Guideline-concordant Treatment Research Articles

Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?

Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment. We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment. 5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)Model1 0.58 (0.45-0.74); ORModel2 0.59 (0.46-0.78); ORModel3 0.62 (0.47-0.81); ORModel4 0.53 (0.40-0.69); ORModel5 0.59(0.46-0.76); p < 0.05]. To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation.

Three-year follow-up study reveals improved survival rate in NSCLC patients underwent guideline-concordant diagnosis and treatment

BackgroundNo studies in China have assessed the guideline-concordance level of the first-course of non-small cell lung cancer (NSCLC) diagnosis and treatment and its relationship with survival. This study comprehensively assesses the current status of guideline-concordant diagnosis (GCD) and guideline-concordant treatment (GCT) of NSCLC in China and explores its impact on survival.MethodsFirst course diagnosis and treatment data for NSCLC patients in Liaoning, China in 2017 and 2018 (n=1828) were used and classified by whether they underwent GCD and GCT according to Chinese Society of Clinical Oncology (CSCO) guidelines. Pearson’s chi-squared test was used to determine unadjusted associations between categorical variables of interest. Logistic models were constructed to identify variables associated with GCD and GCT. Kaplan–Meier analysis and log-rank tests were used to estimate and compare 3-year survival rates. Multivariate Cox proportional risk models were constructed to assess the risk of cancer mortality associated with guideline-concordant diagnosis and treatment.ResultsOf the 1828 patients we studied, 48.1% underwent GCD, and 70.1% underwent GCT. The proportions of patients who underwent both GCD and GCT, GCD alone, GCT alone and neither GCD nor GCT were 36.7%, 11.4%, 33.5% and 18.4%, respectively. Patients in advanced stage and non-oncology hospitals were significantly less likely to undergo GCD and GCT. Compared with those who underwent neither GCD nor GCT, patients who underwent both GCD and GCT, GCD alone and GCT alone had 35.2%, 26.7% and 35.7% higher 3-year survival rates; the adjusted lung cancer mortality risk significantly decreased by 29% (adjusted hazard ratio[aHR], 0.71; 95% CI, 0.53–0.95), 29% (aHR, 0.71; 95% CI, 0.50–1.00) and 32% (aHR, 0.68; 95% CI, 0.51–0.90).ConclusionThe 3-year risk of death is expected to be reduced by 29% if patients with NSCLC undergo both GCD and GCT. There is a need to establish an oncology diagnosis and treatment data management platform in China to monitor, evaluate, and promote the use of clinical practice guidelines in healthcare settings.

Variation in content discussed by specialty in consultations for clinically localized prostate cancer

IntroductionMultidisciplinary consultations improve decisional conflict and guideline-concordant treatment for men with prostate cancer (PC), but differences in the content discussed by specialty during consultations are unknown. MethodsWe audiorecorded and transcribed 50 treatment consultations for localized PC across a multidisciplinary sample of urologists, radiation oncologists, and medical oncologists. Conversation was coded for narrative content using an open coding approach, grouping similar topics into major content areas. The number of words devoted to each content area per consult was used as a proxy for time spent. Multivariable Poisson regression calculated incidence rate ratios (IRR) for content-specific word count across specialties after adjustment for tumor risk and patient demographics. ResultsCoders identified 8 narrative content areas: overview of PC; medical history; baseline risk; cancer prognosis; competing risks; treatment options; physician recommendations; and shared decision making (SDM). In multivariable models, specialties significantly differed in proportion of time spent on treatment options, SDM, competing risks, and cancer prognosis. Urologists spent 1.8-fold more time discussing cancer prognosis than medical oncologists (IRR1.80, 95%CI:1.14–2.83) and radiation oncologists (IRR1.84, 95%CI:1.10–3.07). Urologists (IRR11.38, 95%CI:6.62–19.56) and medical oncologists (IRR10.60, 95%CI:6.01–18.72) spent over 10-fold more time discussing competing risks than radiation oncologists. Medical oncologists (IRR2.60, 95%CI:1.65–4.10) and radiation oncologists (IRR1.77, 95%CI:1.06–2.95) spent 2.6- and 1.8-fold more time on SDM than urologists, respectively. ConclusionsSpecialists focus on different content in PC consultations. Our results suggest that urologists should spend more time on SDM and radiation oncologists on competing risks. Our results also highlight the importance of medical oncologists in facilitating SDM.

Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study.

To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors. Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties. Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits. This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.

Discussion.

Discussion.

Abstract IA008: Racial disparities in guideline-concordant endometrial cancer treatment

Abstract Mortality associated with endometrial cancer is 98% higher among Black as compared with White women. A large body of literature has evaluated differential treatment patterns as a potential determinant of increased mortality among Black women. In most studies, receipt of individual endometrial cancer treatment components (i.e., surgery, radiation, chemotherapy) is compared between Black and White women. Moreover, individual treatment components are typically considered binary variables (received vs. not received) with the received category reflecting a wide spectrum of treatments received. For example, women who receive one vs. six cycles of chemotherapy would be similarly labeled as receiving chemotherapy, despite a clear difference in treatment intensity. In contrast, recent studies have begun to evaluate racial and ethnic differences in the complete course of treatment as a unit, within the context of established guidelines. The National Comprehensive Cancer Network guidelines provide evidence-based endometrial cancer treatment recommendations based on clinical trials and observational research. Surgery is the first step of guideline-concordant treatment and pathology factors captured from surgery inform adjuvant treatment recommendations. Since the distribution of tumor characteristics that guide treatment recommendations varies between Black and White women, we should expect racial differences in use of adjuvant radiation and chemotherapy. However, when conceptualizing treatment as guideline-concordant vs. discordant, racial and ethnic differences clearly signal disparate quality of care. In this presentation, we will discuss the need for research on endometrial cancer treatment disparities to shift from a paradigm of exploring individual treatment components to one in which receipt of guideline-concordant treatment is the focus. Moreover, through the lens of a recently funded grant, we will discuss the value of using an explicit disparities definition in analyses of guideline-concordant treatment, which allows for decomposition of the sources of racial and ethnic disparities. Differences in healthcare related to clinical need or preference are not considered sources of disparities, reflecting the normative view that these differences are acceptable, and therefore, just. On the other hand, unjust sources of disparities include the operation of healthcare systems, the legal and regulatory climate, and discrimination, among other factors. In addition to the selection of a rigorous and nuanced disparities definition, future research on guideline-concordant treatment disparities should investigate the role of multilevel factors that reflect the social determinants of health. Cancer health disparities are entrenched in the social determinants of health, which cannot be effectively addressed at the individual-level alone. Citation Format: Ashley S. Felix. Racial disparities in guideline-concordant endometrial cancer treatment [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr IA008.

Abstract A003: Decomposing racial and ethnic disparities in endometrial cancer survival

