National Cancer Data Base Report 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

Long-term outcomes in patients with advanced adrenocortical carcinoma after image-guided locoregional ablation or embolization.

BackgroundTo evaluate outcomes and survival rates in patients with metastatic adrenocortical carcinoma (ACC) who were treated with image‐guided locoregional treatments (IGLTs).PurposeTo evaluate the overall survival (OS) and clinical impact of IGLT in the management of patients with advanced metastatic ACC.MethodsRetrospective review of 39 patients treated with IGLT between 1999 and 2018 was performed. Short‐ and long‐term efficacy of treatments were defined based upon imaging and clinical data. Subgroup survival analysis was performed on patients with metastatic disease at diagnosis (N = 17) and compared with the same stage group from the most recent National Cancer Database (NCDB) report. Statistical analysis was performed using Cox proportional hazards model.ResultsTreatments were performed at different anatomic sites including liver (N = 46), lung (N = 14), retroperitoneum (N = 5), bone (N = 4), subcutaneous (N = 2), and intracaval (N = 1). Radiofrequency, microwave, cryoablation, or a combination of two modalities (45, 18, 3, 3, respectively) were used in 69 ablation sessions. Intra‐arterial procedures were performed in 12 patients in 18 treatment cycles (range 1–3 per patient). As of a 2019 analysis, 11 patients were alive with a mean follow‐up of 169 months (range 63–292 months) from diagnosis. Two‐ and 5‐year OS rates for all patients were 84.5% and 51%, respectively, and 76.5% and 59% for patients with metastatic disease at diagnosis (N = 17). This compares favorably with an NCDB report of 35% 5‐year survival rate for patients with metastatic disease. Female gender and longer time from diagnosis to first IGLT were found to be predictors of prolonged survival with hazard ratios of 0.23 (p < 0.001) and 0.66 (p = 0.001), respectively.ConclusionIGLT may be associated with prolonged life expectancy in select patients with metastatic ACC.

Impact of Age in Women with Stage I-III Triple Negative Breast Cancer (TNBC): A National Cancer Data Base (2004-2014) Report

Young age has been associated with worse overall survival (OS) in breast cancer patients. While the cause of this is likely multi-factorial, this has been in part attributed to the higher prevalence of the aggressive triple-negative disease in younger cohorts. However, it remains unclear if younger age predicts for worse survival in patients with TNBC. In this study we aimed to assess the impact of age on survival in women with stage I-III TNBC. Women with stage I-III TNBC diagnosed between 2004-2014 were identified in the National Cancer Data Base. Patients with male sex, in situ disease, metastatic disease, or incomplete information were excluded from the analysis. We analyzed demographic factors as well as disease- and treatment-related factors by age group. Statistical analyses including Kaplan-Meier estimates and Cox proportional hazards were calculated for treatment- and disease-related factors. Patients were divided into 4 age-based groups for this analysis, age <36, 36-50, 51-65, and >65. A total of 48,248 women (range 18-90, median 57) were identified in the database with median follow-up of 38 months (range 0.1 to 86.67 months). On univariate analysis, women age <36 did not have a statistically significant difference in OS when compared to women age 36-50 (HR = 0.949, 95% CI 0.841-0.1071, p = 0.3979) or women age 51-65 (HR = 1.078, 95% CI 0.958-1.212, p = 0.2142). Women age >65 had a statistically significant decrease in OS in comparison with women age <36 (HR = 2.030, 95% CI 1.804-2.284, p = <0.0001) in univariate analysis. Increasing T and N stages were associated with decreased OS in all patients except in the T2 stage group (HR = 0.984, 95% CI 0.889-1.091, p = 0.7640) when compared with the T1 and N1 stage groups. However, the different cohorts had similar distribution of stage I, II and III patients. Multivariable Cox proportional hazards model did not demonstrate an increased mortality in the younger patients in comparison with the older patients. When compared to older cohorts, virtually all younger patients underwent chemotherapy and had higher levels of neoadjuvant and combined neoadjuvant and adjuvant chemotherapy, higher rates of mastectomy, and higher rates of post-mastectomy radiation (chi-squared p-value = <0.0001 for all comparisons). These data demonstrate that stage-matched younger patients with TNBC do not have a decreased OS when compared to their older counterparts. However, younger patients tended to have more aggressive chemotherapy and surgery which likely underlies the lack of difference in survival in the younger age groups compared to the older age groups. Thus, younger women do not have worse survival, but may continue to require more aggressive treatment to achieve similar survival rates to their older counterparts.

National Cancer Database report of nonmetastatic esophageal small cell carcinoma.

