while APBI use remained low at &amp;lt;2%. Utilization of HF-WBI was significantly higher in academic centers than comprehensive community cancer centers and community-based cancer centers (p &amp;lt;0.0001). This pattern persisted when controlling for T-stage, hormone receptor/HER2-status, diagnosis year, and patient age &amp;gt;30 years. Table 1 shows frequency of HF-WBI use over time by center type. On multivariate analysis of patients diagnosed in 2011, the following factors were associated with higher use of HF-WBI: treatment at an academic center, older patient age, hormone receptor positivity, pT1 tumor size, and rural residence (Table 2). Table 1: % HF-WBI use Community Cancer CenterComprehensive Community Cancer CenterAcademic Center20040.9%1.7%3.8%20051.6%2.1%3.8%20061.2%2.0%4.6%20071.5%2.8%7.1%20082.9%5.3%10.8%20093.9%8.5%14.7%20105.8%10.7%16.4%20119.6%13.9%20.5% Table 2. Multivariate analysis, year 2011 (n=5568) OR95% CIAcademic Center vs. Community Cancer Center3.062.324.02Academic Center vs. Comprehensive Community Cancer Center1.781.532.08Patient age, 50-90 vs. 18-492.371.863.01T2 vs. T10.540.460.63HER2+ vs. Hormone Receptor +/HER2-0.750.590.97ER-/PR-/HER2- vs. Hormone Receptor +/HER2-0.660.520.84Rural vs. urban2.681.694.24 Conclusions: Utilization of HF-WBI in the US is rising, but remains low overall despite level I evidence showing its non-inferiority to CF-WBI. Given the advantages of HF-WBI in terms of patient convenience and potential healthcare system costs, further research is indicated to explore disparities in HF-WBI utilization in the US and to guide education of breast cancer providers. Citation Format: Yvonne M Mowery, Rachel A Greenup, Kevin Houck, Manisha Palta, Janet K Horton, Eun-Sil S Hwang, Julie A Sosa, Rachel C Blitzblau. Low utilization of hypofractionated radiotherapy for the treatment of early-stage breast cancer in the US [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-10.

MP16-10 EQUITABLE COMMUNITY UTILIZATION OF PARTIAL NEPHRECTOMY NATIONALLY FOR MANAGEMENT OF T1A RENAL TUMORS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2015MP16-10 EQUITABLE COMMUNITY UTILIZATION OF PARTIAL NEPHRECTOMY NATIONALLY FOR MANAGEMENT OF T1A RENAL TUMORS Dhruti Patel and Robert Abouassaly Dhruti PatelDhruti Patel More articles by this author and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.817AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous outcomes research based on the NIS and SEER data has indicated continued underuse of partial nephrectomy as a management strategy for T1a renal masses. Part of this was attributed to the poor diffusion into the community, which we sought to further analyze with the National Cancer Database. METHODS The National Cancer Database captures over seventy percent of newly diagnosed cancer cases in the United States. The national utilization of partial nephrectomy for localized T1a renal masses from 1998 to 2011 was evaluated based on hospital type, either Comprehensive Community Cancer Centers (CCCC) or Academic Cancer Centers (ACC). Only clear cell adenocarcinoma, renal cell carcinoma, papillary adenocarcinoma, chromophobe renal cell carcinoma, sarcomatoid renal cell carcinoma, cystic renal cell carcinoma, and collecting duct renal cell carcinoma were included. Multivariate linear regression and chi-square analyses were performed to evaluate the differences between variables. RESULTS 240,309 cases were identified from 1998 to 2011 with 52% undergoing partial nephrectomy. At both hospital types, utilization of partial nephrectomy annually for T1a renal cancers has statistically significantly (p<0.0001) increased to become the treatment of over half (53%) of all newly diagnosed cases. Based on a multivariate logistic regression, there are a number of factors that affect the utilization of partial nephrectomy. Younger age, white race, private insurance, male gender, hospital type and year all affect the likelihood of partial nephrectomy utilization for T1a tumors. The c statistic for the multivariate linear regression was 0.75. The likelihood of partial nephrectomy is still higher at ACC compared to CCCC (p<0.0001), though a significant number are performed at each hospital type. Both hospital types have similar length of stay, positive surgical margin, 30 day mortality and readmission rates. CONCLUSIONS There has been in a clear shift in the management of T1a renal masses with continued increases in the utilization of partial nephrectomy. This surgical treatment continues to be prevalent in the academic hospital setting and has diffused into the community. This shift may be indicative of the rigorous residency training across the country. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e171 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dhruti Patel More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictors of 30-Day Mortality Following Resection of Early-Stage NSCLC: An Analysis of the National Cancer Database