Abstract Background: Black-White mortality disparities are well-established and continue to widen over time among women diagnosed with endometrial cancer (EC). Yet, few studies have explored the existence or sources of racial/ethnic disparities in EC survival among Hispanic, American Indian/Alaska Native (AI/AN), Asian, and Native-Hawaiian/Pacific Islander (NH/PI) women. EC survival disparities across racial and ethnic groups have been suggested to be linked to differences in sociodemographic, clinical, and access to care characteristics. We examined how these individual- and area-level factors influence the presence of racial/ethnic disparities among women with EC. Methods: Participants were diagnosed between 2004 and 2019 with stages 1A through 4B endometroid and non-endometroid EC in the National Cancer Database (NCDB). Race was categorized as non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, Asian, NH/PI, and AI/AN. We performed Oaxaca-Blinder decompositions of the log overall survival (OS) time assuming an accelerated failure time model with Weibull error, which decomposes observed differences in log survival time into parts potentially explained by differences in measured prognostic factors and differences not explained by measured variables. We examined the following classes of prognostic factors: age at diagnosis, zip code-level demographics (educational attainment, average income, and rurality), access to care (insurance status, facility type and location, treatment delay), Charlson comorbidity score, tumor characteristics (stage and histology), and guideline-concordant treatment (GCT). White women were the comparison group in all decompositions. Results: Compared with NHW women (N=121,069; estimated overall survival for average covariates values (eOS)=19.7 years) eOS was significantly shorter among NHB women (N=15,855; eOS=9.9 years); longer among Asian women (N=5,098; eOS=42.7 years); longer among Hispanic women (N=9,671; eOS=25.9 years); and not significantly different in NH/PI (N=536; eOS=24.8 years) or AI/AN women (N=551; eOS=17.0 years). Measured covariates explained 76.7% of the difference for NHB women (p&amp;lt;0.001); 19.7% for Asian women (p&amp;lt;0.001); and did not significantly explain the difference for Hispanic women (8.4%; p=0.14). Factors significantly contributing to the observed differences for NHB women were tumor characteristics (61.5%); access to care (6.6%); zip code-level demographics (5.1%); comorbidity (3.9%); age (-1.8%); and GCT (1.5%). Significant factors for Asian women were age (16.6%); tumor characteristics (-6.0%); zip code-level demographics (4.7%); access to care (3.0%); and comorbidity (1.6%). Significant factors for Hispanic women were age (45.2%); tumor characteristics (-17.9%); access to care (-13.4%); comorbidity (-2.0%); and GCT (-1.0%). Conclusions: Contributors to EC survival disparities vary by race/ethnicity and strongly implicate the need for research to identify how disparities arise to tailor interventions to reduce survival gaps. Citation Format: Jordyn A. Brown, Jennifer A. Sinnott, Ziyu Gao, Caitlin E. Meade, Macarius M. Donneyong, Tasleem J. Padamsee, Ashley S. Felix. Decomposing racial and ethnic disparities in endometrial cancer survival [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr A003.

Evaluation of guideline-concordant treatment and clinical outcomes in non-small cell lung cancer: A study at a National-Referral Hospital in Indonesia

Non-adherence to guidelines has been demonstrated to affect clinical outcomes. With more than half of the global incidence of lung cancer occurring in Asia, this study aims to evaluate the guideline-concordant treatment (GCT) among Asian patients based on the 2018 NCCN-Asia consensus statements on NSCLC. Patients diagnosed with NSCLC between December 2018 and 2019 were identified from electronic medical records. Patients with complete data were divided into GCT-positive and negative groups. Statistical analyses were performed to analyze survival distributions and the associations between covariates and GCT status. Out of 50 patients, 90% were in stage IV. No patients underwent PET scans nor stereotactic radiotherapy due to the absence of facilities. Overall, 44% of patients were GCT-positive. Most GCT-negative patients did not receive chemotherapy due to poor performance scores. There was a significant difference in the survival distribution between groups (72.7% vs 39.3%, p=0.006). Age and sex were not significantly associated with GCT status (p&gt;0.05). After accounting for other covariates including histology, GCT-negative was still associated with an increased hazard of all-cause mortality (HR 3.07 [1.15-8.12]; p=0.025). Despite limitations, concordance with Asian-specific guidelines independently and significantly improved OS among patients at a national-referral hospital in Indonesia.

Simulating the population impact of interventions to reduce racial gaps in breast cancer treatment.

Inequities in guideline-concordant treatment receipt contribute to worse survival in Black breast cancer (BCa) patients. Inequity-reduction interventions (eg, navigation, bias training, tracking dashboards) can close such treatment gaps. We simulated the population-level impact of statewide implementation of inequity-reduction interventions on racial BCa inequities in North Carolina. Using registry-linked multi-payer claims data, we calculated Black/White inequities in endocrine (ET; n = 12,033) and chemotherapy (CTx; n = 1,819) receipt. We then built cohort- (ET and CTx), and race-stratified Markov models to simulate the potential increase in the proportion of patients receiving ET or CTx and subsequent improvements in BCa outcomes if inequity-reducing intervention were implemented statewide. We report uncertainty bounds representing 95% of simulation results. 75.6% and 72.1% of Black patients received ET and CTx over the 2006-2015 and 2004-2015 periods (vs 79.3 and 78.9% of White patients, respectively). Inequity-reduction interventions could increase ET and CTx receipt among Black patients to 89.9% (85.3, 94.6%) and 85.7% (80.7, 90.9%). Such interventions could also decrease 5-and 10-year BCa mortality gaps from 3.4 to 3.2 (3.0, 3.3) and from 6.7 to 6.1 (5.9, 6.4) percentage points in the ET cohorts and from 8.6 to 8.1 (7.7, 8.4) and from 8.2 to 7.8 (7.3, 8.1) percentage points in the CTx cohorts. Inequity-focused interventions could improve cancer outcomes for Black patients. However, they would not fully close the racial BCa mortality gap. Addressing other inequities along cancer continuum (eg, screening, pre-and post-diagnosis risk factors) is required to achieve full equity in BCa outcomes.

