National Cancer Database Analysis Research Articles

Transplant Still Relevant Even in the Era of Novel Treatments for Multiple Myeloma — National Cancer Database Analysis

Background: Survival of patients with multiple myeloma has significantly improved over the last decade. Several new treatments have been approved for the treatment of myeloma in the last few years that have changed its landscape. Newer drugs with deeper and durable responses have challenged the role of autologous stem cell transplant (auto SCT) in the management of myeloma.Aim: We aimed to study the impact of auto SCT and several other demographic and treatment related factors on the outcome of myeloma by analyzing the data from National Cancer Database (NCDB).Materials and Methods: Data was analyzed from 9218 patients (both men and women aged >18 years) who were diagnosed with multiple myeloma and registered in NCDB between 2010 and 2013 with follow up to the end of 2014. Factors such as age, race, gender, income, education, Charlson comorbidity index (CCI), distance traveled to get cancer care, treatment facility, health insurance and type of treatment (chemotherapy only versus chemotherapy followed by auto SCT) were investigated and the primary outcome was overall survival.Results: The median age of the patients was 66 years. Fifty five percent of patients were male. Around 56% of the patients were older than 65 years. Among the patients reviewed, 73% were Caucasian and 24% African American. As assessed by Charlson comorbidity index, 75% of patients had no major medical comorbidities. Forty six percent of patients received treatment at a facility different from where they were diagnosed with myeloma. Around one third of the patients were treated at an academic facility and the rest at either a community cancer program or comprehensive community cancer program. Treatment was initiated within 2 weeks of diagnosis in 36% of the patients whereas 21% of patients could not start treatment until after 6 weeks from diagnosis. Approximately 53% of patients had health care funding by Medicare, 35% had private insurance, 7% had Medicaid and around 5% of the patients were uninsured. Around 11% of the patients received auto SCT as part of treatment. In a multivariate analysis, after adjusting for other variables, receiving auto SCT was a statistically significant predictor of overall survival. A 71% improvement in survival was observed in patients who received auto SCT for myeloma compared to those who did not. Male gender, age older than 65 years, African American race, major comorbidities as determined by CCI, change of facility for treatment were other significant predictors of survival in the multivariate analysis. Females were 11% less likely to die of myeloma compared to males. Patients older than 65 years had 59% increased risk of dying compared to patients younger than 40 years. African Americans had 17% reduced risk of death compared to Caucasians. Myeloma patients with 1 and 2 medical comorbidities had 31% and 75% increased risk of death respectively compared to those with no comorbidities. Receiving treatment at a facility different from that of diagnosis had a very small survival advantage. Patients with Medicaid, Medicare and no health insurance had 16%, 29% and 19% increased risk of death compared to those with private insurance respectively. Level of education of patients, annual income and distance traveled to the treatment facility did not have any significant impact on the overall survival in multivariate analysis.Conclusions: Even in the era of novel drugs for the treatment of myeloma, auto SCT still has a significant role and offers overall survival benefit according to our NCDB analysis. Male gender, elderly age, 1 or more medical comorbidities, lack of private health insurance were shown to be predictors of poor overall survival. DisclosuresNo relevant conflicts of interest to declare.

A National Cancer Database analysis of the patterns of care for meningeal melanocytoma.

Aim: To evaluate demographics, treatment patterns, radiotherapy utilization and patient outcomes in meningeal melanocytomas. Materials & methods: The National Cancer Database was queried for meningeal melanocytomas diagnosed in 2002-2016. The effects of demographic, clinicaland treatment variables were determined via Kaplan-Meier log-rank and Cox regression analyses. Results: The median and 5-year overall survival were 57.46 months and 48%, respectively. Patients earning ≥$48K showed improved survival (p=0.0319). Radiotherapy and chemotherapy were utilized in 37.7and 9% of patients, respectively. Conclusion: Income significantly affected survival. Surgery remains the mainstay approach. Radiotherapy was delivered in more than one-third of patientsbut did not impact survival. However, further analyses were limited by poor treatment modality information in the database.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An National Cancer Database Analysis

Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer. We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model. A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P=0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P=0.281). Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Effectiveness of a Short Duration of Neoadjuvant Endocrine Therapy in Patients with HR+ Breast Cancer—An NCDB Analysis (2004–2016)

