Difference In Cancer-specific Mortality Research Articles

Prognostic Significance of Pathologic Lymph Node Invasion in Metastatic Renal Cell Carcinoma in the Immunotherapy Era

BackgroundThis study aimed to test the prognostic significance of pathologically confirmed lymph node invasion in metastatic renal cell carcinoma (mRCC) patients in this immunotherapy era.MethodsSurgically treated mRCC patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2018. Kaplan-Meier plots and multivariable Cox-regression models were fitted to test for differences in cancer-specific mortality (CSM) and overall mortality (OM) according to N stage (pN0 vs pN1 vs. pNx). Subgroup analyses addressing pN1 patients tested for CSM and OM differences according to postoperative systemic therapy status.ResultsOverall, 3149 surgically treated mRCC patients were identified. Of these patients, 443 (14%) were labeled as pN1, 812 (26%) as pN0, and 1894 (60%) as pNx. In Kaplan-Meier analyses, the median CSM-free survival was 15 months for pN1 versus 40 months for pN0 versus 35 months for pNx (P < 0.001). In multivariable Cox regression analyses, pN1 independently predicted higher CSM (hazard ratio [HR], 1.88; P < 0.01) and OM (HR, 1.95; P < 0.01) relative to pN0. In sensitivity analyses addressing pN1 patients, postoperative systemic therapy use independently predicted lower CSM (HR, 0.73; P < 0.01) and OM (HR, 0.71; P < 0.01).ConclusionPathologically confirmed lymph node invasion independently predicted higher CSM and OM for surgically treated mRCC patients. For pN1 mRCC patients, use of postoperative systemic therapy was associated with lower CSM and OM. Consequently, N stage should be considered for individual patient counseling and clinical decision-making.Graphical abstractConsort diagram of the study population.

Racial disparities in DLBCL: Analysis of SEER data from 2010-2019.

e18552 Background: Diffuse large B-cell lymphoma (DLBCL) is among the most common subtype of non-Hodgkin’s lymphoma accounting 31% of new cases. Introduction of immunotherapy and cell-based gene therapy has transformed the treatment landscape, yet there continue to be health disparities including differences in treatments received and health outcomes according to socioeconomic status. We aimed to quantify the association between race (white, black, American Indian/Alaska Native, Asian or Pacific Islander [API]) and cancer-specific survival among DLBCL patients. Methods: A retrospective observational study was conducted using the National Cancer Institute’s 2000-2019 Surveillance, Epidemiology, and End Results (SEER) Research Plus Data, 17 registries database. The SEER registry collects data on cancer incidence, patient and disease characteristics, and survival from approximately 35% of the US population. Patients were excluded if they had non-primary DLBCL or missing data. Survival analyses were used to evaluate cancer-specific mortality among 4 racial groups (white, black, American Indian/Alaska Native, API). Cox proportional hazards regression was used to assess the difference in cancer-specific mortality across race groups adjusting for age, sex, marital status, income, rurality, and Ann Arbor Stage. Results: The analytic sample included adult US patients diagnosed with DLBCL from 2010 to 2015 (N = 25,495). Of these 25,495 patients with DLBCL, the majority were White (82.8%), followed by API (9.3%), Black (7.4%), and American Indian/Alaska Native (0.5%). Age at diagnosis, sex, marital status, income differed across race groups. The crude cancer-specific mortality for blacks at year 2 was 29%, while 25% for whites, 24% for American Indians/Alaska Natives, and 29% for API. At year 6, the cancer-specific mortality was 36% for blacks, 33% for whites, 33% for American Indians/Alaska Natives, 35% for API. However, accounting for differences in patient characteristics (adjusting for age, sex, marital status, income, rurality, and Ann Arbor stage) resulted in an increased hazard risk (HR) of cancer-specific mortality for Black and Asian compared to whites (HR 1.28; 95% CI 1.18 to 1.40; and HR 1.19; 95% 1.11 to 1.29, respectively). The HR of cancer-specific mortality comparing American Indian/Alaska Natives to whites was 1.00; 95% CI .73 to 1.38, with the wide confidence intervals indicating that sample size is limited for this comparison. Conclusions: Despite advances in new treatment options, differences in cancer-specific mortality exists between different race groups among patients with DLBCL. The study highlights various sociodemographic features at diagnosis that could reflect disparities and lead to differences in cancer-specific mortality across race groups. It may be feasible to address some of the observed differences at DLBCL diagnosis and this may translate to better outcomes among patients with DLBCL.

