Integrated Network Cancer Programs Research Articles

Overall Survival of Adult Acute Lymphoblastic Leukemia (ALL) Patients By Facility Volume and Type: A National Cancer Database Report

Introduction: The majority of acute lymphoblastic leukemia (ALL) deaths occur in adults, with only 40% of adult ALL patients achieving 5-year leukemic-free survival, and decreasing cure rates with increasing age (Abuasab 2021). ALL treatment is variable across facilities, based on patient and disease features, along with institutional factors (Khullar, 2022). Currently, there are limited studies that investigate adult ALL overall survival (OS) outcomes by facility characteristics. The primary objective of our study was to determine adult ALL OS by facility volume and type for adult patients. Methods: This retrospective study analyzed de-identified National Cancer Database (NCDB) files from 2004-2016. ALL patients >18 years of age met inclusion criteria. Facility type was not available for patients <40 years of age, and was excluded from analysis. Baseline patient characteristics were extracted and sub-grouped by age >18 to <40 and >40. Summary statistics included frequency (%) for categorical variables and median [IQR] for non-normal continuous variables. Group differences were compared with Chi-square or Kruskal-Wallis rank sum tests. Facility volume was determined by a maximally selected log-rank statistics, with high volume (HV) versus low volume (LV) cut point at >91%. Academic programs (APs) included academic/research and integrated network cancer programs. Community programs (CPs) included community and comprehensive community programs. OS Kaplan Meier (KM) curves censored by death or last follow-upwere created for facility volume and type. Analysis was conducted with R software 4.0.3. The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, these institutions have not verified and are not responsible for the methodology or findings of this research. Results: 22,453 ALL patients were included in the study (>18 to <40 years N=7860; >40 years N=14,593). 12,453 (55.5%) patients were treated at HV and 10,000 (44.5%) at LV centers. 9708 (66.5%) of patients >40 years were treated at APs and 4885 (33.5%) patients were treated at CPs. For both age cohorts, patients were more likely to be male, White, Non-Hispanic, have a Charlson Comorbidity Index of 0, private insurance, a median income >$63,000, and reside in a metro area 10-100 miles from the treatment center (P < 0.001)(Table 1). Analysis of patients >18 to <40 years found no significant OS difference between patients treated at LV and HV centers (mOS 64.4 mo., 95% CI 62.2-67.6 vs. 60.9 mo., 58.2-63.4; p = 0.1). Analysis of patients >40 years found longer OS in patients treated at LV CP (red line) compared to HV AP (purple line) (mOS 71.1 mo., 95% CI 66.6-75.8% vs. mOS 56.9 mo., 95% CI 56.6-62.7; P <0.0001) (Figure 1). OS was greater at LV compared to HV centers (mOS 68.7 mo., 95% CI 65.2-71.5 vs. 59.5 mo., 95% CI 56.6-62.3; P < 0.0001) and OS was greater at CPs compared to APs (mOS 69.2 mo., 95% CI 65.0-72.6 vs. 61.2 mo., 95% CI 58.5-63.4; p = 0.00049). Discussion: This large, national study provides insight into OS in adult ALL patients by treatment facility. Despite a paucity of differences in patient characteristic trends between age cohorts, we found OS differed by facility volume in older ALL patients but not younger adult patients. Interestingly, OS of young adult ALL patients was not uniformly superior to older patients. OS in patients >40 years was longest in those treated at LV and CPs, and shortest amongst patients treated at HV and APs. Potentially, patients with more advanced/high-risk disease, and therefore worse prognosis, were selectively treated at HV and APs, accounting for inferior OS. Additionally, perhaps more aggressive treatments were attempted at HV and APs, increasing risk of death in the older adult population. Finally, differences in sociodemographics may have driven OS differences. Our study was limited by its retrospective nature, the delay in reported NCDB data and current clinical practice, and missing facility type for patients <40 years. Conclusion: OS in adult ALL patients >40 years was significantly different by facility volume and type, with the greatest OS in patients treated at LV and CPs, and the least OS at HV and APs. Amongst patients >18 to 40 years of age, there was no difference in OS by facility volume. Future research is needed to understand and improve adult ALL OS trends observed between treatment facilities. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prognostic factors in patients receiving surgery and radiation therapy for retroperitoneal sarcoma: A machine-learning analysis