Associations Between Patient Experience With Care, Race and Ethnicity, and Receipt of CRC Treatment Among SEER-CAHPS Patients With Multiple Comorbidities.

Patients with colorectal cancer (CRC) and multiple comorbidities are less likely to receive guideline-concordant treatment (GCT), a disparity exacerbated by racial and ethnic disparities in GCT. Yet, positive patient experiences with care are associated with more appropriate care use. We investigated associations between patient experiences with care, race and ethnicity, and receipt of GCT for CRC among older adults with multiple comorbidities. We used SEER-Consumer Assessment of Healthcare Providers and Systems (CAHPS) data to identify participants diagnosed with CRC from 2001 to 2017 at age ≥67 years with additional chronic conditions. Stage-specific GCT was identified following recommendations in the NCCN Guidelines for Colon and Rectal Cancer. Patient experiences with care were identified from CAHPS surveys. Multivariable log-binomial regression estimated associations between race and ethnicity and receipt of GCT by experiences with care. A total of 2,612 patients were included. Those reporting excellent experience with getting care quickly were 5% more likely to receive GCT than those reporting less-than-excellent experience (relative risk [RR], 1.05; 95% CI, 1.04-1.05). When reporting less-than-excellent experience with getting care quickly, non-Hispanic Black (NHB) patients were less likely than non-Hispanic White (NHW) patients to receive GCT (RR, 0.80; 99.38% CI, 0.78-0.82), yet NHB patients were more likely to receive GCT than NHW patients when reporting excellent experience (RR, 1.05; 99.38% CI, 1.02-1.09). When reporting less-than-excellent experience with getting needed care, Hispanic patients were less likely than NHW patients to receive GCT (RR, 0.91; 99.38% CI, 0.88-0.94), yet Hispanic patients were more likely to receive GCT than NHW patients when reporting excellent experience (RR, 1.06; 99.38% CI, 1.03-1.08). Although excellent patient experience among those with multiple comorbidities may not be strongly associated with receipt of GCT for CRC overall, improvements in experiences of accessing care among NHB and Hispanic patients with CRC and additional comorbidities may aid in mitigating racial and ethnic disparities in receipt of GCT.

Abstract A129: Association of concordance with guidelines of the National Comprehensive Cancer Network and overall survival in Puerto Rican women with endometrial cancer