Cancer-Specific Mortality Differences in Specimen-Confined Radical Prostatectomy Patients According to Lymph Node Invasion

PurposeTo test cancer-specific mortality (CSM) differences in specimen-confined (pT2) prostate cancer (PCa) at radical prostatectomy (RP) with lymph node dissection (LND) according to lymph node invasion (LNI). MethodsRP + LND pT2 PCa patients were identified (surveillance, epidemiology, and end results 2010-2015). CSM-FS rates were tested in Kaplan-Meier plots and multivariable Cox-regression (MCR) models. Sensitivity analyses respectively addressing patients with 6 or more lymph nodes analyzed and pT2 pN1 patients were performed. ResultsOverall, 32,258 patients with pT2 PCa at RP + LND were identified. Of these, 448 (1.4%) patients harbored LNI. Five-year CSM-free estimates were 99.6% for pN0 vs. 96.4% for pN1 (P < .001). In MCR models, pN1 (HR: 3.4, P < .001) independently predicted higher CSM. In sensitivity analyses addressing patients with 6 or more lymph nodes analyzed (n = 15,437), 328 (2.1%) pN1 patients were identified. In this subgroup, 5-year CSM-free estimates were 99.6% for pN0 vs. 96.3% for pN1 (P < .001) and, in MCR models, pN1 independently predicted higher CSM (HR: 4.4, P < .001). In sensitivity analyses addressing pT2 pN1 patients, 5-year CSM-free estimates were 99.3, 100 and 84.8% for ISUP GG 1-3 vs. 4 vs. 5, respectively (P < .001). ConclusionsIn patients with pT2 PCa a small proportion harbor LNI (1.4%-2.1%). In such patients, CSM rate is higher (HR 3.4-4.4, P < .001). This higher CSM risk seems to virtually exclusively apply to ISUP GG5 patients (84.8% 5-year CSM-free rate).

African American vs. Caucasian race/ethnicity in adrenocortical carcinoma patients.

In some primaries African American race/ethnicity predisposes to higher stage and worse survival. We tested for differences in cancer specific mortality (CSM) and other-cause mortality (OCM) in patients with adrenocortical carcinoma (ACC) according to African American vs. Caucasian race/ethnicity. We hypothesized that African Americans present with higher tumor stage and grade, do not receive the same treatment and benefit of lower survival than Caucasians. Within Surveillance, Epidemiology, and End Results database, we identified 1016 ACC patients: 123 (12.1%) African Americans vs. 893 (87.9%) Caucasians. Propensity score matching (age, sex, marital status, grade, T, N and M stages, treatment type), cumulative incidence plots Poisson-smoothing and competing risk regression (CRR) were used. Compared to Caucasians, African Americans were more frequently unmarried (56.9% vs. 35.5%, p < 0.001). No clinically meaningful or statistically significant differences were observed for age, grade, T, N, and M stages, as well as for treatment type (all p > 0.05). After propensity score matching (1:4), 123 African Americans and 492 Caucasians remained and were included in CRR analysis. In multivariable CRR models, CSM and OCM rates were not different between the two race/ethnicities (hazard ratio: 0.84, p = 0.3). In African Americans five-year CSM rates were 31.2% and 75.3% in respectively European Network for the Study of Adrenal Tumors (ENSAT) stages I-II and III-IV vs. 32.9% and 75.4% in Caucasians. Overall five-year OCM rates were 11.0% vs. 10.1% in respectively African Americans and Caucasians. Unlike other primaries, in ACC African American race/ethnicity is not associated with higher disease stage at initial diagnosis or worse survival.

Racial and ethnic differences in type II endometrial cancer mortality outcomes: The contribution of sociodemographic, clinicopathologic, and treatment factors