BackgroundThe addition of radiation therapy to surgery for retroperitoneal sarcoma remains controversial. Improved patient selection may help identify optimal candidates for multimodality treatment. The aim of this analysis was to define prognostic factors among patients who receive radiation therapy and surgery to aid in patient selection for multimodal therapy. MethodsPatients who received radiation therapy and underwent curative-intent resection for retroperitoneal sarcoma between 2004 and 2016 were identified from a national cohort in the United States (National Cancer Database). A machine-based classification and regression tree model was used to generate similar groups of patients relative to overall survival based on preoperative factors. ResultsA total of 1,443 patients received radiation therapy in addition to surgery. Median age was 61 years old and 55.0% were female. Most patients (66%) received care at an academic or integrated network cancer program. With a median follow-up of 84 months, receipt of radiation therapy was not associated with improved overall survival (P = .81). Classification and regression tree analysis revealed a significant association between overall survival and American Joint Committee on Cancer stage group, age, tumor histology, and Charlson comorbidity score. Application of these parameters via machine learning stratified patients into 5 cohorts with distinct survival outcomes. In the most favorable cohort (Cohort 1: American Joint Committee on Cancer stage group ≤II, age ≤61, histology including fibrosarcoma, well differentiated liposarcoma, myxoid liposarcoma, and leiomyosarcoma), the 5-year overall survival was 81.7% and median overall survival was not reached; in the least favorable cohort (Cohort 6: American Joint Committee on Cancer stage group >II, age >68) where the 5-year survival was 41.3% and median overall survival was 45.2 months (P < .001 versus Cohort 1). ConclusionIn the absence of a defined survival benefit, patients with advanced American Joint Committee on Cancer stage group, older age, and medical comorbidities have relatively unfavorable overall survival after combined modality therapy and therefore stand the least to gain from the addition of radiation therapy to surgery. In contrast, younger patients with good performance status and retroperitoneal sarcoma histologies with a higher propensity for local recurrence may have the greatest opportunity to benefit from radiation therapy.

34689 Merkel cell carcinoma: The effect of facility type on patient outcomes

Introduction: Significant progress has been made in the management of patients with Merkel cell carcinoma over the last decade. It is unclear how the type of the health care facility at which treatment occurs may alter patient outcomes. Methods: Data from Merkel cell cancers (MCCs) reported to the National Cancer Data Base (NCDB) between 2004-2017 were examined. Type of institutions were: Academic/Research Cancer Program (ARP), Comprehensive Community Cancer Program (CCCP); Integrated Network Cancer Program (INCP) and Community Cancer Program (CCP). Results: A total of 15,771 patients with MCCs and known institution type and disease stage where they received treatment and disease stage were analyzed. The majority of patients were treated at an ARP (n = 7190, 45.6%) or a CCCP (n = 5688, 36.1%). Patients treated at ARP were younger (ARP = 73.4 yrs vs CCCP = 75.2 yrs, CCP = 74.9 yrs, INCP = 74.3 yrs; P < .001) and had a higher percentage of Charlson/Deyo score of 0 (ARP = 74.7%, CCCP = 70.9%, CCP = 73.1%, INCP = 72.8; P < .001). Treatment at ARPs was associated with improved overall survival (median OS: ARPs: 75 mo, CCCP: 46 mo, CCP: 34.3 mo, INCP: 51.9 mo; P < .001). The difference in survival persistent for stage 1 (median OS: ARPs: 101 mo, CCCP: 74.9 mo, CCP: 77.1 mo, INCP: 93.4 mo; P < .001), stage 2 (median OS: ARPs: 63.6 mo, CCCP: 41 mo, CCP: 31.7 mo, INCP: 48.9 mo; P < .001), stage 3 (median OS: ARPs: 51.9 mo, CCCP: 34.5 mo, CCP: 27.2 mo, INCP: 36.5 mo; P < .001) and stage 4 (median OS: ARPs: 11.6.6 mo, CCCP: 10 mo, CCP: 10.1 mo, INCP: 9.4 mo; P < .005). Treatment at ARP was associated with more frequent use of immunotherapy (ARP = 2.1%, CCCP = 1.3%, CCP = 1.3%, INCP = 1.5%; P = .001). Conclusions: Treatment of MCC at ARPs is associated with improved overall survival. The association of improved outcomes with ARP persist for early and late disease stages.

Use of Palliative Interventions at End of Life for Advanced Gastrointestinal Cancer.

Despite the well-established benefits of palliative care, little is known about the use of palliative interventions among patients with advanced gastrointestinal (GI) cancer near the end of life (EOL). A national cohort study analyzed 142,304 patients with advanced GI cancers (stage 3 or 4) near EOL (death within 1 year of diagnosis) in the National Cancer Database (2004-2014) who received palliative interventions (defined as treatment to relieve symptoms: surgery, radiation, chemotherapy, and/or pain management). The study used multivariable hierarchical regression evaluate the association between the use of palliative interventions, temporal trends, and patient and hospital factors. Overall, 16.5% of the patients were treated with a palliative intervention, and use increased over time (13.4% in 2004 vs 19.8% in 2014; trend test, p < 0.001). Palliative interventions were used most frequently for esophageal cancer (20.6%) and least frequently for gallbladder cancer (13.3%). Palliative interventions were associated with younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99), recent diagnosis year (OR, 1.05; 95% CI, 1.04-1.06), black race (white [ref]; OR, 1.07; 95% CI, 1.01-1.12), insurance status (no insurance [ref]; private: OR, 0.92; 95% CI ,0.95-0.99), hospital type (community cancer program [ref]; integrated network cancer programs: OR, 1.37; 95% CI ,1.07-1.75), and stage 4 disease (OR, 2.17; 95% CI, 2.07-2.27). Patients in southern and western regions were less likely to receive palliative intervention (Northeast [ref]; OR, 0.76; 95% CI, 0.62-0.94 and OR 0.46; 95% CI, 0.37-0.57, respectively). Increased palliative intervention use over time suggests ongoing changes in how care is delivered to GI cancer patients toward EOL. However, sociodemographic and geographic variation suggests opportunities to address barriers to optimal EOL care.