BackgroundNational medical/surgical organizations have recommended the use of neoadjuvant endocrine therapy (NET) to bridge surgery delay of weeks to months for patients with hormone receptor positive (HR+) breast cancer during the ongoing coronavirus disease 2019 (COVID-19) pandemic. The effects of NET of varying durations on pathologic response are unclear. Using the National Cancer Database (NCDB), we evaluated objective response to short (< 9 weeks), moderate (9–27 weeks), and long (> 27 weeks) duration of NET.Patients and MethodsThe study cohort included female patients diagnosed with nonmetastatic invasive HR+ breast cancer, stratifying by those who received NET versus no NET between 2004 and 2016. Pathologic response was grouped into four categories (complete, downstaged, stable, upstaged) by comparing clinical and pathologic staging data. Objective response to NET included complete, downstaged, and stable pathologic response. Clinical characteristics were compared using χ2 and analysis of variance (ANOVA) tests. Multivariable logistic regression was used to determine factors associated with NET use and objective response according to NET duration.ResultsA minority (1.2%) received NET in our cohort. Factors associated with NET use included older age, non-Black patients, more advanced clinical stage, higher comorbidity score, government insurance, and lobular histology. Objective response rate (ORR) was 56.7%, 52.1%, and 49.0% after short, moderate, and long NET duration, respectively.ConclusionShort NET duration did not result in an inferior ORR. Future study to evaluate the interaction between surgery delay and NET use on clinical outcome will provide insights into the safety of NET to bridge potential surgery delay in patients with HR+ breast cancer.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-10287-5.

Undifferentiated Embryonal Sarcoma of the Liver in Children Versus Adults: A National Cancer Database Analysis.

Simple SummaryUndifferentiated embryonal sarcoma of the liver (UESL) is the third most common type of liver malignancy in the pediatric population, following hepatoblastoma and hepatocellular carcinoma. In comparison to children, UESL is an extremely rare malignancy in adults. Although historically treatment was limited to surgical resection and survival was poor, the combination of surgical treatment and chemotherapy recently has led to improved survival. We attempted to examine the characteristics and outcomes of children and adults with UESL in a contemporary U.S. cohort. We showed that children demonstrate favorable survival with multimodal treatment, while adults demonstrate inferior outcomes and future research endeavors should focus on refining currently available treatment modalities for adults with UESL.This study evaluates the clinicopathological characteristics and outcomes of children vs. adults with undifferentiated embryonal sarcoma of the liver (UESL). A retrospective analysis of 82 children (<18 years) and 41 adults (≥18 years) with UESL registered in the National Cancer Database between 2004–2015 was conducted. No between-group differences were observed regarding tumor size, metastasis, surgical treatment, margin status, and radiation. Children received chemotherapy more often than adults (92.7% vs. 65.9%; p < 0.001). Children demonstrated superior overall survival vs. adults (log-rank, p < 0.001) with 5-year rates of 84.4% vs. 48.2%, respectively. In multivariable Cox regression for all patients, adults demonstrated an increased risk of mortality compared to children (p < 0.001), while metastasis was associated with an increased (p = 0.02) and surgical treatment with a decreased (p = 0.001) risk of mortality. In multivariable Cox regression for surgically-treated patients, adulthood (p = 0.004) and margin-positive resection (p = 0.03) were independently associated with an increased risk of mortality. Multimodal treatment including complete surgical resection and chemotherapy results in long-term survival in most children with UESL. However, adults with UESL have poorer long-term survival that may reflect differences in disease biology and an opportunity to further refine currently available treatment schemas.

Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review

BackgroundInsurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014. MethodsNational Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected. ResultsTwo-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2–204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5–230 %) and the average decrease of uninsured rates was 55 % (13.4–73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities. ConclusionMedicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed. Policy SummaryThis study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.

P1090 - National Cancer Database analysis assessing the impact of treatment modalities on survival outcomes in localized neuroendocrine prostate adenocarcinoma

P1090 - National Cancer Database analysis assessing the impact of treatment modalities on survival outcomes in localized neuroendocrine prostate adenocarcinoma

Outcomes of surgically managed primary lung sarcomas: a National Cancer Database analysis.