Abstract Background: Endometrial cancer represents a significant burden in Puerto Rico, as it is one of the most common cancers among women. Although it has a favorable prognosis when diagnosed early, it remains the fifth leading cause of cancer-related deaths among women living in Puerto Rico. This highlights the need to address healthcare disparities and improve the quality of the healthcare system. Treatment guidelines are designed to assist healthcare professionals in offering the best possible care to patients by providing evidence-based suggestions. Implementing standardized practices is crucial to enhancing healthcare quality outcomes. Our objective was to assess the concordance of National Comprehensive Cancer Network (NCCN) guidelines for endometrial cancer treatment and its association with overall survival. Methods: Data on endometrial cancer patients aged 18 years and older diagnosed between 2009 and 2015 was obtained from the Puerto Rico Central Cancer Registry, linked to the Puerto Rico Health Insurance Administration database (n=2,114). The association between clinical aspects, health system, and socioeconomic factors with receipt of guideline-concordant treatment was evaluated using logistic regression. Overall survival (OS) was calculated using the Kaplan-Meier method. Univariate and multivariate-adjusted Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between guideline-concordant treatment and OS. Results: In our cohort, 53.9% of patients received guideline-concordant treatment. Patients receiving treatment at a Commission on Cancer (CoC)-accredited facility are twice as likely to receive guideline-concordant treatment than non-accredited facilities (95% CI: 1.71-2.98). Individuals who received an assessment from a gynecologist oncologist are 90.0% more likely to receive treatment based on NCCN guidelines than those who did not (95% CI: 1.56-2.32). Private insured patients are 28.0% more likely to receive guideline-concordant treatment than Medicaid patients (95% CI: 1.02-1.61). In Cox regression models, guideline-concordant treatment was associated with a lower mortality risk compared to women who did not receive guideline-concordant treatment (95% CI: 0.59- 0.89). Conclusion: Receiving guideline-concordant treatment is a strong predictor of improved survival rates in endometrial cancer patients. Additionally, patients treated at CoC-accredited hospitals and by gynecologic oncologists tend to receive higher-quality care. Given that guidelines based on effective treatment standards have been demonstrated to enhance cancer patient outcomes, we must encourage and support factors contributing to their increased adoption. By doing so, we can strive to improve the prognosis and overall well-being of individuals affected by endometrial cancer in Puerto Rico. Citation Format: Yisel Pagan-Santana, Karen J. Ortiz-Ortiz, Maira Castañeda-Avila, Ruth Rios-Motta. Association of concordance with guidelines of the National Comprehensive Cancer Network and overall survival in Puerto Rican women with endometrial cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A129.

Evaluation of physicians prescribing of COVID-19 guideline–directed outpatient treatments in a primary care walk-in clinic

BackgroundCoronavirus disease 2019 (COVID-19) is a respiratory virus that has afflicted millions of individuals in the United States. A few medications have been determined to be beneficial for outpatient treatment. The medications in use against mild-to-moderate COVID-19 in the outpatient setting during the study period are nirmatrelvir-ritonavir, remdesivir, molnupiravir, and bebtelovimab. Proper assessment and treatment of patients with mild-to-moderate COVID-19 in the outpatient setting is critical to reducing rates of disease progression and hospitalization. ObjectiveThis study aimed to evaluate the appropriateness of the prescribing by internal medicine physicians for mild-to-moderate Coronavirus disease 2019 (COVID-19) infections based on the National Institutes of Health (NIH) guideline–directed COVID-19 outpatient treatment options. MethodsThis is a retrospective chart review examining the outpatient treatment of mild-to-moderate COVID-19 by internal medicine physicians between February 2022 and August 2022. Patients were eligible if they were 18 years or older, had a positive home or polymerase chain reaction (PCR) test, completed a telehealth visit within 7 days of the positive test, and were prescribed either nirmatrelvir-ritonavir, remdesivir, molnupiravir, or bebtelovimab for COVID-19 treatment. The primary end point was the appropriateness of COVID-19 treatment in the outpatient setting based on NIH guidelines, patient characteristics, and prescribing information for the medications. The secondary end point was hospitalization within 30 days of initiation of outpatient COVID-19 treatment. The presence or absence of a clinical pharmacist consultation at the time of prescribing was recorded as a process measure. ResultsA total of 376 encounters were assessed, of which 226 were included and analyzed. A total of 210 participants (93%) received nirmatrelvir-ritonavir. The remaining participants received molnupiravir or bebtelovimab. Overall, guideline-concordant treatment for mild-to-moderate COVID-19 was prescribed for 200 participants (88%). Among patient characteristics, only glomerular filtration rate (GFR) had a statistically significant difference between groups prescribed medication for the treatment of mild-to-moderate COVID-19. Fifty-six participants (25%) received clinical pharmacist consultation. Three participants were hospitalized for COVID-19 within 30 days of receiving an appropriately prescribed medication for treatment. Nirmatrelvir-ritonavir was the only medication potentially prescribed inappropriately due to lack of being renally dose adjusted and the extensive drug-drug interactions. ConclusionNirmatrelvir-ritonavir was the most prescribed medication for the treatment of mild-to-moderate COVID-19, consistent with its position as first-line therapy and widespread accessibility. The study results will inform future educational opportunities, such as in-service presentations and handouts, that may improve the prescribing of outpatient treatment for mild-to-moderate COVID-19 moving forward.