ObjectiveThe burden of type II endometrial cancer (EC) is rising dramatically in the U.S. Although type II EC disproportionately affects Black women, the magnitude of racial/ethnic differences in type II EC mortality outcomes and factors underlying these differences remain understudied. We examined racial/ethnic differences in cancer-specific and overall mortality in women with type II EC and quantified the extent to which mortality differences are mediated by sociodemographic, clinicopathologic, and treatment factors. Methods14,710 women ≥18 years with type II EC from 2007 to 2016 were identified from the Surveillance, Epidemiology, and End Results database. The association between race/ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, and non-Hispanic Asian/Pacific Islander [NHAPI]) and cancer-specific and overall mortality was examined. Mediation analysis was used to identify factors underlying differences in mortality outcomes. ResultsNHB women had a higher risk of cancer-specific mortality than NHW women (hazard ratio [HR]: 1.22, 95% CI: 1.12–1.33), whereas NHAPI (HR: 0.88, 95% CI: 0.78–0.99) and Hispanic women (HR: 0.91, 95% CI: 0.81–1.01) had a lower risk of cancer-specific mortality than NHW women. Differences in clinicopathologic (stage, grade, histologic subtype), sociodemographic (insurance type, geographic region and location, neighborhood socioeconomic status), and treatment factors (treatment type, lymphadenectomy) explained 43.5%, 8.1%, and 7.3% of the difference in cancer-specific mortality between NHB and NHW women, respectively. Similar results were noted for overall mortality. ConclusionsMultidisciplinary and multilevel approaches that integrate and address social and biological factors are needed to reduce the disproportionate burden of type II EC mortality in NHB women.

Differences in Cancer-Specific Mortality after Trimodal Therapy for T2N0M0 Bladder Cancer according to Histological Subtype.

We aimed at assessing the impact of non-urothelial variant histology (VH), relative to urothelial carcinoma of the urinary bladder (UCUB), on cancer-specific mortality (CSM) in T2N0M0 bladder cancer patients treated with trimodal therapy (TMT). TMT patients treated for T2N0M0 bladder cancer were identified within the Surveillance, Epidemiology, and End Results database (2000−2018). Patients who underwent TMT received trans-urethral resection of the bladder tumor, chemotherapy, and radiotherapy. CSM-FS rates were tested using Kaplan−Meier plots and multivariable Cox-regression (MCR) models according to histological subtype: UCUB vs. neuroendocrine carcinoma vs. squamous cell carcinoma vs. adenocarcinoma. A total of 3846 T2N0MO bladder cancer patients treated with TMT were identified. Of these, 3627 (94.3%) harbored UCUB, while 105 (2.7%), 85 (2.2%), and 29 (0.8%) harbored neuroendocrine carcinoma, squamous cell carcinoma, and adenocarcinoma, respectively. In Kaplan−Meier analyses, 3-yr CSM-FS rates were 57% for UCUB, 51% for neuroendocrine carcinoma, 35% for squamous cell carcinoma, and 60% for adenocarcinoma (p-value < 0.0001). In MCR models, only squamous cell carcinoma exhibited higher CSM than UCUB (HR 1.98, 95%CI 1.5−2.61, p-value < 0.001). Despite the small number of observations, squamous cell carcinoma distinguished itself from UCUB based on worse survival in T2N0M0 patients after TMT.

Cancer specific mortality in patients with collecting duct vs. clear cell renal carcinoma

BackgroundCollecting duct carcinoma (CDC) is biologically more aggressive than clear cell renal cell carcinoma (ccRCC). We tested for differences in cancer specific mortality (CSM) rates according to CDC vs. ISUP (International Society of Urological Pathology) 4 ccRCC histological subtype. We hypothesized that the survival disadvantage still applies, even after most detailed adjustments. MethodsWithin Surveillance, Epidemiology, and End Results database (2004–2018), we identified 380 CDC vs. 6273 ISUP 4 ccRCC patients of all stages. Propensity score matching (age, sex, race/ethnicity, T, N, and M stages, nephrectomy, and systemic therapy status), Kaplan-Meier plots and multivariable Cox regression models were used. ResultsAll 380 CDC were matched (1:2) with 760 ISUP4 ccRCC patients. Prior to matching CDC patients exhibited higher rates of lymph node invasion (37.6 % vs. 14.7 %, p < 0.001), and of distant metastases (40.8 % vs. 30.4 %, p < 0.001). Systemic therapy rates were higher in CDC (29.5 % vs. 20.5 %, p < 0.001). However, nephrectomy rates were higher in ISUP4 ccRCC patients (97.5 % vs. 84.7 %, p < 0.001). After matching, in multivariable Cox regression models addressing CSM, CDC was associated with a HR of 1.5 (p < 0.001) in the overall population vs. 1.9 (p = 0.014) in stage I-II vs. 1.4 (p = 0.022) in stage III vs. 1.6 in stage IV (p < 0.001), relative to ISUP4 ccRCC. ConclusionCDC patients exhibited 40–90 % higher CSM than their ISUP4 ccRCC counterparts in the overall analysis, as well as in stage specific analyses. The CSM disadvantage applies despite higher rates of systemic therapy in CDC patients.