Equity vs. variety: Demographic and facility factors are associated with variation in adjuvant treatment for stage IB grade 3 endometrioid endometrial cancer (193)

Equity vs. variety: Demographic and facility factors are associated with variation in adjuvant treatment for stage IB grade 3 endometrioid endometrial cancer (193)

P775: CLINICAL OUTCOMES AND SOCIOECONOMIC FACTORS IN CHRONIC MYELOMONOCYTIC LEUKEMIA IN THE UNITED STATES USING THE NATIONAL CANCER DATABASE: 2004-2017

Background: Chronic myelomonocytic leukemia (CMML) is a rare myeloid malignancy characterized by proliferation of dysplastic monocytic cells and carries a risk for leukemic transformation. Previously, we described the incidence and outcomes of CMML at the population level (2004-2015) using the Surveillance, Epidemiology, and End Results Program (SEER) and National Cancer Database (NCDB) (Ruan et al., ASH 2020). We studied population-based outcomes in CMML using the NCDB from 2004-2017. Aims: Our aim was to understand the impact of social determinants of health on outcomes in CMML. Secondly, we studied if the outcomes of CMML have improved. Methods: The NCDB is a nationwide oncology outcomes database for >1500 cancer programs in the US and Puerto Rico, capturing 70% of all newly diagnosed cases of cancer. We queried the NCDB using the ICD-O-3 diagnosis code 9945/3 from 2004-2017. Only patients (pts) with diagnostic confirmation via histopathologic examination were included. Percent without high school degree (HSD) reflects the education level within the pt’s zip code, which was stratified into 4 quartiles. Median household income was estimated by matching the pt’s zip code at time of diagnosis against US Census 2000 data, which was stratified into 4 quartiles. Hazard ratios (HR) with confidence intervals (CI) were calculated using a Cox proportional hazards model. Overall survival (OS) was estimated using the Kaplan-Meier method. Variables significant in univariable analysis were included in a multivariable analysis. Results: We identified 7143 CMML pts in the NCDB. The median age at diagnosis was 72 years (interquartile range [IQR] 65-81) and 4386 (61%) were males. With a median follow up of 6.1 years (IQR 3.6-9.4), the median OS was 1.4 years (IQR 0.4-3.8). 1600 (23%) had private insurance, 4862 (70%) had Medicare, 298 (4%) had Medicaid, and 129 (2%) were uninsured. In univariate analysis, private insurance had an improved OS compared to patients with Medicaid (HR 1.2, 95% CI 1.06-1.4; p value 0.007), Medicare (HR 1.5, 95% CI 1.4-1.6; p value < 0.001), and other government insurance (HR 1.5, 95% CI 1.1-2.0; p value 0.004). Pts living in a zip code with percent of adults without an HSD of < 14% had an improved OS compared to zip codes with > 29% (HR 1.2, 95% CI 1.1-1.3; p value < 0.001). Median household income by zip code of ≥ $46,000 had an improved OS compared to < $30,000 (HR 1.2, 95% CI 1.1-1.4; p value < 0.001). Receiving treatment at an academic program had an improved OS compared to community cancer programs (HR 1.2, 95% CI 1.1-1.3; p value < 0.001), comprehensive community cancer programs (HR 1.3, 95% CI 1.3-1.4; p value < 0.001), and integrated network cancer programs (HR 1.3, 95% CI 1.2-1.4; p value < 0.001). Finally, pts diagnosed in 2012-2017 had an improved OS compared to pts diagnosed in 2004-2011 (HR 0.8, 95% CI 0.8-0.9; p value < 0.001). Variables significant in univariate analysis were included in multivariate analysis (Table 1). When education level and median household income per zip code were included in multivariate analysis, education level remained statistically significant and income did not. Image:Summary/Conclusion: CMML continues to have a poor prognosis, but OS has improved in recent years. Socioeconomic factors including insurance status, level of education and median household income per zip code, and facility type appear to be associated with outcomes. On multivariable analysis, age < 65, private insurance (vs government insurance), living in a zip code with increased percent HSD, and treatment at an academic program had improved outcomes.

Gastric Neuroendocrine Tumor Treatment and Survival Outcome Depends on Facility Type.

Gastric neuroendocrine tumors (gNETs) are rare cancers for which surgery may improve survival. We aim to determine if facility type affects treatment and survival outcomes. The NCDB was queried for patients with gNET from 2004-2016 and stratified into Academic/Research Program (ARP), Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), or Integrated Network Cancer Program (INCP). Overall survival along with clinical and demographic features was compared. Median survival was improved in patients treated at an academic program: 137.3 months versus 88.0, 96.3, and 100.2 for CCP, CCCP, INCP, respectively (P < .0001). Patients treated at academic centers were more likely to have surgery (64.2% vs 59.1%, 57.5%, 51.4%, P < .0001). After propensity matching for age, race, grade, stage, insurance status, and comorbidity score, survival benefit from treatment at an academic center remained (P = .03), particularly for patients undergoing surgery (P < .0001) and chemotherapy (P = .04). Patients with gNET treated at an academic hospital had improved median survival after propensity matching and may benefit from treatment at academic rather than community medical centers.