Predictors of 30-Day Mortality Following Resection of Early-Stage NSCLC: An Analysis of the National Cancer Database

Prevalence and Predictors of Neoadjuvant Therapy for Stage IIIA Non-Small Cell Lung Cancer in the National Cancer Database: Importance of Socioeconomic Status and Treating Institution

The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients. Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classified as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively. The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not. Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.

Leveraging the strengths of an academic health system to improve community cancer care.

218 Background: To improve community cancer care quality, UC Davis Health System formed the UC Davis Cancer Care Network (CCN) to partner with select cancer centers in California to offer leading-edge care close to home. Hospital-based community cancer centers become affiliates of the UC Davis CCN through an evaluation process led by UC Davis. By synergizing the strengths of an academic health system and community-based oncology care, the network formalizes the commitment to collaboration with community providers. Methods: This quality model relies on a central university-based team interacting with affiliate sites to support them in their local missions. Affiliates progress through three phases of development of their cancer program. Each phase adds layers of quality to the organization. CCN staff members coordinate the phases: 1) Review and Develop Operations—site specific structures needed to be a comprehensive community cancer center; 2) Make Connections—within the network and the local community; 3) Become Self-Directed—identifying own needs and direction. The partnership attributes include: joint marketing, system synergies, certification assistance, coordinated service line development, dedicated personnel resources, on-site educational opportunities, and quality oversight. Results: Performance measurement includes: local market share, ACOS accreditation, adherence to national quality and patient satisfaction standards, assessment of community health needs and benefits, and enhancement of local capabilities (inpatient oncology unit, radiation, pathology, radiology, and surgical oncology services). Conclusions: This model demonstrates the benefit of partnering the strengths of an academic health system and community cancer programs to provide quality care.

Patient and Institutional Predictors of Trimodality Therapy for Stage III Non-Small Cell Lung Cancer (NSCLC) in the National Cancer Database

The optimal locoregional therapy for stage III non-small cell lung cancer is controversial, with definitive chemoradiation therapy (CRT) and trimodality therapy (chemoradiation therapy followed by surgery, TMT) serving as competing strategies. Randomized data suggest a progression-free but no overall survival benefit from surgical resection, an ambiguous result that has led to varying practice patterns. Indeed, the implementation of TMT in the United States has not been closely examined. In this study, we used the National Cancer Database (NCDB) to determine predictors of TMT among a large cohort of patients, focusing on the importance of demographic and institutional parameters. Patients with stage III NSCLC treated between 1998 and 2010 at Commission on Cancer-accredited programs were included in this study. Patients must have received concurrent CRT with or without subsequent surgical resection. Demographic, clinical and non-clinical parameters were extracted from the NCDB, and the patient volume of stage III NSCLC (patients treated per site per year) was determined; high-volume center was defined as the upper decile. Per NCDB coding, the type of treatment center was stratified into academic, comprehensive community cancer center (CCC), and non-comprehensive CCC. Logistic regression was used for univariable analyses, and a multivariable model was prepared using stepwise selection. A total of 49,534 patients were included in this cohort, 3,843 (7.8%) of whom underwent TMT. Out of stage 19,002 IIIA patients, 10.3% underwent TMT. Multivariable predictors of TMT included demographic, clinical and non-clinical factors. Demographic factors were: white race (odds ratio [OR] 1.36), younger age (lowest [LQ] vs highest [HQ] quartile, OR 4.31), percent of adults per zip code with at least high school education (HQ vs LQ, OR 1.37). Clinical factors were: stage (IIIA vs IIIB, OR 3.02) and squamous histology (OR 1.26). Non-clinical factors were: early treatment era (first vs last 3 years, OR 1.30), private insurance (OR 1.53), increasing distance from the treatment center (HQ vs LQ, OR 1.81), geographic region (Northeast vs other, OR 1.35), type of center (academic program vs comprehensive CCC or non-comprehensive CCC, OR 1.53 and 2.01, respectively), and treatment at high-volume institutions (OR 1.26). TMT was not commonly implemented across Commission on Cancer accredited programs. White race, level of education and private health insurance – measures often associated with higher socioeconomic status – were statistically significant predictors of TMT. The academic nature and volume of the facility strongly influenced TMT, suggesting more aggressive practice patterns in university-based, high-volume institutions.