BackgroundPrimary lung sarcoma (PLS) represents a rare form of lung cancer with outcomes that are poorly defined by small datasets. We sought to characterize clinical and pathological characteristics and associated survival within the surgically managed subgroup of these unusual pulmonary malignancies.MethodsWe performed a retrospective analysis of the National Cancer Database (NCDB), which was queried for cases of surgically managed PLS diagnosed between 2004–2014. Adjusted mortality was evaluated in a multivariable Cox proportional hazards model and compared to surgically manage non-small cell lung cancer (NSCLC) patients from the same time period.ResultsA total of 695 patients with surgically managed PLS were identified with 37 different histologic subtypes. The mean age of diagnosis was 57.7 years (range, 18–90 years). A majority of patients underwent surgical resection alone (64.3%) with an estimated 5-year overall survival (OS) of 51%. The multivariable Cox model identified increasing age, Charlson-Deyo score ≥2, high tumor grade, tumor size >5 cm, positive margins, and positive lymph nodes to be associated with higher risk for mortality (P<0.05). Compared to 101,428 surgically managed patients with adenocarcinoma, PLS patients were younger with fewer comorbidities but had larger tumors, higher grade tumors, and were more likely node negative (P<0.001). Surgery with adjuvant chemotherapy was associated with worse survival than surgery alone (HR 1.41, 95% CI: 1.05–1.88). The extent of parenchymal resection (lobar vs. sublobar) was not predictive for survival. Five-year OS was lower for patients with PLS (44%) than adenocarcinoma (53.6%, P<0.001).ConclusionsThe survival of surgically managed PLS is reasonable and impacted by tumor attributes and the completeness of surgical resection. Further study to define the role of multimodal therapy is indicated.

Outcomes with brachytherapy based dose escalation for gleason 8 versus 9-10 prostate cancer: An NCDB analysis

IntroductionThe addition of brachytherapy (BT) in high risk prostate cancer is supported by Level 1 evidence. Whether all high risk patients benefit from BT to the same extent is unknown. The National Cancer Database (NCDB) was used to investigate overall survival (OS) differences between GS 8 and 9-10 treated with external beam radiation (EBRT) only or BT +/- EBRT. Materials and MethodsWe included localized prostate adenocarcinoma definitively treated with radiation between 2004-2014. Patients were stratified into various radiation treatment groups: EBRT 7560 - 8640 cGy, EBRT 5940 - 7540 cGy, and BT +/- EBRT. All EBRT only and BT +/- EBRT patients received ADT. A multivariable Cox proportional hazard model was used to assess OS. Propensity score matching was used to account for differences between groups. Median survival was determined based on Kaplan-Meier survival curves. Results30,698 patients were included. On multivariable analysis among GS 8 patients, BT was associated with improved OS compared to 7560 - 8640 cGy (HR–0.80 (95% CI 0.70-0.92, P = 0.002). In Gleason 9-10 BT did not result in improved OS compared to 7560 – 8640 cGy (HR- 0.91 (95% CI 0.79 – 1.05, P = 0.212). Results remained significant with propensity score matching and removing patients with medical comorbidities. ConclusionBT was associated with improved OS when compared to 7560 – 8640 cGy in GS 8, but not in Gleason 9-10 disease. This hypothesis generating study suggests there may be variable benefit with BT in high risk prostate cancer patients on OS. Future prospective studies are needed to investigate whether the benefit of BT is similar across all high risk prostate cancer patients.

Treatment patterns and outcomes of locally advanced gall bladder cancer: A National Cancer Database (NCDB) analysis.

e16147 Background: Gall bladder (GB) cancer is rare but an aggressive disease especially when presenting at an advanced stage. There is controversy regarding the best treatment approach for locally advanced disease. In this NCDB analysis, we aim to study treatment patterns for T3, T4, and/or N1 GB cancer and estimate survival for each treatment modality. We also sought to investigate clinical and socioeconomic predictors of treatment selection. Methods: We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 39,229 patients diagnosed with GB cancer between 2004-2017. We excluded patients who were not treated at the reporting facility, those with no histologic confirmation of the diagnosis, those with no survival data available and those with T1, T2 and metastatic disease. We did exploratory analysis and divided patients into six arms based on treatment modality (Table). Stepwise multivariable regression models were used to analyze predictors of treatment selection. Survival estimates were calculated using the Kaplan Meier and proportional Cox hazard regression methods. Results: We identified 7,004 patients with GB cancer who fulfilled the inclusion and exclusion criteria. Median age was 68 years. There were 69.5% females, and the majority of patients were white (66.1%). Receiving treatment at an academic/research center (OR 0.37, 95% CI 0.19-0.73, p &lt;0.01), black patients (OR 0.55 95% CI 0.36-0.85, p &lt;0.01) and higher education (OR 0.58, 95% CI 0.37-0.91, p 0.02) decreased the odds of receiving surgery. Meanwhile, the presence of lymphovascular invasion was seen more amongst patients with receipt of surgery. For patients who underwent radiation, increasing age (OR 0.97, 95% CI 0.97-0.98, p &lt;0.01) and higher histologic grade (OR 0.65, CI 0.46-0.92, p .02) were associated with less radiation use. Median income between $50,354-$63,332 (OR 1.28, 95% CI 1.02-1.60, p 0.04) was associated with more radiation use. Patient who received triple therapy had improved survival compared with other modalities (HR 0.51, CI 0.46-0.57, p &lt;0.01). Median overall survival (OS) for the whole population was 13.0 months (CI 12.6-13.5) (Table) Conclusions: American patients with T3, T4, and/or N1 GB cancer received variable treatment modalities. Patients who underwent triple-modality therapy in our analysis had improved adjusted-overall survival compared with other modalities. Limitations include unmeasured confounding factors, selection bias and the retrospective design. We also identified clinical and socioeconomic factors that affect treatment selection.[Table: see text]