Amputation Predisposes to Higher Cancer-Specific Mortality Than Limb Salvage Surgery in Pediatric Patients With Osteosarcoma of the Limbs: A Propensity Matching Analysis.

ObjectiveWith the development of osteosarcoma treatment, limb salvage surgery is gradually replacing amputation as the primary surgical option. Most pediatric osteosarcomas of the limbs undergo limb-salvage surgery. We aimed to use propensity score matching (PSM) analysis test the difference in cancer-specific mortality (CSM) between amputation and limb-salvage surgery in pediatric patients with Osteosarcoma of the limbs. PSM is a statistical method used to deal with data from an Observational Study. The PSM method is designed to reduce the influence of biases and confounding variables to make a more reasonable comparison between experimental and control groups.MethodsPatient information was downloaded from the SEER (surveillance, epidemiology, and End Results) database from 2004 to 2018. We included all primary pediatric osteosarcoma patients who underwent limb salvage or amputation. Multivariate logistic regression models were used to explore the factors influencing patient choice of amputation. Differences in CSM and other causes of mortality (OSM) between limb salvage and amputation were analyzed using cumulative incidence plots and competitive risk regression tests after 1:1 proportional propensity score matching.ResultsA total of 1,058 pediatric patients with limbs Osteosarcoma were included. Patients who underwent amputations were more likely to be male (OR 1.4, P = 0.024) and more likely to have distant metastasis (OR 2.1, P < 0.001). Before propensity matching, CSM was 1.4 times higher in patients undergoing amputation than in patients undergoing limb salvage (P = 0.017) and 3.4 times higher in OSM (P = 0.007). After adjustment for propensity matching, CSM was 1.5 times higher in patients undergoing amputation than in patients undergoing limb salvage (P = 0.028), but there was no significant difference in OSM (HR 3.2, P = 0.078).ConclusionsOur results suggested that amputation is associated with a 1.5-fold increase in CSM in pediatric patients with limbs Osteosarcoma. Therefore, in the surgical selection of pediatric patients with Osteosarcoma, limb salvage surgery should be the first choice in the absence of other contraindications.

Partial vs. radical nephrectomy in non-metastatic pT3a kidney cancer patients: a population-based study.

The aim of this study was to test for differences in cancer specific mortality (CSM) rates between radical nephrectomy (RN) and partial nephrectomy (PN) in pT3a nmRCC patients. Within the surveillance, epidemiology, and end results database (2005-2016), 13,177 pT3a patients treated with either PN or RN were identified. Before and after 1:2 ratio propensity score (PS)-match between PN and RN patients, cumulative incidence plot and competing risks regression (CRR) were used to test differences in CSM and other cause mortality (OCM) rates. Relative to PN (N.=1615, 22.5%), RN patients harbored higher tumor size (72 vs. 38 mm; >70 mm 51 vs.10%), of more aggressive histology, collecting duct (0.4 vs. 0.2%) and sarcomatoid (2.3 vs.0.8%), of higher grade (51.0 vs. 37.5%). After PS-matching and OCM adjustment, 5-year CSM was 3-fold higher after RN than PN (P<0.01). Similarly, after PS matching and CSM adjustment, also 5-year OCM rates were higher after RN (HR: 1.59, P=0.0003). PN does not appear to compromise the oncological outcomes in patients with pT3a or high-grade renal masses when compared with RN. Therefore, these concerns should not deter a surgeon from attempting PN when otherwise technically feasible.

This Month in Adult Urology

This Month in Adult Urology

Cancer-specific mortality after radical prostatectomy vs external beam radiotherapy in high-risk Hispanic/Latino prostate cancer patients