Locoregional Small Cell Carcinoma of the Bladder: Clinical Characteristics and Treatment Patterns

Because small cell carcinoma of the bladder is a relatively rare tumor type, literature about its treatment remains limited. We determined patterns of care and survival after treatment in what is to our knowledge the largest series to date of patients with locoregional small cell carcinoma of the bladder. We identified patients with localized/locally advanced (cTis-cT4, cN0 or cM0) bladder small cell carcinoma diagnosed between 1998 and 2010 from the National Cancer Database (NCDB). Treatment was categorized as bladder preservation therapy, radical cystectomy alone, bladder preservation therapy with multimodal treatment or radical cystectomy plus multimodal treatment. We performed Kaplan-Meier overall survival analysis to evaluate differential survival between treatment groups. A total of 625 patients met study inclusion criteria. Median age at diagnosis was 73 years (range 36 to 90) and 65% of patients presented with cT2 disease. Patients were treated with bladder preservation therapy (174 or 27.8%), bladder preservation therapy plus multimodal treatment (333 or 53.3%), radical cystectomy alone (46 or 7.4%) and radical cystectomy plus multimodal treatment (72 or 11.5%) with a 3-year overall survival rate of 23% (95% CI 15-32), 35% (95% CI 30-45), 38% (95% CI 17-60) and 30.1% (95% CI 16-47), respectively. Overall survival was most favorable for radical cystectomy alone plus neoadjuvant chemotherapy with a 3-year rate of 53% (95% CI 19-79). In the United States locoregional small cell carcinoma of the bladder develops predominantly in white males, in whom treatment is performed at metropolitan, comprehensive community cancer centers. Most patients were treated with bladder preservation therapy and most received multimodal therapy. Patients who received neoadjuvant chemotherapy followed by radical cystectomy had the most favorable survival.

Facility Size and Its Influence on the Presentation and Treatment of in Situ Breast Carcinoma in the United States

Studies have suggested that outcomes from breast cancer are improved when treatment is rendered at high-volume teaching centers. The current study was undertaken to examine the impact of facility type on the presentation and treatment of "early" breast carcinoma across the United States. Breast cancer data were available from the American College of Surgeons National Cancer Database. The cohort consisted of 305,358 patients presenting with in situ cancers and no prior treatment from 2000 to 2008. Data were stratified by type of treatment facility, "invasive" versus "noninvasive" nature of the tumor, and treatment performed. Only 15 per cent of patients presented to community cancer centers (CCCs). Despite this, a greater percentage presented with invasive disease at CCCs (82.1%) compared with comprehensive community cancer centers (CCCCs; 80%) or teaching/research facilities (T/Rs; 70.2%). In examining the in situ cohort, a higher percentage of patients at CCCs were treated with breast conservation than at CCCCs or T/Rs. Although small, these differences were statistically significant. These data do not support the contention that only "early" cases of breast cancer present and are treated at community centers. In early breast cancer, patients are as likely to receive state-of-the-art treatment at a CCC as they are at a T/R.