Abstract A137: Drive time to physicians and outcomes for bladder cancer

Abstract Introduction: Poor geographic access to cancer care providers can delay treatment and limit access to high quality care. Previous research has shown that for patients with bladder cancer, time to cystectomy and receipt of neoadjuvant chemotherapy are associated with improved survival. Travel burden may be an important barrier to timely guideline-concordant treatment and is particularly relevant for residents of rural areas, which are often medically underserved. This study examines the association between drive time to medical oncologists and urologists and clinical outcomes for muscle-invasive bladder cancer (MIBC) patients. Data and Methods: We used information on physician location from the Centers for Medicare and Medicaid Services and patient-level data from the 2010-2016 Pennsylvania Cancer Registry linked to Pennsylvania Healthcare Cost Containment Council (PHC4) inpatient discharge data through 2018. We examined patients in Pennsylvania with a first lifetime bladder cancer diagnosis who underwent radical cystectomy at a non-federal short-term general hospital identified in PHC4. Outcomes examined were surgery within 90 days, receipt of neoadjuvant chemotherapy, 90-day mortality and 90-day readmission. We estimated multivariable linear regression models at the patient level. Our primary exposures were the natural log number of minutes from the patient’s home census tract centroid to the nearest medical oncologist and the nearest urologist. We controlled for patient age, sex, race/ethnicity, tumor size, tumor node involvement, and Elixhauser comorbidity index. We included a control for whether the patient received neoadjuvant chemotherapy in models estimating the association between drive times and cystectomy within 90 days. We also controlled for area-level characteristics, including ZIP code median and area deprivation index quartile. Standard errors were clustered at the county level.Results: The study included 954 patients with MIBC, 1,520 medical oncologists, and 976 urologists in Pennsylvania. Mean (SD) drive time to the nearest oncologist was 17.1 (11.4) minutes and median drive time was 14.4 minutes. Mean drive time to the nearest urologist was 13.9 (9.2) minutes and median drive time was 11.7 minutes. A 30-minute increase in drive time to the nearest urologist was associated with a 12.5 percentage point lower likelihood of undergoing cystectomy within 90 days (95% CI: -24.3 to -0.6). A 30-minute increase in drive time to the nearest oncologist was associated with an 11.9 percentage point lower likelihood of receiving neoadjuvant chemotherapy (95% CI: -23.4 to -0.4). Drive time was not significantly associated with 90-day mortality or readmission within 90 days. Conclusions: Drive time to both oncologists and urologists is associated with timely receipt of guideline-recommended care for patients with MIBC. Understanding the impact of geographic access to medical oncologists and urologists on clinical outcomes for patients with MIBC can inform providers and policymakers in addressing geographic equity in cancer care. Citation Format: Sruthi Muluk, Coleman Drake, Zhaojun Sun, Manisha Bhattacharya, Bruce Jacobs, Lindsay M. Sabik. Drive time to physicians and outcomes for bladder cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A137.

Impact of interventions to reduce racial disparities in receipt of breast cancer guideline-concordant treatment: A statewide simulation analysis.