PurposeTo test for differences in cancer-specific mortality (CSM) rates in Hispanic/Latino prostate cancer patients according to treatment type, radical prostatectomy (RP) vs external beam radiotherapy (EBRT).MethodsWithin the Surveillance, Epidemiology, and End Results database (2010–2016), we identified 2290 NCCN (National Comprehensive Cancer Network) high-risk (HR) Hispanic/Latino prostate cancer patients. Of those, 893 (39.0%) were treated with RP vs 1397 (61.0%) with EBRT. First, cumulative incidence plots and competing risks regression models tested for CSM differences after adjustment for other cause mortality (OCM). Second, cumulative incidence plots and competing risks regression models were refitted after 1:1 propensity score matching (according to age, PSA, biopsy Gleason score, cT-stage, cN-stage).ResultsIn NCCN HR patients, 5-year CSM rates for RP vs EBRT were 2.4 vs 4.7%, yielding a multivariable hazard ratio of 0.37 (95% CI 0.19–0.73, p = 0.004) favoring RP. However, after propensity score matching, the hazard ratio of 0.54 was no longer statistically significant (95% CI 0.21–1.39, p = 0.2).ConclusionWithout the use of strictest adjustment for population differences, NCCN high-risk Hispanic/Latino prostate cancer patients appear to benefit more of RP than EBRT. However, after strictest adjustment for baseline patient and tumor characteristics between RP and EBRT cohorts, the apparent CSM benefit of RP is no longer statistically significant. In consequence, in Hispanic/Latino NCCN high-risk patients, either treatment modality results in similar CSM outcome.

Cancer-specific survival after radical prostatectomy versus external beam radiotherapy in high-risk and very high-risk African American prostate cancer patients.

To test for differences in cancer-specific mortality (CSM) rates between radical prostatectomy (RP) vs external beam radiotherapy (EBRT) in National Comprehensive Cancer Network (NCCN) high-risk African American patients, as well as Johns Hopkins University (JHU) high-risk and very high-risk patients. Within the Surveillance, Epidemiology, and End Results database (2010-2016), we identified 4165 NCCN high-risk patients, of whom 1944 (46.7%) and 2221 (53.3%) patients qualified for JHU high-risk or very high-risk definitions. Of all 4165 patients, 1390 (33.5%) were treated with RP versus 2775 (66.6%) with EBRT. Cumulative incidence plots and competing risks regression models addressed CSM before and after 1:1 propensity score matching between RP and EBRT NCCN high-risk patients. Subsequently, analyses were repeated separately in JHU high-risk and very high-risk subgroups. Finally, all analyses were repeated after landmark analyses were applied. In the NCCN high-risk cohort, 5-year CSM rates for RP versus EBRT were 2.4 versus 5.2%, yielding a multivariable hazard ratio of 0.50 (95% confidence interval [CI] 0.30-0.84, p = 0.009) favoring RP. In JHU very high-risk patients 5-year CSM rates for RP versus EBRT were 3.7 versus 8.4%, respectively, yielding a multivariable hazard ratio of 0.51 (95% CI: 0.28-0.95, p = 0.03) favoring RP. Conversely, in JHU high-risk patients, no significant CSM difference was recorded between RP vs EBRT (5-year CSM rates: 1.3 vs 1.3%; multivariable hazard ratio: 0.55, 95% CI: 0.16-1.90, p = 0.3). Observations were confirmed in propensity score-matched and landmark analyses adjusted cohorts. In JHU very high-risk African American patients, RP may hold a CSM advantage over EBRT, but not in JHU high-risk African American patients.

External beam radiotherapy and radical prostatectomy are associated with better survival in Asian prostate cancer patients.

To test the effect of race/ethnicity on cancer-specific mortality after radical prostatectomy or external beam radiotherapy in localized prostate cancer patients. In the Surveillance, Epidemiology and End Results database 2004-2016, we identified intermediate-risk and high-risk white (n = 151 632), Asian (n = 11 189), Hispanic/Latino (n = 20 077) and African American (n = 32 550) localized prostate cancer patients, treated with external beam radiotherapy or radical prostatectomy. Race/ethnicity-stratified cancer-specific mortality analyses relied on competing risks regression, after propensity score matching for patient and cancer characteristics. Compared with white patients, Asian intermediate- and high-risk external beam radiotherapy patients showed lower cancer-specific mortality (hazard ratio 0.58 and 0.70, respectively, both P ≤ 0.02). Additionally, Asian high-risk radical prostatectomy patients also showed lower cancer-specific mortality than white patients (hazard ratio 0.72, P = 0.04), but not Asian intermediate-risk radical prostatectomy patients (P = 0.08). Conversely, compared with white patients, African American intermediate-risk radical prostatectomy patients showed higher cancer-specific mortality (hazard ratio 1.36, P = 0.01), but not African American high-risk radical prostatectomy or intermediate- and high-risk external beam radiotherapy patients (all P ≥ 0.2). Finally, compared with white people, no cancer-specific mortality differences were recorded for Hispanic/Latino patients after external beam radiotherapy or radical prostatectomy, in both risk levels (P ≥ 0.2). Relative to white patients, an important cancer-specific mortality advantage applies to intermediate-risk and high-risk Asian prostate cancer patients treated with external beam radiotherapy, and to high-risk Asian patients treated with radical prostatectomy. These observations should be considered in pretreatment risk stratification and decision-making.