Patterns of regional node irradiation therapy following breast-conserving surgery: Report from the National Cancer Data Base 2003-2007.

1101 Background: A recent randomized trial (MA.20) showed that regional nodal irradiation (RNI) in addition to breast irradiation in high risk node negative and 1-3 node positive patients undergoing breast-conserving therapy (BCT) reduced the risk of recurrence and improved disease-free survival. We investigated the trends of RNI use in the United States and related factors for the use of RNI using the National Cancer Data Base. Methods: This study includes 292,598 stage I-III breast cancer patients without neoadjuvant therapy who underwent BCT from 2003-2007. We investigated pathological, patient, and facility factors related to RNI use, by multivariable logistic regression, with odds ratio (OR) estimations. Results: The proportion of radiotherapy use after BCT slightly declined from 78.6% in 2003 to 75.6% in 2007. The use of breast irradiation plus RNI decreased from 10.8% in 2003 to 8.3% in 2007 (p&lt;0.0001). The number of tumor positive lymph nodes strongly determined the use of additional RNI: 4.4% patients with negative nodes, 22.8% patients with 1-3 nodes, and 39.7% patients with 4 or more nodes received breast irradiation plus RNI after undergoing BCT (p&lt;0.0001). The proportion of patients undergoing RNI significantly decreased over the study period from 43.3% to 37.2% in the 4+ node positive group, and from 23.6% to 22.0% in the 1-3 node positive group. At comprehensive community cancer centers, 25.5% patients with 1-3 positive nodes were treated with breast irradiation plus RNI (vs. 23.2% in community cancer centers and 21.1% in academic/research cancer centers). Among node negative patients, 11.5% of those with tumor size greater than 5 cm received additional RNI, compared to 4.3% in patients with tumors less than 5cm (p&lt;0.0001). Other significant factors related to RNI use included higher tumor grade, younger age, facility location, and facility volume. Conclusions: The use of RNI varies by number of tumor positive nodes and facility factors. Only 22.8% of patients with 1-3 positive nodes underwent RNI. Future studies are needed to determine if the use of RNI will increase after publication of the MA.20 trial especially for the 1-3 node positive group.

Can pancreaticoduodenectomy performed at a comprehensive community cancer center have comparable results as major tertiary center?

Pancreatic resection is a definitive treatment modality for pancreatic neoplasm. Pancreaticoduodenectomy (PD) is the primary procedure for tumor arising from head of pancreas. Prognosis is overwhelmingly poor despite adequate resection. We maintained a prospective database covering years 2001 to 2010. Outcome data is analyzed and compared with those from tertiary centers. Sixty-two patients with various histology were included. Pylorus preserving pancreatico-duodenectomy (PPPD), classic pancreaticoduodenectomy, and subtotal pancreatectomy were procedures performed. Three patients had portal venorrhaphy performed to obtain clinically negative margin. Forty six patients had malignancy on final pathologic analysis. The average age of patients was 63. Mean preoperative CA19-9 for exocrine pancreatic malignancies was higher than for more benign lesions. There was a decrease in operative time during this period. Blood transfusion was uncommon. There was very few pancreatic leak among the patients. Two bile leaks were identified, one controlled with the drainage tube and the other one required repeat surgery. The primary reason for the prolonged hospitalization was gastric ileus. For patients without a gastrostomy tube, nasogastric tube was kept in until gastric ileus resolved. 30 days mortality rate was calculated at 4.8. Mean survival time during our follow up was 30.6 months. Comparing to published literature, present series' mortality, morbidity, and survival are similar. Five year survival was 39%. Despite overall poor outcome for patients with pancreatic and biliary malignancies, we conclude that surgery can be performed in community hospitals with special interest in treating pancreatic disorder, offering patients equivalent survival and quality of life as those operated in tertiary centers.