160 Background: Inequities in the receipt of guideline-concordant treatment contribute to worse survival in Black breast cancer (BCa) patients. Inequity reduction interventions (e.g., navigation, bias training, and real-time treatment tracking) may close such treatment gaps. However, evidence to date has been derived from small-scale interventional studies, and the potential impact of these interventions on population-level disparities is unclear. The aim of this study was to simulate the effect of implementing inequity reduction interventions on observed racial inequities in treatment and downstream outcomes after BC diagnosis. Methods: We used data from the North Carolina (NC) Cancer Information and Population Health Resource - which links multi-payer claims to state cancer registry data, for women diagnosed with BCa in 2004-2017 - to calculate Black/non-Black inequities in the receipt of chemotherapy (CTx) within 4 months for women ages &lt;70 with hormone receptor-negative stage Ib-III BCa (n=2,223) and endocrine therapy (ET) within 12 months for stage I-III hormone receptor-positive BCa (n=16,220) in NC. Using effect estimates from trials of inequity-reducing interventions, we simulated the potential increase in the proportion of patients receiving CTx or ET if such interventions were implemented statewide. We estimated the effect of this potential increase in CTx and ET receipt on 10-year BCa mortality by building cohort-, race-, and treatment receipt-stratified simulation Markov models. We report confidence bounds representing 95% of simulation results. Results: Only 70.7% and 72.9% of Black patients in our cohorts received guideline-recommend ET and CTx, respectively, in 2004-2017 (versus 74.3 and 79.4% of non-Black patients, respectively; p&lt;.005). Statewide implementation of inequity reduction interventions could increase ET and CTx receipt among Black patients to 84.3% (79.1-89.3%) and 86.8% (81.5-91.9%), respectively. This would be expected to reduce 10-year BCa mortality among Black patients from 14.2% to 13.6% (13.3-13.9%) in the ET cohort and from 29.4% to 28.7% (28.3-29.1%) in the CTx group. As a result, the racial mortality gap would decrease from 5.7 to 5.2 (4.9-5.5) from 7.0 to 6.6 (6.2-6.9) in the CTx cohorts, respectively. Conclusions: Implementation of interventions designed to reduce treatment inequities are likely to improve cancer care equity. However, increases intreatment receipt alone will not close the BCa mortality gap. Inequities at other points on the cancer continuum, such as in pre-diagnostic risk factors, screening, diagnostic work-up, and post-treatment factors, may explain residual gaps which will require more comprehensive interventions to achieve full equity in breast cancer outcomes.

P2.31-11 Impact of Stage-Specific Guideline Concordant Treatment in Small Cell Lung Cancer in Victoria, Australia

P2.31-11 Impact of Stage-Specific Guideline Concordant Treatment in Small Cell Lung Cancer in Victoria, Australia

Disparities in Access to Radiotherapy Among Hispanic/Latinx Populations in the United States: How Far Have We Left to Go?

The Hispanic/Latinx population has consistently faced disparities in oncology access and outcomes with cancer being the leading cause of death in this population. We evaluate recent research in radiation therapy disparities among the Hispanic/Latinx population in the United States since our seminal analysis from 2017. A PubMed literature search was conducted for articles published from January 2017 through March 2023. Four term combinations were utilized, including: (1) "Hispanic" and "Radiotherapy" and "Disparities", (2) "Latino" and "Radiotherapy" and "Hispanic", (3) "Hispanic" and "Radiation" and "Disparities", and (4) "Latino" and "Radiation" and "Disparities." Included studies were those taking place in the United States, examined radiation oncology care, and examined health disparities. Fifty-eight of 245 articles returned met inclusion criteria and spanned 6 disparity-types: (1) Stage at Presentation, (2) Time to Treatment Initiation & Completion, (3) Receipt of Treatment and Guideline-Concordant Care, (4) Geography, (5) Clinical Trial Access and (6) Insurance Barriers and Treatment Center Type. The most common disparity was receipt of treatment and guideline-concordant care (n=39 studies), demonstrating that the Hispanic/Latinx population was less likely to receive guideline-concordant treatment or treatment at all. In additon, studies identified disparities in time to treatment and completion (n=12), geography (n=5), clinical trial access (n=3), and insurance and treatment center access (n=5). Disparities in radiotherapy access remain prominent for the Hispanic/Latinx population through a multitude of barriers, despite increasing interest in disparities research. Continued health care disparities research with tangible interventions are needed in radiation oncology to properly understand and address this problem.

The costs and inequities of precision medicine for patients with prostate cancer: A call to action.