BackgroundEsophageal small cell carcinoma (ESCC) is a rare malignancy for which there is no consensus management approach. This is the largest known analysis of nonmetastatic ESCC patients to date, evaluating national practice patterns and outcomes of surgical‐based therapy vs chemoradiotherapy (CRT) vs chemotherapy alone.MethodsThe National Cancer Data Base was queried for esophageal cancer patients with histologically confirmed nonmetastatic ESCC. Univariable and multivariable logistic regression ascertained factors associated with receipt of surgical‐based management. Kaplan‐Meier analysis evaluated overall survival (OS) and the log‐rank test is used to compare OS between groups; Cox univariate and multivariate analyses determined variables associated with OS.ResultsAltogether, 323 patients were analyzed; 64 (20%) patients underwent surgical‐based therapy, 211 (65%) CRT, and 48 (15%) chemotherapy alone. On multivariable analysis, no single factor significantly predicted for administration of surgery. Despite no OS differences between the surgery‐based (median OS 21 months) and CRT arms (18 months), both were superior to CT alone (10 months) (P < 0.001). Among other factors, receiving any local therapy independently predicted for higher OS over chemotherapy alone on Cox multivariate analysis (P < 0.001).ConclusionsThis study of a large, contemporary national database demonstrates that most ESCC is treated with CRT in the United States; adding local therapy to systemic therapy may be beneficial to these patients, although individualized multidisciplinary management is still recommended.

Utilization Patterns for Stereotactic Radiosurgery in the Management of Meningioma: A National Cancer Database Report

The purpose of our study was to evaluate the utilization of stereotactic radiosurgery (SRS) by race in the management of benign and malignant meningioma. The NCDB is a joint project of the American Cancer Society and the Commission on Cancer of the American College of Surgeons, and is a nationwide, comprehensive clinical surveillance resource oncology data set that captures 70% of all newly-diagnosed malignancies in the United States annually. Data for patients meeting the ICD-O-3 criteria for meningioma and undergoing radiation therapy were extracted from the Participant Use File (PUF) 2013 data file encompassing the years 2004 to 2013. Trends of use by race and independent factors related to SRS use were studied. Race categories included White (Wh), Black (Bl), American Indian (AI), Asian (As), and Hawaiian/Polynesian (HP). Statistical analyses were performed on IBM SPSS Statistics version 23.0. Association between SRS use and independent factors was assessed using a general linear model for univariate analysis (UVA), and a linear regression model for multivariate analysis (MVA). A total of 179,498 patients diagnosed with meningioma were identified in the PUF 2013 file. Of these, 17,353 patients underwent RT (56.2% SRS and 43.8% non-SRS). Demographics for this group of patients were: Median age 60, female 70.6%, Wh 83.1%, Bl 13.1%, AI 0.3%, As 3.3%, and HP 0.2%. For patients undergoing SRS, 25.6% of patients were over 70, 95.1% had benign tumors, 70% had tumors <4cm, 80% of patients underwent SRS as monotherapy, and 19.8% of patients underwent combined modality therapy. For the entire population, SRS use increased from 58.8% in 2004 to 62.2% in 2005, and then steadily decreased (48.3% in 2013; p< 0.001). When evaluated by race, Wh patients tended to have the highest rate of SRS use (59.6% in 2004, 64.5% peak in 2005, and 48.2% in 2013), and Bl patients had the lowest rate (53.9% in 2004, 57.7% peak in 2007, and 48.5% in 2013). As patients tended to have the second highest SRS utilization, and detailed analyses for AI and HP patients were limited secondary to small patient numbers. Of the 17 variables evaluated, 10 variables were significant on both UVA and MVA: Year of diagnosis, patient age, insurance status, histology, behavior, tumor size, grade, margin status, facility type and location, and Crowfly distance. SRS utilization in the treatment of meningioma peaked in 2005, and has slowly decreased. Numerous factors were associated with SRS use including demographic, tumor characteristics, and the use of surgery. Race was significant on UVA, with Bl patients being less likely to undergo SRS treatments, but not on MVA. Further research is needed to better understand the causes underlying these observed trends.

National Cancer Database Report of Lymphadenectomy Trends in Endometrial Cancer.