Facility type and late-stage Thyroid Hürthle Cell Adenocarcinoma: A NCDB Review.

e18074 Background: Hürthle cell adenocarcinoma, or oxyphilic adenocarcinoma, is a rare and invasive cancer accounting for 3-4% of all thyroid malignancies. Surgical removal is the most common treatment. Survival differences based on treatment facility have been identified in other cancers, but this has not yet been studied in Hürthle cell adenocarcinoma. This study utilizes the National Cancer Database (NCDB) to investigate facility survival differences. Methods: Using the NCDB, 2,900 patients with stage III or IV oxyphilic adenocarcinoma of the thyroid were identified with ICD-O-3 histology code 8290/3 and primary site C739 between years 2004 and 2016. Facility types included community cancer, comprehensive community cancer, academic/research, and integrated network cancer programs. Between-facility type survival differences were estimated by the Kaplan-Meier method and associated log-rank tests. Descriptive statistics of race, sex, stage, facility location, urban/rural 2013, primary payer, median income quartile, and Charlson-Deyo score were used. All analysis was conducted using SPSS statistical software version 27. Results: Survival data was available for 2,017 stage III patients and 644 stage IV patients. In stage III, survival was lower in community programs when compared to academic/research (p = .011) and integrated network programs (p = .017). In stage IV, survival was also lower in community programs when compared to academic/research (p = .007) and integrated network programs (p = .011). No significant difference was seen within other comparisons. In both stages, the highest percentage of patients were white, had a Charlson-Deyo score of 0, and were treated in an urban metro area. Sex and facility location were variable among all stages and facilities. In stage III, private insurance was most common overall and for academic/research programs, but Medicare was the majority for other facility types. In stage IV, Medicare was most common overall and for each facility. The median income quartile was &gt; $63,000 across all facility types for stage III and overall for stage IV, although stage IV treated in community and integrated network programs were most commonly between $48,000-$62,999. Conclusions: Patients with late-stage Hürthle cell adenocarcinoma have worse survival when treated in a community program than other facility types. Most demographics were consistent across stage and facility type, except for sex, primary insurance, median income, and facility location. This data contributes to a developing understanding of differences in cancer survival.[Table: see text]

Facility type and it's impact on survival in Ewing's sarcoma: An NCDB analysis.

e23505 Background: Previous studies have reported a significant association between facility type and survival in cancer patients. This study aimed to investigate the impact of treatment facility type on overall survival for Ewing’s Sarcoma. A secondary objective was to identify differences in distribution of demographic variables between facility types. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with Ewing’s sarcoma from 2004 to 2018. Four facility types were identified: Academic/Research Programs, Community Cancer Programs, Comprehensive Community Center Programs, and Integrated Network Cancer Programs. Descriptive statistics and Kaplan Meier curves were used to measure survival in these patients and Chi-square was used to evaluate differences in demographics. Data was analyzed using SPSS and statistical significance was set at α = 0.05. Results: Of 269 patients queried, 49% were treated at an academic facility. Academic Programs had the longest median survival of 54 months; Community Cancer Programs had the shortest median survival of 9 months. Statistically significant survival differences were found between all facility types on log-rank comparison (p &lt; 0.050), except for survival between Integrated Network and Community Cancer Programs (p = 0.162). Academic Programs had the highest overall survival when compared to Community Cancer Programs (p = 0.000), Comprehensive Community Cancer Programs (p = 0.026), and Integrated Cancer Networks p = (0.003). Chi-Square analysis revealed an association between facility type and cancer stage at diagnosis (p = 0.044) as well as between facility type and primary payer status (p = 0.026). Notably, 58% of patients treated at Community Programs presented with stage IV disease and 41% were insured by Medicare. Additional log-rank comparisons and Kaplan Meier curves showed private insurance was associated with significantly higher survival compared with Medicaid (p = 0.043), Medicare (p = 0.001) and uninsured patients (p = 0.010). Patients treated at Comprehensive Community (70%) and Academic Programs (67%) had the highest proportion of patients with private insurance. Conclusions: This study showed that Ewing Sarcoma patients treated in an Academic/Research program facility experienced increased survival compared with other facility types. Patients treated at Community Cancer Programs were more likely to present with stage IV disease and were more likely to be on Medicare. Future studies may investigate additional factors that influence potential barriers to care for Ewing Sarcoma patients.[Table: see text]

Survival trends in hilar and extrahepatic cholangiocarcinoma based on Facility type: A National Cancer Database analysis.