Financial toxicity is a growing problem in the delivery of cancer care and contributes to inequities in outcomes across the cancer care continuum. Racial/ethnic inequities in prostate cancer, the most common cancer diagnosed in men, are well described, and threaten to widen in the era of precision oncology given the numerous structural barriers to accessing novel diagnostic studies and treatments, particularly for Black men. Gaps in insurance coverage and cost sharing are 2 such structural barriers that can perpetuate inequities in screening, diagnostic workup, guideline-concordant treatment, symptom management, survivorship, and access to clinical trials. Mitigating these barriers will be key to achieving equity in prostate cancer care, and will require a multi-pronged approach from policymakers, health systems, and individual providers. This narrative review will describe the current state of financial toxicity in prostate cancer care and its role in perpetuating racial inequities in the era of precision oncology.

Biomarker Testing, Treatment, and Outcomes in Patients With Advanced/Metastatic Non-Small Cell Lung Cancer Using a Real-World Database.

Little is known about the impact of up-front biomarker testing on long-term outcomes in patients with advanced or metastatic non-small cell lung cancer (a/mNSCLC). This study compared overall survival (OS) by biomarker testing status and by receipt of guideline-concordant therapy in a large real-world cohort of patients with a/mNSCLC in the United States. This retrospective study used an a/mNSCLC database derived from real-world electronic healthcare records. Patients diagnosed with nonsquamous a/mNSCLC who initiated first-line therapy on or after January 1, 2015, were included. We describe the testing of patients for actionable biomarkers and whether they subsequently received guideline-recommended first-line treatment. OS was defined as the number of months from the initiation of first-line therapy to the date of death or end of follow-up, and was described using Kaplan-Meier analysis. Multivariable Cox proportional hazard modeling was conducted to compare OS between groups adjusting for baseline covariates; adjusted hazard ratios (HRs) were reported. A total of 21,572 patients with a median age of 69 years (IQR, 61-76 years) and follow-up of 9.5 months (IQR, 3.5-21.5 months) were included. Among patients in the database, 88% had a record of receiving testing for at least 1 biomarker at any time, and 69% of these patients received testing before or at the start of first-line treatment. The adjusted hazard of death was 30% higher in patients who never (vs ever) received biomarker testing in the database (HR, 1.30; 95% CI, 1.24-1.37), and 12% higher in patients who did not receive (vs did receive) biomarker testing before or at the start of first-line treatment (HR, 1.12; 95% CI, 1.08-1.16). The adjusted hazard of death was 25% higher in patients who did not receive guideline-concordant first-line treatment (vs those who did) after having a biomarker-positive disease (HR, 1.25; 95% CI, 1.13-1.40). Findings suggest that receipt of first-line treatment that is concordant with biomarker testing results and treatment guidelines is associated with improved survival outcomes in patients with a/mNSCLC in the United States.

Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study.

The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region. A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients ("traced cohort"). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI). Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83-6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07-2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%-76.3%) and 45.3% (95% CI, 38.9%-51.7%), respectively. Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.

Medicaid expansion is associated with treatment receipt, timeliness, and outcomes among young adults with breast cancer.

Female breast cancer is a common cancer in young adults, an age group with the highest uninsured rate. Among 51 675 young adult women (ages 18-39 years) diagnosed with breast cancer between 2011 and 2018 in the National Cancer Database, we estimated changes in guideline-concordant treatment receipt, treatment timeliness, and survival associated with the Affordable Care Act Medicaid expansion. Of young adults with stage I-III estrogen receptor-positive or progesterone receptor-positive breast cancer, Medicaid expansion was associated with a net increase of 2.42 percentage points (95% confidence interval [CI] = 0.56 to 4.28 percentage points) in the percentage receiving endocrine therapy. Among all young adults with stage I-III breast cancer, Medicaid expansion was associated with a net reduction of 1.65 percentage points (95% CI = 0.08 to 3.22 percentage points) in treatment delays defined as treatment initiation of at least 60 days after diagnosis and a net increase of 1.00 percentage points (95% CI = 0.21 to 1.79 percentage points) in 2-year overall survival. Our study provides evidence of benefit in cancer care and outcomes from Medicaid expansion among the young adult population.