Lymph node involvement has a significant impact on prognosis that may direct adjuvant therapy. The role of routine lymph node staging (LNS) is controversial given conflicting results in multiple studies. Our aims are to describe treatment patterns of LNS, identify factors impacting LNS, and quantify the contemporary trends. The National Cancer Data Base was queried for patients undergoing hysterectomy for endometrioid and serous uterine carcinomas from 2003 to 2012. For endometrioid tumors, LNS was considered indicated if at least 1 of 4 criteria was met. Multivariate logistic regression and Cox proportional hazards model were used. A total of 161,683 patients were identified who received hysterectomy for 155,893 (96.4%) endometrioid and 5790 (3.6%) serous carcinomas. Receipt of LNS was significantly associated with greater than 50% myometrial invasion (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.55-1.73), grades 3 to 4 (OR, 3.03; 95% CI, 2.83-3.25), and tumor size greater than 2 cm (OR, 1.17; 95% CI, 1.28-1.26). Of the 97,152 patients with endometrioid carcinoma who met criteria for comprehensive staging, 73,268 (75.4%) underwent LNS. Patients with endometrioid carcinoma meeting criteria for LNS were less likely to receive LNS if they were of African American race (OR, 0.92; 95% CI, 0.86-0.98), had Medicaid insurance status (OR, 0.75; 95% CI, 0.69-0.81), had Medicare insurance (OR, 0.82; 95% CI, 0.79-0.86), or received care at a community program (OR, 0.39; 95% CI, 0.33-0.46). Nationally, most patients with greater than 50% myometrial invasion, grades 3 to 4, and/or tumor size greater than 2 cm receive LNS, but this was significantly impacted by insurance status, demographic characteristics, and facility location/type.

National Cancer Data Base report of associations, patterns, and survival benefit of lymphadenectomy in endometrial cancer

National Cancer Data Base report of associations, patterns, and survival benefit of lymphadenectomy in endometrial cancer

Age and Utilization Patterns for Accelerated Partial Breast Irradiation: A National Cancer Database Report

Age and Utilization Patterns for Accelerated Partial Breast Irradiation: A National Cancer Database Report

Abstract IA41: Standard of care and clinical disparities in epithelial ovarian cancer

Abstract Ovarian cancer afflicts approximately 204,000 women worldwide, with ∼125,000/year deaths. In the United States more than 22,000 new cases of ovarian cancer diagnosed with over 14,000 disease-related deaths.[1] The standard of care in ovarian cancer includes expedient access to the health care system, consultation with a gynecologic oncologist, surgical intervention, and multiagent platinum-based chemotherapy. Prognostic factors for improved survival in women with ovarian cancer include younger age; early stage; low-grade and serous histology; good performance status; disease biology (BRCA1 and 2 mutation carriers have a better prognosis); and low volume of residual disease at the time of cytoreductive surgery. In contrast, African-American race, low socioeconomic status (SES), geographic location, and insurance status have been associated with worse survival and increased probability of not receiving appropriate standard of care treatment.[2-7] These differences in ovarian cancer outcomes linked to race, social, and economic factors indicate that health care disparities exist in the treatment of this gynecologic cancer. In this presentation, we will (1) review the standard of care for epithelial ovarian cancer treatment, (2) discuss the variables affecting the outcome for patients with epithelial ovarian cancer, (3) describe the factors contributing to healthcare disparities, and (4) discuss the evidence for clinical disparities in epithelial ovarian cancer care and outcomes. Causes of healthcare disparities are complex and include differences in race/ethnicity, SES, insurance status, education level, geographic location, culture, healthcare system factors (adherence to treatment guidelines, and access to care), and disease biology.[2-7] The following are highlighted in this presentation: Population-based studies have demonstrated that African-American women are at increased risk of ovarian cancer death compared to non-Hispanic Caucasian women.Population-based studies have demonstrated that African-American women are less likely to undergo site-specific surgery or surgical staging for ovarian cancer compared to Caucasian women.African-American women were less likely to seek care at high-volume hospitals or be operated on by high-volume surgeons.African-American women and those with Medicaid/Medicare payer status are less likely to receive standard of care therapy based on National Comprehensive Cancer Network (NCCN) guidelines.Geographic location away from a high-volume hospital is associated with increased risk of non-adherent ovarian cancer care.Geographic barriers to standard treatment disproportionately affect racial minorities and women of low-SES.In contrast to population-based studies, retrospective single academic institution studies and ancillary analysis of large cooperative group phase III trials in advanced ovarian cancer have demonstrated no difference in overall survival in women of African-American and Caucasian descent. The reported research in ovarian cancer indicates that unequal delivery of quality care, obstacles to the delivery of recommended care, and limited access to expert care may account for the disparities seen in ovarian cancer care. The U.S. Department of Health and Human Services has targeted disparities in access to health care as the centerpiece of the Healthy People 2020 campaign and the Department of Health and Human Services (HHS) has unveiled an action plan to reduce racial and ethnic Health disparities.[8, 9] The 5 goals of the HHS Disparities Action Plan are: (1) transform health care; (2) strengthen the nation's Health and Human Services infrastructure and workforce; (3) advance the health, safety, and well-being of the American people; (4) advance scientific knowledge and innovation; and (5) increase the efficiency, transparency, and accountability of HHS programs. The HHS Disparities initiative will specifically target programs to increase knowledge of, access to, and utilization of biomedical and behavioral procedures to reduce cancer disparities.[9] Listed below are future research objectives that will reduce and potentially eliminate health care disparities in ovarian cancer in the United States: Improve our knowledge of the interaction between race, ethnicity, SES, geographic location and ovarian cancer health care disparities across the United States to harmonize existing data and identify opportunities for intervention.Improve our knowledge regarding cultural barriers to care.Promote community-based participatory research to increase ovarian cancer awareness and review standards of care.Develop interventions to provide expedient access to expert care by trained specialists in Gynecology Oncology, cytoreductive surgery, and administration of multiagent platinum-based chemotherapy in order to increase the likelihood of NCCN adherent standard of care therapy.