e13536 Background: The diagnosis and treatment of Cholangiocarcinoma continues to pose a challenge. Due to their rarity, few studies have examined the impact of facility type on the survival of patients with extrahepatic cholangiocarcinoma. The hypothesis of this study was that differences in the outcome of patients at different facility types exist. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with hilar and extra-hepatic cholangiocarcinoma from 2004 to 2017 using ICD-O-3 histology codes. We used four different cohorts to assess survival amongst those at different facility types: academic/research programs, community cancer programs, comprehensive community center programs, and integrated network cancer programs. Data was analyzed and descriptive statistics and Kaplan Meier curves were produced using SPSS to measure survival in these patients with statistical significance set at α = 0.05. Results: Using the database, a total of 57,146 patients with hilar and extrahepatic cholangiocarcinoma were identified. Overall median survival in these patients was 11.2 months. Patients at Academic/research programs had a median survival of 14 months (95% CI 14.1-14.8 p &lt; 0.001). In comparison, median survival of 9.7 months (95%CI 9.3-10.2 p &lt; 0.001) and 8.7 months (95% CI 8.4-8.9 p &lt; 0.001) was noted in Integrated network and Comprehensive community cancer programs, respectively. Community cancer programs had the lowest median survival rate in patients with all extrahepatic biliary tract cancers included in our study was 6.9 months (95% CI 6.4-7.7 p &lt; 0.001). Specifically, patients with Klatskin tumors at Academic/Research programs had median survival of 10.3 months (95% CI 8.6-11.9 p &lt; 0.0010) compared to median survival of 3.6 months in patients treated at Community Cancer program. We also studied specific histology types such as papillary and mucinous adenocarcinomas. In papillary adenocarcinomas, there are no statistically significant differences in median survival in different facility types. In mucinous adenocarcinomas, median survival of 26.5 months was found in academic/research program patients compared to 16.2 months in Comprehensive Community Cancer program patients (p &lt; 0.001). Conclusions: Median overall survival in patients with hilar and extrahepatic cholangiocarcinoma was significantly higher in academic/research programs compared to other facility types. Further studies are needed to ascertain why academic/research programs have superior outcomes in these patients.

Treatment facility: Effects on stage IV osteosarcoma survival.

e23501 Background: Osteosarcoma is a malignant, bone-forming tumor that makes up approximately 20% of bone cancers. Osteosarcoma has an overall 5-year survival of 68%, so to see significant changes in survival, this study looks only at Stage IV osteosarcoma. Osteosarcoma is most commonly treated with a combination of chemotherapy and surgery, but no studies have been conducted to investigate the facility type at which treatment is received and its effect on survival outcomes. The goal of this study is to investigate the survival of patients with stage IV osteosarcoma based on treatment facility type. Methods: There were 1,634 patients with stage IV osteosarcoma identified in the National Cancer Database (NCDB), with 657 including data on facility type. SPSS version 27 was used to generate both descriptive statistics regarding demographics and Kaplan-Meier curves to determine the impact treatment facility type has on overall survival. Results: Stage IV osteosarcoma was more common in males (59.5%) and white race (77%) with 55.4% receiving treatment at academic centers, 22.5% at comprehensive community programs, 16.9% at integrated cancer programs, and 5.2% at community cancer programs. Patients on Medicare also demonstrated a decreased overall survival when compared to all other insurance types (p &lt; 0.001). In stage IV osteosarcoma patients, there were statistically significant differences in survival outcomes when comparing each facility type to each other (with p values all &lt; 0.05), except for the comparison between comprehensive community cancer programs and integrated network cancer programs. Patients who received treatment at academic/research programs demonstrated the best overall survival with a median of 7.29 months when compared to community center programs, comprehensive community cancer programs, and integrated network programs (with p values of &lt; 0.001, 0.046, and 0.03, respectively). Patients treated at academic research programs were more likely to be white males with private insurance or Medicare. Conclusions: Patients treated at academic centers for stage IV osteosarcoma had better survival outcomes compared to those treated at nonacademic facilities. These patients were more likely to be white, insured individuals. African Americans and Medicare patients were associated with increased risk of mortality from stage IV osteosarcoma. Future studies can be done with multivariate analyses to determine other variables that may affect outcomes in this patient population.[Table: see text]

Outcomes in patients undergoing curative surgery for gastric cancer by facility type and socioeconomic factors: An analysis of the National Cancer Database (NCDB).

4066 Background: Surgical and medical treatment for resectable gastric cancer is complex, and multidisciplinary team involvement is essential to provide optimal treatment outcomes. However, socioeconomic disparities influence the quality of medical care patients receive. We hypothesized that facility type, median income, insurance type, and location would impact patients' overall survival (OS). Methods: In a retrospective analysis of NCDB data, we identified patients with stage II and III gastric adenocarcinoma who underwent curative-intent surgical resection and chemotherapy between 2004-2018. Demographic and socioeconomic factors were studied, including treatment facility type, median household income, urban/rural residence, and insurance status. Multivariate Cox proportional hazard model was used to evaluate the impact of these variables on overall survival (OS). The Kaplan-Meier method was used to estimate OS. Log-rank test was used to compare the OS between groups. Results: Based on the criteria listed above, 36,318 patients were identified: 76.3% were Caucasian, 14.4% black, 7.2% Asian, and 2.0% other. 56.4% lived in large metropolitan areas (LM), 29.9% in small/medium metropolitan areas (SM), and 14.2% in rural areas (RA). Patients who were treated in academic/research programs had significantly better OS (mOS 40.5 months) compared to integrated-network cancer programs (mOS 34.0 months, HR 0.897, p &lt; 0.0001), comprehensive community cancer programs (mOS 31.0 months, HR 0.89, p &lt; 0.0001), and community cancer programs (mOS 29.5, HR 0.881, p &lt; 0.0001). Patients from LM had better OS compared to those from SM and RA (mOS 39.0, 32.1, 29.9 months respectively, p &lt; 0.0001). Privately insured patients had improved OS compared to Medicare-insured patients (mOS 40.8 vs 29.7 months, HR 0.758, p &lt; 0.0001). Higher annual income (≥ $63,000) was positively associated with improved OS (p &lt; 0.0001). Conclusions: Outcomes for patients with gastric cancer treated with surgery and chemotherapy are strongly influenced by socioeconomic variables, including place of residence, treatment setting, insurance, and income level. We highlight improved outcomes in patients who resided in LM and were treated at academic/research centers. A potential hypothesis for this trend is increased access to specialized, multidisciplinary care and clinical trials.

Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival.

During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes. Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP). A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001). Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.

Abstract P2-12-17: Comparative outcomes of Neoadjuvant versus Adjuvant chemotherapy in HR+/HER2- node positive breast cancer

Abstract Background Neoadjuvant therapy is considered for patients with hormone receptor (HR) positive/Human Epidermal Growth factor Receptor (HER) 2 negative breast cancers primarily to reduce tumor size and optimize surgical outcomes, and improve the chances for breast conservation. This approach rarely leads to pathological complete response and raises concerns about potential adverse outcomes due to delaying surgery. The objective of this study was to compare long term outcomes in patients receiving neoadjuvant (NAC) versus adjuvant chemotherapy (AC) for node positive breast cancer and to analyze survival in these groups when stratified by clinical stage. Methods We sampled the National Cancer Database (NCDB) (2004-2016) for patients with HR positive [estrogen receptor (ER) positive and/or progesterone receptor (PR) positive], HER2 negative, clinically diagnosed node positive breast cancers. We performed a multivariate logistic regression analysis to summarize demographic, geographic, and disease characteristics associated with the specific chemotherapy regimen. We then used multivariate cox regression models to compare hazard ratios for the same variables and plotted Kaplan-Meier survival plots to look for survival rate differences (S) between NAC and AC stratified by stage IIA, IIB, IIIA, and IIIB. Results Out of the 134,704 female patients who were included in this analysis (79.2% Caucasian, mean age 59.13 years), 24.9% received NAC, and 46.3% AC. In our study, patients older than 70 years had lower odds of receiving either NAC or AC (NAC: OR = 0.33, 95% CI = 0.31 - 0.35, p &amp;lt;0.001 and AC: OR = 0.31, 95% CI = 0.29 - 0.32, p &amp;lt; 0.0001) while those on private insurance had increased odds of getting either NAC or AC (NAC: 1.33, 95% CI = 1.23 - 1.45, p &amp;lt; 0.001 and AC: OR = 1.13, 95% CI = 1.06 - 1.21, p = &amp;lt;0.001) as compared to their counterparts. Patients with higher income (OR = 1.134, 95% CI = 1.064 - 1.209, p = &amp;lt;0.001), and those receiving treatment at an Integrated Network Cancer Program (OR = 1.405, 95% CI = 1.318 - 1.498, p &amp;lt; 0.001) were associated with higher odds of receiving NAC as compared to AC. However, patients were less to receive AC at an Integrated Network Cancer Program (OR = 0.784, 95% CI = 0.743 - 0.828, p &amp;lt;0.001), and with a Charlson/Deyo score of 3 or more (OR = 0.632, 95% CI = 0.561 - 0.712, p &amp;lt;0.001). Upon stratification, NAC as opposed to AC was associated with a longer S for patients with Stage IIIB (NAC: median S = 108.19 months, 95% CI = 101.71 - 114.67, and AC: median S = 89.63, 95% CI = 82.78 - 96.48, p &amp;lt;0.001). While data for stage IIA showed similar survival rates for both NAC and AC, it favored AC for other stages (IIB and IIIA). We analyzed characteristics associated with the benefit from chemotherapy overall, and noted that in patients with HR+, HER2 negative and node positive breast cancer, patients who received chemotherapy had a predicted greater survival as opposed to those who did not receive any chemotherapy whether NAC (HR = 0.565, 95% CI = 0.545 - 0.586, p &amp;lt; 0.001) or AC (HR = 0.545, 95% CI = 0.529 - 0.561, p &amp;lt; 0.0001). Hispanic ethnicity ( HR = 0.721, 95% CI = 0.661 - 0.787, p &amp;lt;0.001), private insurance (HR = 0.510, 95% CI = 0.479 - 0.544, p &amp;lt; 0.001), higher income (HR = 0.869, 95% CI = 0.826 - 0.914, p &amp;lt;0.001), care at an academic program (HR = 0.870, 95% CI = 0.833 - 0.908, p &amp;lt;0.001) and being located in the West South Central region (HR = 0.860, 95% CI = 0.803 - 0.921, p &amp;lt;0.001) were associated with greater S as compared to their counterparts in their respective subgroups. Conclusions In this large database, our data suggests that AC confers superior survival, compared to NAC in patients with HR positive, HER2 negative, and node positive breast cancer except for patients with Stage IIIB breast cancer. Also, chemotherapy given in any setting appears to improve survival overall. Citation Format: Iktej Singh Jabbal, Diana Saravia, Marita Yaghi, Nadeem Bilani, Leah Elson, Hong Liang, Zeina Nahleh. Comparative outcomes of Neoadjuvant versus Adjuvant chemotherapy in HR+/HER2- node positive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-12-17.