Life expectancy in metastatic prostate cancer patients according to racial/ethnic groups.

To quantify the magnitude of differences between observed overall survival and respective, age-adjusted Social Security Administration life tables-derived life expectancy in Caucasian, African American, Hispanic/Latino and Asian metastatic prostate cancer patients. Furthermore, to test for differences in cancer-specific mortality and other-cause mortality according to race/ethnicity. We relied on the 2004-2006 Surveillance, Epidemiology and End Results database to identify Caucasian, African American, Hispanic/Latino and Asian metastatic prostate cancer patients. Social Security Administration life tables were used to compute 10-year life expectancy for comparisons with observed overall survival. Poisson regression plots showed cancer-specific mortality relative to other-cause mortality for each race/ethnicity. A total of 2574 (64.2%) patients were Caucasian, 753 (18.8%) were African American, 453 (11.3%) were Hispanic/Latino and 227 (5.7%) were Asian, respectively. The median age at diagnosis was 72years in Caucasian patients, 68years in African American patients, 70years in Hispanic/Latino patients and 72years in Asian patients. Observed overall survival rates were always lower compared with respective predicted life expectancy. The magnitude of the difference between observed overall survival and predicted life expectancy at 10years was highest in African American patients (-52.2%), followed by Caucasian patients (-48.3%), Hispanic/Latino patients (-46.1%) and Asian patients (-37.4%). African American patients showed the highest cancer-specific mortality rates (71.1%) and second-highest other-cause mortality rates (17.4% vs highest 18.4% in Caucasian patients), despite having the youngest age at diagnosis. Asian patients showed the lowest cancer-specific mortality rates (65.5%, P<0.0001) and lowest other-cause mortality rates (13.3%, P=0.04), despite having the oldest age at diagnosis. Despite having the youngest age at diagnosis, African American patients show the least favorable survival profile in metastatic prostate cancer. Conversely, Asian patients show the most favorable survival profile in metastatic prostate cancer, despite having the oldest age at diagnosis.

The Association of Medicaid Insurance and Affordable Care Act Expansions with Survival among Patients with Testicular Cancer.

Following passage of the Affordable Care Act, Medicaid access was expanded in several states beginning in 2014. We sought to determine the oncologic implications by comparing outcomes between testicular germ cell tumor patients with Medicaid and those without insurance, and by assessing for changes in outcomes after 2014. A total of 18,506 men with seminomatous or nonseminomatous germ cell tumors were identified within the Surveillance, Epidemiology, and End Results database (2007-2016). Multivariable Cox proportional hazards, Fine and Gray competing-risks regression, propensity score matching, cumulative incidence plots and segmented Poisson regression models were used. Compared to no insurance, Medicaid insurance was not associated with differences in all-cause mortality or cancer-specific mortality among seminoma patients (all-cause mortality: HR=1.24, p=0.87; cancer-specific mortality: HR=0.92, p=0.75) or nonseminoma patients (all-cause mortality: HR=1.13, p=0.33; cancer-specific mortality: HR=1.10, p=0.51). Among matched Medicaid and uninsured patients, there was again no difference in cancer-specific mortality for those with seminoma (p=0.81) or nonseminoma (p=0.23). There was a 99% increase in Medicaid enrollment in expansion states in the post-Affordable Care Act era. There was no difference in post-expansion all-cause mortality between expansion states and nonexpansion states for men with seminoma (p=0.42) or nonseminoma (p=0.53). Medicaid enrollment increased in expansion states following the Affordable Care Act. However, there was no difference in survival between Medicaid patients and uninsured patients, or between patients in expansion states versus nonexpansion states, highlighting the need for population-level policy interventions to improve access and quality of care among testicular cancer patients with Medicaid.