Survival trends of older adult patients with diffuse large B-cell lymphoma: A National Cancer Database analysis.

7542 Background: 60-70% of patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) can be cured with R-CHOP or R-CHOP-like immunochemotherapy. However, patients ≥80 years of age were either excluded or underrepresented in modern DLBCL trials, and their outcomes are understudied. The aim of this study is to define the survival trends and risk factors for inferior survival in older adult patients with DLBCL. Methods: Patients with newly diagnosed DLBCL were identified from the National Cancer Database (2004-2017, representing the rituximab era). Clinical characteristics, treatment, and outcomes were compared between patients ages ≥ 80, 65-79, and &lt; 65 years. The Kaplan-Meier method and Cox proportional hazards model were used for survival analysis. Results: A total of 231,756 patients with newly diagnosed DLBCL were identified; 46,250 (20%) were ≥80 years, 87,702 (38%) were 65-79 years, and 97,904 (42%) were &lt; 65 years. Patients ≥80 years were more likely to have a higher Charlson-Deyo Comorbidity Index score (CDS) (CDS ≥2, 12% vs 11% vs 8%, p = 0.001), less likely to receive systemic chemotherapy (63% vs 83% vs 89%, p &lt; 0.001), and more likely to receive treatment at a non-academic center (71% vs 65% vs 48%, p &lt; 0.001), compared to patients 65-79 and &lt; 65 years, respectively. Median overall survival (OS) was significantly worse for patients ≥80 years compared to patients 65-79 years (11.6 vs 61.0 months, p = 0.001) and patients &lt; 65 years (11.6 vs 178.1 months, p = 0.001). During the study period, the median OS had only minimally improved for patients ≥80 years (10.6 months in 2004-2007 vs 11.5 months in 2008-2011 vs 12.3 months in 2012-2016, p = 0.006). In contrast, the OS improvement appears more meaningful in patients 65-79 years (median in months: 51 vs 61.2 vs 65.9, p = &lt; 0.001) and patients &lt; 65 years (median in years: 14.6 vs 11.3 vs not reached, p &lt; 0.001) in the prespecified intervals (2004-07, 2008-11, and 2012-16). In multivariate analysis, the most substantial risk factor for worse survival in patients ≥80 years was not receiving systemic therapy (hazard ratio [HR] = 3.26, 95%CI = 3.01-3.54, p = 0.001). Other risk factors associated with worse survival included high-risk IPI score (HR = 2.16, 95%CI = 1.96-2.39, p = 0.001), CDS score ≥2 (HR = 1.56, 95%CI = 1.40-1.73, p = 0.001), male sex (HR = 1.16, 95%CI = 1.09-1.24, p = 0.001), B symptoms at diagnosis (HR = 1.16, 95%CI = 1.08-1.25, p = 0.001), and treatment at a non-academic center (HR = 1.1, 95%CI = 1.01-1.20, p = 0.001). Conclusions: Patients ≥ 80 years of age with DLBCL have a significantly inferior survival which has not meaningfully improved in recent years. More than 1/3 of patients ≥ 80 years did not receive systemic therapy. Older adult patients with DLBCL should be assessed for fitness for chemotherapy using validated geriatric assessment tools. Novel therapeutic strategies with favorable safety profiles are urgently needed for this expanding patient population.