Epidemiology and survivorship of soft tissue sarcomas in adults: a national cancer database report

The National Cancer Data Base (NCDB) of the American College of Surgeons gather demographic and survival data on ∼70% of cancers in the USA. We wanted to investigate the demographic and survivorship data on this potentially more representative cohort of patients with soft tissue sarcomas. We selected 34 of the most commonly encountered soft tissue sarcomas reported to the NCDB, provided that each entity contained a minimum of 50 cases. This report summarizes the demographic and survivorship data on 63,714 patients with these 34 histologically distinct soft tissue sarcomas reported to the NCDB from 1998 to 2010. The overall survivorships of these sarcomas were near the lower limits of many prior reports due to the all-inclusive, minimally biased inclusion criteria. The overall best prognosis was Dermatofibrosarcoma NOS (not otherwise specified). (5-year survivorship 92%). The worst prognosis was Dedifferentiated Chondrosarcoma (5-year survivorship 19%). New observations included Biphasic Synovial Sarcoma demonstrating a better 5-year survivorship (65%) compared to spindle-cell synovial sarcoma (56%, P < 0.031) and Synovial Sarcoma, NOS (52%, P < 0.001). The demographic and 2- and 5-year survivorship data for all 34 soft tissue sarcomas are presented herein. This extent of demographic and survival data in soft tissue sarcomas is unprecedented. Because of the large number of cases and the inclusive nature of the NCDB, without restriction to certain stages, categories, or treatments, it is less subject to selection bias. Therefore, these data are thought to be more reflective of the true overall prognosis given the current management of sarcoma across the NCDB contributing sites.

A National Cancer Data Base report on mesothelioma.

e18501 Background: This is the first report on mesothelioma using Commission on Cancer National Cancer Database information and this is the largest study on mesothelioma to date. Methods: Using the National Cancer Database (NCDB) 26,605 patients diagnosed with mesothelioma between 2000 and 2010 were identified and analyzed. The NCDB contains data from more than 70% of all new cancers diagnosed in the U.S. each year. Results: The majority of mesothelioma patients are Caucasian (89%), males (78%), over the age of 70 (60%), and are diagnosed with stage IV disease (41%). The majority of patients (41%) received no first course treatment. The patients that were most likely to have surgery include patients &lt;70 years old, at academic centers, with stage I-III disease, and of these only 37% received surgery and 15% received no first course treatment. The youngest patients &lt;50 years received the most surgical therapy (36%) and the oldest patients &gt;80 received the least (12%). Patients with private insurance received more surgical treatment (28%) than patients with Medicaid (22%), Medicare (18%), and VHA (12%)(p&lt;0.009). Private insurance holders also received no first course treatment less often (29.6%) than Medicaid (37%), Medicare (46%), VHA (52%), and uninsured patients (37%)(p&lt;0.002). Conclusions: The majority of patients with mesothelioma are elderly, Caucasian males and many of which do not receive treatment. The standard of care for resectable stage I-III mesothelioma includes surgery and chemotherapy. The results from this study indicate that 41% of all patients received no first course treatment and only 21% of patients received surgical treatment. Of patients most likely to receive surgery, only 37% of patients received surgical treatment and 15% of these patients did not receive any first course treatment. Age and insurance status also affect treatment as the youngest patients and private insurance holders received the most surgical treatment. [Table: see text]

The National Cancer Data Base report on the utilization of an adjuvant immunotherapy in stage III melanoma in relation to age.