All-cause and cancer-specific overall survival in kidney transplant recipients with pre-transplant malignancies in a German cohort

Kidney insufficiency and immunosuppression are well established contributors of tumor development, both before and after kidney transplantation. Patients with pre-transplant malignancies (PTM) are at risk of tumor recurrence and of the development of an unrelated tumor after transplantation. In this retrospective study of a German patient cohort, we analyzed 1089 patients that underwent kidney transplantation to determine the frequency, recurrence rate and overall survival of patients with pre-existing tumors across a 10-year period. PTM were found in 5.79% of the patients and appeared at a mean time of 7.39 (SD 6.8) years before transplantation. The tumors were most frequently of urologic (41.43%) origin, followed by malignancies of the skin (25.71%) and gynecologic tumors (10%). Tumor recurrence was observed in one case (1.6%) where the patient died of metastatic spinocellular carcinoma. Patients with pre-existing malignancies had a statistically significantly worse overall survival compared to transplant recipients without tumors (HR = 2.71, 95% CI 1.49–4.969). However, these differences could be entirely ascribed to the age (HR = 1.06, 95% CI 1.04–1.08) and gender (HR = 1.67, 95% CI 1.11–2.52) of the patients. We found that there was no difference in cancer-specific mortality or posttransplant cancer rate between patients with and without pre-existing malignancies (HR = 0.94, 95% CI 0.21–4.26).

The significance of preoperative estimated glomerular filtration rate on survival outcomes in patients who underwent radical cystectomy and non-continent urinary diversion.

ABSTRACTPurpose To evaluate the influence of preoperative renal function on survival outcomes in patients who underwent radical cystectomy (RC) with non-continent urinary diversion (UD).Materials and Methods A total of 132 patients with bladder cancer who underwent RC with non-continent UD due to urothelial carcinoma from January 2006 toMarch 2017 at our tertiary referral center were retrospectively evaluated. Patients were divided into 2 groups as those with estimated glomerular filtration rate (eGFR) <60mL/min/1.73 m2 and ≥60mL/min/1.73 m2 according to preoperative eGFR levels. Patients’ characteristics, preoperative clinical data, operative data, pathologic data, oncologic data and complications were compared between the groups.Results The mean age was 64.5±8.7 (range: 32 - 83) years and the median follow-up was 30.9±31.7 (range: 1-113) months. There were 46 patients in Group 1 and 86 patients in Group 2. There was no difference in cancer-specific mortality (45.6% for group 1 and 30.2% for group 2, p=0.078) and survival (56.8±8.3 months for group 1 and 70.5±5.9 months for group 2, p=0.087) between the groups. Overall mortality was higher (63% for group 1 and 40.7% for group 2, p=0.014) and overall survival (43.6±6.9 months for group 1 and 62.2±5.8 months for group 2, p=0.03) was lower in Group 1 compared to Group 2.Conclusions Overall mortality was higher and overall survival was lower in patients with preoperative eGFR <60mL/s. More patients had preoperative hydronephrosis with eGFR< 60mL/s.

Conditional Survival of Patients With Nonmetastatic Renal Cell Carcinoma: How Cancer-Specific Mortality Changes After Nephrectomy.

Conditional survival (CS) may reveal important differences in cancer-specific mortality (CSM) among patients with nonmetastatic renal cell carcinoma (nmRCC). This study assessed CS according to T and N stages in patients treated surgically for nmRCC. Within the SEER database (2001-2015), all patients with nmRCC treated with either partial or radical nephrectomy were identified. CSM-free estimates according to T and N stage and substage groupings (pT1aN0-pT4N0 and pTanyN1) and multivariable Cox regression models with adjustment for Fuhrman grade and histologic subtype were assessed. According to T and N stage and substage groupings, the following patients were included in the study: 35,966 (46.2%) with pT1aN0 disease; 18,858 (24.2%) with pT1bN0; 5,977 (7.7%) with pT2aN0; 2,511 (3.2%) with pT2bN0; 11,839 (15.2%) with pT3aN0; 1,037 (1.3%) with pT3b-cN0; 402 (0.5%) with pT4N0; and 1,302 (1.7%) with pTanyN1. Conditional CSM-free survival estimates were 98.2% at 1 year versus 98.0% at 10 years of event-free follow-up for patients with pT1aN0 disease, relative to baseline. Conversely, pT4N0/pTanyN1 conditional CSM-free survival estimates were 55.8% at 1 year versus 77.9% at 8 years of event-free follow-up. Attrition due to mortality was highest in patients with pT4N0/pTanyN1 disease. In multivariable Cox regression analyses, T stage, tumor grade, and histologic subtype represented independent predictors, but no interactions were identified. Tumor stage and its substages represent extremely important determinants of prognosis after lengthy event-free follow-up. The recorded observations have critical importance for physicians regarding patient follow-up and counseling.