Impact of socioeconomic disparities on diagnosis and overall survival in small cell lung cancer: A National Cancer Database analysis.

8515 Background: Small cell lung cancer (SCLC) accounts for approximately 13% of all lung cancer diagnoses in the United States. The demographics of this disease have evolved over time; in the 1970s 28% of patients with SCLC were female, while in the early 2000s, 50% were female. Remarkable differences in incidence, mortality rates, and trends by race and geographic location have also been noted. There has been a paucity of data regarding changes in epidemiology and patient demographics in SCLC since the early 2000s. Given recent treatment advances, the impact these factors have on patient outcomes for SCLC requires further evaluation. Methods: We identified all patients with SCLC in the NCDB from 2004 to 2016. Differences in demographic, disease, and treatment characteristics were assessed by year of diagnosis using Chi-square test. The effect of age, race, insurance status, income, distance to treatment center, and education level on overall survival (OS) was assessed by log-rank test. Results: There were 137,253 cases of SCLC diagnosed in the NCDB between 2004-2010 and 124,796 cases between 2011-2016. Patients diagnosed after 2010 were significantly older, had more comorbidities, had more stage IV disease, were more frequently treated at academic centers, more commonly had government primary payer insurance, and lived significantly further away from their treatment center. There were significant differences in gender, race/ethnicity groups, education level, and residence area, with more females, more African Americans, more patients without a high school diploma, and more rural patients diagnosed after 2010. OS in general improved between the two time periods, with median OS of 8.41 months (95% CI: 8.34-8.48%) and 5-year OS rate of 6.8% (95% CI: 6.6-6.9%) in patients diagnosed between 2004-2010 and median OS of 8.61 months (95% CI: 8.54-8.67%) and 5-year OS rate of 8.7% (95% CI: 8.5-8.9%) in patients diagnosed after 2010, despite an increase in stage IV disease in the latter group. Some of the differences in demographics were associated with changes in OS. Older patients, male patients, Caucasian patients, patients with stage IV disease, patients with government primary payer insurance, and rural patients all had significantly worse OS. Patients without comorbidities and patients treated at an academic center had significantly better OS. OS was found to significantly increase as both income and education level increase. Conclusions: SCLC continues to be a frequent cancer diagnosis. Despite improvement in overall survival during the time frame studied, there were significant disparities noted in key demographics that negatively affect access to healthcare resources, including rural communities, distance to an academic center, income, insurer, and education level. Collective efforts to impact these disparities will likely lead to improved outcomes for patients with SCLC.

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

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

Outcomes of stage IV melanoma in the era of immunotherapy (IO): A National Cancer Database (NCDB) analysis.

e21520 Background: The majority of data for IO in melanoma stems from trials that have specific inclusion criteria and often exclude important populations. In this analysis, we present the first real-world evidence of outcomes for stage IV patients (pts) with cutaneous melanoma receiving IO from 2015–2017 (addition of anti-PD-1 therapies) and factors associated with receipt of IO, and compare these outcomes with pts receiving IO (likely interferon and interleukin-2) from 2004–2010, and IO (addition of ipilimumab) from 2011–2014. Methods: The NCDB was analyzed to identify pts with stage IV melanoma from 2004–2017. Pts were categorized into receipt of IO or not during time periods 2004–2010, 2011–2014, and 2015–2017. Overall survival (OS) was analyzed by Kaplan-Meier, log-rank, and Cox proportional hazard models; IO status was analyzed using logistic regression. Results: 24,544 pts were analyzed from 2004–2017. Overall, 5,238 pts (21.3%) that received IO had improved median OS compared to those that did not (20.2 vs. 7.4 mos; p&lt;0.0001). 4.1% received IO from 2004-2010, 7.8% from 2011-2014, and 9.4% from 2015-2017. Three-year OS significantly improved in pts treated with IO across treatment years; p&lt;0.0001 (Table). Similarly, median time to IO initiation improved over time: 62 days in 2011-2014 vs. 49 days in 2015-2017 (p&lt;0.0001). In the overall cohort, age&lt;65 years, female gender, private insurance, no comorbidities, residence in metropolitan area, and treatment at academic centers were associated with better OS (p&lt;0.0001 for all). Race was not associated with differences in OS (p=0.07). Multivariate analysis for 2015-2017 demonstrated that lack of treatment with IO [HR 1.98, 95%CI 1.81-2.17], radiation therapy [HR 1.20, 95%CI 1.09-1.32], presence of liver metastases [HR 1.87, 95%CI 1.63-2.13], and lack of surgery [HR 1.68, 95%CI 1.45-1.93] were independently associated with worse OS (p&lt;0.0001 for all). In multivariate analysis, receipt of IO from 2015-2017, was associated with age&lt;65 years [OR 1.27, 95%CI 1.08-1.50], African American race [OR 5.88, 95%CI 1.60-28.58], lack of comorbidities [OR 1.43, 95%CI 1.23-1.66], and treatment at academic centers [OR 1.44, 95%CI 1.26-1.65] (p&lt;0.05 for all). Conclusions: OS was improved in stage IV melanoma pts receiving IO, with the highest OS rate in 2015-2017. Our findings that represent a real-world population are consistent with recent trials, like KEYNOTE 006 and CheckMate 067 where 3-year OS for anti-PD-1 therapy was 50% and 52%, respectively. In our study, African Americans demonstrate a 5-fold increase in likelihood of receiving IO, a population underrepresented in clinical trials. Significant socioeconomic factors may impact receipt of IO and survival.[Table: see text]