Abstract P2-12-12: The effect of Neoadjuvant Chemotherapy in reducing the need for axillary lymph node dissection in HR+/HER2- node positive breast cancers

Abstract Background In recent years, indications for neoadjuvant treatment (NAC) have been extended to patients with operable disease at diagnosis and it is increasingly being used in patients to reduce extent of axillary involvement and allow for more limited surgery in the breast and axilla. The increasing use of this therapy however has raised questions about optimal surgical exploration of the axilla post-chemotherapy. In this study therefore, we aimed to analyze the effect of NAC in reducing the need for axillary lymph node dissection (ALND), regardless of pathologic nodal status, in those who present with clinically node positive disease at diagnosis. Methods We sampled the National Cancer Database (NCDB) (2004-2016) for female patients with hormone receptor (HR) positive [estrogen receptor (ER) positive and/or progesterone receptor) (PR) positive], human epidermal growth factor receptor 2 (HER 2) negative, clinically node positive breast cancers. We then performed a multivariate logistic regression analysis to evaluate associations between chemotherapy regimen, disease, demographic, and geographic characteristics with the patients undergoing ALND. Statistics were performed using SPSS version 28.0 (190). Results N= 134704 female patients were included in the analysis; 79.2% Caucasian, mean age 59.13 years (SD = 13.95). Receiving NAC was associated with lower odds of undergoing ALND (OR = 0.849, 95% CI = 0.822 - 0.879, p &amp;lt;0.001) as compared to adjuvant chemotherapy (AC). On multivariate analysis, patients younger than 50 years old (ref, p = 0.005), black (OR = 0.824, 95% CI = 0.788 - 0.862, p &amp;lt;0.001), and uninsured (ref, p&amp;lt;0.001) were associated with lower odds of undergoing ALND as compared to their counterparts. In contrast, receiving care at Integrated Network Cancer Programs (OR = 1.182, 95% CI = 1.107 -1.261, p &amp;lt; 0.001) and residing in the Pacific region (OR = 1.519, 95% CI = 1.402 - 1.646, p &amp;lt; 0.001) was associated with a higher odds of patients undergoing ALND as compared to their counterparts. Conclusion Our findings indicate that for HR+/HER2-, node positive breast cancer, receiving chemotherapy in the neoadjuvant setting is associated with lower odds of ALND compared to when chemotherapy is received adjuvantly. Further studies exploring the effect of NAC on the nodal status post operatively, would help strengthen our findings. Additionally, while the use of chemotherapy remains a clinical decision, our study highlights that disparities in terms of sociodemographic and geographic factors may influence the receipt of such treatment in this cohort of patients. Citation Format: Iktej Singh Jabbal, Diana Saravia, Marita Yaghi, Nadeem Bilani, Leah Elson, Hong Liang, Zeina Nahleh. The effect of Neoadjuvant Chemotherapy in reducing the need for axillary lymph node dissection in HR+/HER2- node positive breast cancers [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-12-12.

Exploring the Paucity of the Diagnosis: Epithelioid Hemangioendothelioma of the Liver

Intoduction: Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor of unpredictable natural history. No large-scale studies have been published evaluating this disease due to its rare occurrence. Method: The National Cancer Database was reviewed between 2004-2016 to identify patients undergoing non-palliative therapy. We stratified the cohort by surgical intervention as wedge/segmental resection, lobectomy/extended lobectomy and transplant. Univariate analysis was performed to identify variables associated with survival. Results: We identified 229 patients with HEH. Median age at diagnosis was 55 years. Majority were female (61.1%) and white (84.3%). Majority received no chemotherapy (70.8%), received their care at an academic center (58%) and had Charlson-Deyo score of 0 (75%). Only one-third underwent surgery as part of their treatment. 27 underwent wedge/segmental liver resection,18 underwent hepatic lobectomy/extended lobectomy and 22 underwent liver transplant. 30-day and 90-day mortality was 3%. There was no difference in survival irrespective of the extent of liver resection. Age greater than 55 years,Asian race compared to White and a higher Charlson-Deyo score compared to score zero were associated with worse OS. Patients receiving care at an academic/research program or comprehensive community cancer program had significantly improved survival (HR 0.39,p=0.008 and HR 0.45,p=0.037 respectively) compared to care at an integrated network cancer program. Conclusions: This desctiptive study represents a large proportion of patients with HEH. Only a third of the patients underwent surgery as treatment for this disease. Older age, higher Charlson-Deyo score and Asian race predicted a worse survival. Receiving care an at academic center predicted an improved survival.