Can pancreaticoduodenectomy performed at a comprehensive community cancer center have comparable results as tertiary centers?

e14514 Background: We maintained a prospective database covering the time period from 2001 to 2010. We believe that the outcome achieved at a small cancer center can be similar to a tertiary cancer...

Is pancreaticoduodenectomy performed at a comprehensive community cancer center comparable to tertiary centers' results?

334 Background: We maintained a prospective database covering the period from 2001 to 2010. Outcome data are analyzed. We believe that the outcome achieved at a small cancer center is comparable to a tertiary cancer center. Methods: Our study measures the outcome of pancreaticoduodenectomy. Data were compared to the published literature. Results: There are 62 patients with histology-proven pancreatic cancer; ampullary adenocarcinoma and other histology types were included in the study. PPPD was performed in 41 patients. Twenty patients had classic PD. Three patients had portal venorrhaphy. Fifty patients had malignancy, whereas 11 had a benign histology. One case had dual histology (ductal carcinoma and neuroendocrine). The average age of patients was 63. Mean preoperative CA19-9 for exocrine pancreatic malignancies was 638, whereas for benign lesions and endocrine tumors it was 122. Average operative time is 6 hours 25 minutes for surgeries before 2005 and 5 hrs 48 minutes for surgeries performed after 2005. Blood transfusion was rare with 15 patients received blood product. There was one perioperative death due to ischemic bowel (4.3%). Average length of stay in the hospital was 15 days (range 0-87 days). There was no pancreatic leak among any of the patients. Two bile leaks were identified, one controlled with the drainage tube and the other one required repeat surgery. 30 days mortality rate was calculated at 10%. To date, 27 patients have died, with two from causes unrelated to carcinoma. Mean survival during our study period is 30.6 months. In comparison to published literature, the mortality, morbidity, and survival are similar. In the literature five year survival for pancreatic cancer patients treated with pancreaticoduodenectomy ranges from 10% to 29%. Conclusions: In our study 5-yr survival was 45%. Despite overall poor outcome for patients with pancreatic and biliary malignancies, surgery can be performed in community hospitals with special interest in treating pancreatic disorder, offering patients prolonged survival and quality of life. Pancreaticoduodenectomy is effective and safe with low hospital mortality and with acceptable complication rates. No significant financial relationships to disclose.

Implementing and Measuring the Impact of Patient Navigation at a Comprehensive Community Cancer Center

To determine whether patient navigation in a comprehensive community cancer center affects patient and staff perceptions of patient preparation for treatment, access to care, and overall satisfaction. Program evaluation with patient and staff surveys. Comprehensive community cancer center accredited by the American College of Surgeons in the southeastern United States with 1,037 analytic cases of cancer in 2007; population of the main county served is about 177,963. 48 patients (28 navigator and 20 non-navigator) and 26 employees, including physicians, nurses, and other support staff. A 10-item survey with Likert scale format was sent to a stratified sample of 100 newly diagnosed patients with cancer. A five-item survey with the same format was sent to 40 staff working with the patients. Patient navigation. Patients who received navigation services responded more positively to survey statements. Statistical significance (p > 0.05) was identified in 7 of 10 statements when patient groups were compared. Provider responses indicated agreement with all five statements included in the survey. Patients with cancer and oncology staff reported that patient navigation is effective in increasing patient satisfaction and decreasing barriers to care. Patient navigation is an emerging trend in cancer care. Patient navigators can play a significant role in assisting patients with coordinating services across the continuum of care. Continued research is essential in refining the role and eminence of patient navigators.