1644P - Continuation of annual screening mammograms and breast-cancer mortality in women over 70

BackgroundRandomized clinical trials (RCTs) have shown that initiating breast cancer (BC) screening between ages 50 to 69 and continuing it for 10 years decreases BC mortality. None of the existing RCTs included women over 74 and all included few women aged 70-74, such that the 95% confidence interval (CI) ranged from preventing 32.1 deaths to causing 17.2 deaths. However, there is no RCT data on when a woman should stop receiving BC screening, yet an estimated 52% of women over 75 receive screening mammograms in the US. A future randomized trial to study when to stop screening may be infeasible and potentially unethical. We used insurance claims data to emulate a (hypothetical) target trial of the effect of continuing screening on BC mortality among Medicare beneficiaries aged 70-74 or 75-84 years. MethodsWe emulated a hypothetical trial using a population-based cohort study with 20% random sample of Medicare (1999-2008). We selected 1,058,013 Medicare beneficiaries aged 70 to 84 with a life expectancy of at least 10 years and no previous diagnosis of BC, and who received a BC screening. We compared the following two strategies: continuing annual screening vs. stopping screening mammograms. The main outcome was 8-year standardized risk of BC mortality by age group (70-74, 75-84). Estimates are standardized by baseline and time-varying variables. ResultsIn the 70-74 age group, the estimated 8-year BC-specific death risk difference (95% CI) of continuing vs. stopping screening was -1.0 deaths per 1000 women (-2.3 to 0.1); hazard ratio 0.78 (0.63 to 0.95). In the 75-84 age group, the corresponding risk difference was 0.07 deaths per 1000 women (-0.93 to 1.3); hazard ratio 1.00 (0.83 to 1.19). The estimated 8-year risk of BC was 5.5% under the continue screening strategy (5.3% in the 70-74 age group, 5.8% in the 75-84 age group), and 3.9% under the stop screening strategy (3.9% in the 70-74 age group, 3.9% in the 75-84 age group). ConclusionsAmong women who have received at least one screening mammogram, we estimated that, compared with stopping BC screening, continuing screening past the age of 75 years results in no material difference in cancer-specific mortality over the following 8-year period. Our results in the age range of 70-74 match those of existing randomized clinical trials. Legal entity responsible for the studyThe authors. FundingUS National Institutes of Health. DisclosureAll authors have declared no conflicts of interest.

The impact of severe mental illness on lung cancer mortality of patients with lung cancer in Finland in 1990–2013: a register-based cohort study

BackgroundAlthough the link between severe mental illness (SMI) and elevated cancer mortality is well established, few studies have examined lung cancer survival and SMI in detail. Our study compared cancer-specific mortality in patients with lung cancer with and without a history of SMI and analysed whether mortality differences could be explained by cancer stage at presentation, comorbidity or differences in cancer treatment. MethodsWe identified patients with their first lung cancer diagnosis in 1990–2013 from the Finnish Cancer Registry, their preceding hospital admissions due to SMI from the Hospital Discharge Register and deaths from the Causes of Death statistics. Competing risk analyses were used to estimate hazard ratios (HRs) for the impact of SMI on mortality. ResultsOf the 37,852 lung cancer cases, 12% had a history of SMI. Cancer-specific mortality differences were found between patient groups in some cancer types after controlling for stage at representation and treatment. Men with a history of psychosis had excess mortality risk (HR = 1.24, 1.06–1.45) in squamous cell carcinoma. Similar excess risk was found among women with psychosis in small-cell carcinoma (HR = 1.76, 1.41–2.19) and in squamous cell carcinoma (HR = 1.67, 1.26–2.20) and among women with mood disorders in adenocarcinoma (HR = 1.37, 1.08–1.74). Patient group differences in HRs in five-year mortality did not markedly change from the 1990s. ConclusionsWe found elevated cancer-specific mortality among persons with a history of SMI. Collaboration between patients, mental healthcare professionals and oncological teams is needed to reduce the mortality gap between patients with cancer with and without SMI.