Autologous stem cell transplantation (ASCT) versus whole brain radiation (WBRT) as a consolidation therapy in primary CNS lymphoma (PCNSL): A nationwide analysis.

2062 Background: High dose methotrexate-based regimens remain the most effective treatment against PCNSL but optimal consolidative strategy has yet to be determined. There is lack of high scale clinical trials comparing WBRT versus ASCT as consolidation therapy. Only two phase II randomized clinical trials (PRECIS and IELSG 32) have addressed this question. In this comprehensive national cancer database (NCDB) analysis, we examine the effect of WBRT versus ASCT on survival in PCNSL, we also sought to investigate clinical and socioeconomic predictors of treatment selection Methods: We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 16579 patients diagnosed with PCNSL between 2004 and 2016. We excluded patients who tested positive for HIV, and those who started chemotherapy &gt; 120 days or started radiation &gt; 365 days since diagnosis, to account for immortal time bias. Patients were divided into two treatment groups based on consolidation therapy: ASCT and WBRT. Multivariable regression models were used to analyze predictors of treatment selection. To account for variable baseline characteristics, we used propensity score weighting methodology. Survival estimates were calculated using the Kaplan-Meier and Cox proportional hazard regression methods Results: We identified 1620 patients with PCNSL who fulfilled the inclusion criteria. ASCT and WBRT were received by 197 patients and 1423 patients, respectively (Table). On multivariable analysis, increased age decreased the odds of receiving ASCT (OR 0.997, CI: 0.996-0.999, P &lt;.001). Patients live in rural areas (OR 1.174, CI: 1.051-1.312, P=.005), those with higher education (OR 1.089, CI: 1.020-1.163, P=.01), and those who live further from the treating facility (OR 1.001, CI: 1.001-1.001, P&lt;.001) received more ASCT. With a median follow up duration of 27.8 months, adjusted-median OS was 91.4 months and not reached for WBRT and ASCT groups, respectively (log-rank P&lt;.001). Adjusted 3-year OS was 82% and 67% in ASCT and WBRT, respectively (HR: 0.43, CI: 0.29-0.64, P&lt;.001) Conclusions: Consolidation with ASCT had improved OS compared with WBRT. There is a trend toward increased ASCT use and decreased WBRT use over the study period. We found clinical and socioeconomic factors that affected treatment selection.[Table: see text]

Racial and socioeconomic disparities in ocular surface squamous neoplasia: a National Cancer Database analysis

ABSTRACT Purpose A retrospective population-based study to investigate racial and socioeconomic disparities in patients diagnosed with ocular surface squamous neoplasia (OSSN). Methods To explore racial disparity, we selected OSSN patients with known age, insurance, gender and zip code-level income and education from the National Cancer Database (NCDB). Comparisons of clinical and socioeconomic variables stratified by race were made with the chi-square or Mann-Whitney tests. Survival outcome was examined a Cox regression model. Results Of the 2,402 identified patients from 2004 to 2015, 117 were black. Unadjusted differences were found between groups in regard to age, histology, insurance, income, and education. Black patients in comparison to white patients were younger (mean age: 62 years vs. 70 years; p < .001), represented a higher proportion of Medicaid use (10.3% vs. 3.2%; p < .001) or uninsured (10.3% vs. 2.7%; p < .001), and were more likely to reside in areas of low educational attainment (32.5% vs. 16.1% of whites; p < .001). Multivariate analysis found significantly higher risk of death in patients who were male (HR: 1.66, 95% CI 1.37–2.01) or black (HR: 1.57, 95% CI 1.03–2.38). Conclusion Disparities in socioeconomic factors were observed in black patients with OSSN. OSSN occurred earlier in blacks, who were also socioeconomically disadvantaged and faced higher risk of death.

Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis

BackgroundMalignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy. MethodsPatients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010–2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared. ResultsA total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables. ConclusionPatients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.

Characteristics and overall survival inpediatric versus adult pituitary adenoma: a National Cancer Database analysis.

Pituitary adenomas in the pediatric population are extremely rare, resulting in limited information in the literature on these patients. In this study, data from the National Cancer Database (NCDB) to compare pituitary adenoma clinical presentations, treatment management patterns, and overall survival between pediatric and adult patients. The NCDB was queried for all cases of histologically confirmed pituitary adenoma treated between 2004 and 2015. Patients were primarily stratified as either pediatric (< 18years) or adult (≥ 18years). Patient demographics/socioeconomics and resulting outcomes were then compared. 1893 pediatric and 77,993 adult patients with pituitary adenomas were evaluated. Average tumor size for pediatric and adult patients was 13.6 ± 13.2mm and 20.1 ± 13.1mm, respectively (p < 0.001). Pediatric patients were more likely to undergo gross total resection, less likely to receive adjuvant radiation, more likely to receive medical therapy, more likely to undergo active surveillance, and exhibited improved 5-year and 10-year overall survival (OS) (all p < 0.001). Temporal analysis demonstrated a significant increase in endoscopic approach over time (from 48 to 65%) in the pediatric population (R2 = 0.722, p = 0.03). On univariate analysis in the pediatric population, African American race compared to Caucasians (HR: 5.85, 95% CI 1.79-19.2, p < 0.003), patients with government insurance compared to those with private insurance (HR: 5.07, 95% CI 1.31-19.6, p < 0.02) and uninsured patients compared to those with private insurance (HR: 14.4, 95% CI 2.41-86.5, p < 0.003) were associated with decreased OS. Lastly, patients who underwent GTR had improved OS compared to those who underwent subtotal resection (HR: 0.08, 95% CI 0.008-0.93, p < 0.04) in the pediatric population. Compared to adults, children with pituitary adenomas more commonly underwent GTR, less frequently underwent adjuvant radiotherapy, more frequently underwent medical management and active surveillance, and had improved survival. Temporal analysis demonstrated increasing utilization of the endoscopic approach for surgical treatment of pediatric and adult pituitary adenoma patients. Level III.

Practical demonstration of time bias with administration of adjuvant therapy in lung cancer

Purpose/BackgroundImmortal time bias (ITB) can hinder appropriate interpretations of studies administering adjuvant therapies. Given the increase in National Cancer Data Base (NCDB) analyses evaluating postoperative radiation therapy (PORT) as an adjuvant therapy, we sought to practically demonstrate the effects of ITB by performing a series of simulated NCDB analyses. MethodsA simulated NCDB analysis was performed to examine how the reported benefit of PORT in stage III non-small cell lung cancer (NSCLC) may change with adjustment for ITB utilizing sequential land mark analysis (SLMA) and time dependent Cox (TDC) modeling. ResultsOn the simulation analysis of 6440 NSCLC patients, we found that the omission of PORT without ITB adjustment was associated with an increased risk of death (HR 1.17, p < 0.0001). After performing a sequential LMA, the detrmient of omitting PORT continued to decrease until it was no longer significant at 8 months, HR 1.05 (p = 0.09). With the TDC model, although still significant, the relative benefit of PORT decreased, to a HR of 1.07 (p = 0.02). ConclusionsImmortal time bias can alter the results of survival analyses if not carefully accounted for. Adjusting for this bias is essential for accurate data interpretation and to better quantify the impact and effect size of adjuvant therapies such as PORT.

Lobectomy Demonstrates Superior Survival Than Segmentectomy for High-Grade Non-Small Cell Lung Cancer: The National Cancer Database Analysis.

Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2cm, margins ≥ 2cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB). The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics. 11091 patients were included with 10413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48months vs 68.30months for segmentectomy, P = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, P = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy. Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.