Improving Survival for Patients with Breast Cancer Compared with Intramural and Extramural Benchmarks

Background Advances in the early detection and treatment of breast cancer during the past 20 years should have been associated with increased survival. Patients and Methods We examined outcomes for patients with invasive breast cancer diagnosed before and after opening a hospital-affiliated comprehensive community cancer center and compared rates of improvement in survival with national benchmarks. Survival data for patients with invasive cancer were obtained from the Hoag Hospital tumor registry. National Surveillance Epidemiology and End Results (SEER) survival data for all eras reported for 1981–2001 were used for extramural comparisons. Results Observed 5-year survival improved from 79% to 84% ( P = 0.003) for patients diagnosed with invasive breast cancer during 1986–1991 compared with 1992–1999, the eras immediately before and after opening Hoag Cancer Center. During 1981–1993, relative 5-year survival rates increased slowly, nationally and locally, with both at 86% for 1986–1993. Since then, Hoag relative 5-year survival rates have steadily increased to 97% compared with 88% for SEER during 1995–2001. Improved survival for Hoag patients was observed for all general stages of disease and associated with increased use of systemic treatment and radiation therapy in addition to surgery. Conclusion The existence of Hoag Cancer Center has been associated with improved survival for patients with invasive breast cancer and for all stages of disease. The rate of improvement has been more rapid than observed nationally. Systematic dissemination of new information might have resulted in earlier adoption of improved screening and diagnostic and multidisciplinary treatment approaches that led to higher survival rates.

1128: The Effect of Hospital Type and Case Volume on the Delivery of Radiation Therapy for Localized Prostate Cancer: Insight From an American College of Surgeons Special Study

In the context of radiation therapy for localized prostate cancer, total dose and complication rate are important quality indicators, as several randomized clinical trials support dose-escalation in improving freedom from failure. The aim of the study was to determine the relationship between hospital volume/type and external beam radiation therapy (EBRT) quality of care parameters, with particular attention to total radiation dose and complication rate. As an initiative to assess quality of care (QOC) for localized prostate cancer, a Commission on Cancer (CoC) Special Study (2004) of the American College of Surgeons (ACoS) generated a national, hospital-based sample from 800 facilities reporting to the CoC National Cancer Data Base. This consisted of 5,230 men with early-stage prostate cancer diagnosed in 2000-1, of whom 1,385 received EBRT. Explicit chart review was used to determine compliance with 23 quality indicators (EBRT-related structural and process of care measures) developed at a multidisciplinary panel organized by RAND. Included in the data collection were absolute dose and post-radiation complications (rectal fistula, urethral stricture, acute and chronic proctitis, acute and chronic cystitis). Hospitals were stratified by case volume (≤ 12, 13-26, 27-52, and ≥ 53 cases annual prostate EBRT volume) and type as defined by the CoC (community cancer center, comprehensive community cancer center, and teaching/research). Analyses were performed using SAS version 9.1 (SAS Institute, Cary, NC). Teaching/research facilities prescribed greater mean dose (71.8 Gy) and were more likely to prescribe ≥ 70 Gy (82.0%) when compared to comprehensive community cancer centers (67.9 Gy and 69.6%) and community cancer centers (68.8 Gy and 69.4%, p<0.0001). When stratified by case volume, there was no significant difference in mean dose (p=0.12). However, the lowest volume centers (≤ 12 cases annually) were less likely to prescribe ≥ 70 Gy (62.7%) when compared to all others (74.8%, p<0.0001). Teaching/research facilities reported a lower complication rate (13.4%) compared to comprehensive community cancer centers (17.4%) and community cancer centers (25.1%, p<0.0001). On multivariate analysis, hospital type was the most significant predictor of complication rate (p=0.0015) when adjusted for age, initial PSA, stage, Gleason score, use of neoadjuvant hormonal therapy, number of co-morbidities, and measures of socio-economic position. The adjusted risk of complications was 62% lower at teaching/research facilities (OR=0.38, 95%CI 0.22-0.64) when compared to community cancer centers. There was no significant difference in complication rate between the lowest volume centers (18.0%) and all others (17.3%, p=0.49). In this nationally-representative sample, teaching/research facilities were found to prescribe greater radiation doses in EBRT for prostate cancer, while simultaneously reporting a lower complication rate. Centers treating > 12 cases annually were more likely to prescribe ≥ 70 Gy, and did not report a difference in complication rate. For prostate cancer treated with EBRT and dose escalation, consideration should be given to concentrating care at teaching/research facilities and higher volume centers.