Impact of Treating Facility on Overall Survival and Treatment in Multiple Myeloma (MM) Using National Cancer Database (NCDB)

Introduction:Prior studies have shown poorer outcomes in Black and Hispanic patients and in patients with lower median household income and education 1-5. In MM, we hypothesize that facility affiliation and case volume affects overall survival (OS) and rates of frontline treatment (including chemotherapy, immunotherapy, autologous stem cell transplant [ASCT] and palliative care).Methods:This is a retrospective analysis of 174,551 MM patients in the NCDB database, over the age of 18 years, between 2004-2016. Facility types include community cancer programs, comprehensive community cancer programs, academic/research cancer programs and integrated network cancer programs. High volume facilities had new MM cases per year ≥ 99 th percentile, and all other facilities were classified as low volume. Multivariable analyses used Cox proportional hazard analysis for OS and logistic regression for use of treatment, adjusted for age, sex, race, Hispanic origin, education, great circle distance, CCI score, and type of county (depending on population size). Kaplan-Meier method was used to estimate median OS, and the log rank test was used to compare OS across predictor variables.Results:The median age was 67 years (range 18-90) with 55% males, and 76% White vs 20% Black. In academic/research cancer programs, the median OS in high volume centers was 75.5 mo vs 50.2 mo in low volume centers (p<0.01). In community cancer programs, the median OS in high volume centers was 55.2 mo vs 35.5 mo in low volume centers (p<0.01). In multivariable analyses, the OS was higher in academic/research cancer programs vs community cancer programs (hazard ratio of 0.87 p<0.01). There was no significant difference in OS at integrated network cancer programs or comprehensive community cancer programs vs community cancer programs. The odds of utilizing chemotherapy were higher in academic/research cancer programs compared to community cancer programs (p<0.01 for both), whereas the odds of receiving palliative care were similar between both facility types (p=0.25). The odds of utilizing ASCT were higher in all facilities when compared to community cancer programs (p<0.01). The odds of utilizing palliative care were higher at integrated network cancer programs and comprehensive community cancer programs compared to community cancer programs (p<0.01 for both). Facilities with low volume of cases had significantly lower odds of utilizing chemotherapy, immunotherapy and ASCT when compared to high volume facilities; however had significantly increased odds of receiving palliative care.Discussion:Our results show that academic/research cancer programs with high volumes have the best OS in MM. Additionally, academic/research cancer programs are more likely to give chemotherapy, immunotherapy, and ASCT, but less likely to give palliative care. We theorize that academic/research cancer programs with a high volume of cases likely have increased resources, which optimizes outcomes. Given that ~25% of patients with MM die in the first year 6, there is a recognized need to identify strategies to improve early outcomes in patients treated at community cancer programs and low volume facilities. [Display omitted] DisclosuresLai: Jazz Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Speakers Bureau; Macrogenics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Speakers Bureau; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Facility Type Affects Treatment Outcomes for Patients With Mucinous Cystic Neoplasms and Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Academic centers report better outcomes for pancreatic ductal adenocarcinoma. We hypothesized that treatment outcomes for mucinous cysts differ according to institution type. Using the National Cancer Data Base, we analyzed data on patients with mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs). Of 3278 identified patients, 2622 (80%) had IPMNs and 656 (20%) had MCNs. While most academic/research programs (ARCPs, 84.9%) treated more than 10 patients/year, this was true for only 59% of integrated network cancer programs, 37.3% of comprehensive community cancer programs, and 0% of community cancer programs (P < 0.001). Surgery was used more often in ARCPs and for smaller tumors. The ARCPs had higher rates of margin negative resections with retrieval of 15 or more nodes with the lowest 30- and 90-day mortality rates. The median overall survival was better in ARCPs (110.3 months) than comprehensive community cancer programs (75.1 mo), community cancer programs (75.1 mo), or integrated network cancer programs (100.8 mo, P < 0.001). Treatment of MCNs and IPMNs of the pancreas at academic centers is associated with a higher probability of pancreatectomy, disease identification in a noninvasive stage, and better overall survival. Centralization of care for mucinous pancreatic cysts will lead to improved outcomes.

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma.

Patients with metastatic hepatocellular carcinoma (HCC) suffer symptoms of both end-stage liver disease and cancer. Palliative care (PC) enhances the quality of life via symptom control and even improves survival for some cancers. Our study characterized rates of PC utilization among metastatic HCC patients and determined factors associated with PC receipt. We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2016. Chi-square tests were used to analyze two cohorts: those who received PC and those who did not. Logistic regression was performed to assess the impact of clinicodemographic factors on the likelihood of receiving PC. PC utilization was low at just 17%. Later yearof diagnosis, insured status, and higher education level were associated with an increased likelihood of receiving PC. Treatment at academic centers or integrated network cancer programs increased the likelihood of receiving PC compared to treatment at a community center (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03-1.33 and OR = 1.25, 95% CI = 1.07-1.45; respectively). Hispanics were significantly less likely to received PC than non-Hispanic Whites (OR = 0.73, 95% CI = 0.64-0.82). PC utilization among patients with metastatic HCC remains low. Targeted efforts should be enacted to increase the delivery of PC in this group.

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

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