e19000 Background: The 5-year survival of Stage III melanoma ranges from 30-70%. High dose interferon alfa-2b (IFN) is an adjuvant immunotherapy approved in 1995 for stage III melanoma, however, its use has been limited by its significant toxicity and modest benefit. We hypothesized the utilization of adjuvant immunotherapy is less in older age group compared to younger patients. Methods: Using the National Cancer Data Base (NCDB) aggregate data, demographic, socioeconomic, insurance information, and treatment data were analyzed. Proportions were compared using Pearson Chi squared tests. Results: From 2000-2008, 27,365 cases of stage III melanoma were reported to NCDB. Most patients were male (63%) and Caucasian (94.2%). Twenty-nine percent were over the age of 70. Educational and socioeconomic factors across all age groups were not significantly different. The primary insurer for patients younger than 60 was a managed care plan (54.3%) as compared to Medicare with supplemental insurance for patients older than 60 (47.4%). In terms of systemic therapy, 23% received immunotherapy alone, 6% received chemotherapy alone, 2% received both, and 66% received no therapy. When compared to patients under age 39, older age groups were significantly less likely to receive adjuvant immunotherapy as shown in the table below. Conclusions: There is an inverse relationship between age and the use of adjuvant immunotherapy. Further study is planned to adjust for comorbidity, socioeconomic status using patient-level data. [Table: see text]

A Novel Therapeutic Vaccine of Mouse GM-CSF Surface Modified MB49 Cells Against Metastatic Bladder Cancer

Immunotherapy is considered effective for muscle invasive bladder cancer mini metastasis. We developed what is to our knowledge a novel technology by which streptavidin tagged mouse GM-CSF was displayed on the surface of biotinylated bladder cancer cells to induce antitumor immunity. Mouse subcutaneous and lung metastasis bladder cancer models were established. Mice were injected subcutaneously with 1 × 10(6) mouse GM-CSF surface modified MB49 bladder cancer cells and monitored for tumor growth and survival. Immunohistochemical and flow cytometric assay were done to assess the proportion of T lymphocytes. The T-lymphocyte cytotoxicity assay was performed to assess MB49 specific cytotoxicity. On day 60 after MB49 implantation the vaccine cured mice were injected subcutaneously with MB49 or RM-1 cells in the left or right hind leg, respectively. They were monitored for survival and T-lymphocyte cytotoxicity. Mouse GM-CSF surface modified vaccine significantly inhibited tumor growth in the subcutaneous model and extended survival in the lung model. More CD4 and CD8 T cells appeared at tumor sites and in peripheral blood in the vaccine treated group than in other control groups. Splenocytes from the vaccine treated group showed the most potent cytotoxicity on MB49 cells. Cured mice in the vaccine treated group resisted the second injection of MB49 bladder cancer cells but not the RM-1 prostate cancer cell challenge. Mouse GM-CSF surface modified MB49 bladder cancer cell vaccine induced specific antitumor immunity and was efficient for metastatic bladder cancer.

The National Cancer Database report on advanced-stage epithelial ovarian cancer: Impact of hospital surgical case volume on overall survival and surgical treatment paradigm

Objective To examine the effect of hospital procedure volume and other prognostic variables on overall survival outcome and likelihood of receiving standard recommended care among patients with advanced-stage epithelial ovarian cancer. Methods The National Cancer Data Base (NCDB) was searched for patients undergoing primary treatment for FIGO Stage IIIC/IV epithelial ovarian cancer from 1996 to 2005. The average annual surgical procedure volume was derived for each reporting hospital. Quartile ranking discriminated four groups of hospitals based on annual surgical volume: low (< 9), intermediate (9–20), high (21–35), and very high (> 35). Cox proportional hazards modeling was used to determine the impact on overall survival of hospital surgical volume adjusted for treatment, FIGO/AJCC stage, ethnicity, age, payer status, household income, and tumor grade. Binomial multivariate logistic regression modeling was used to assess differences in patient demographic, tumor, and treatment variables between high/very high volume hospitals and low/intermediate volume hospitals. Results A total of 45,929 patients were identified. After adjusting for other factors, overall survival was significantly correlated with hospital case volume: very high (reference); high (HR 0.98, 95% CI = 0.92–1.04); intermediate (HR 1.08, 95% CI = 1.01–1.15); and low (HR 1.14, 95% CI = 1.07–1.22). Compared to low and intermediate volume hospitals, patients treated at very high and high-volume hospitals were less likely to receive neo-adjuvant chemotherapy (OR = 0.33, 95% CI = 1.18–1.50) or surgery alone (OR = 0.77, 95% CI = 0.73–0.82) instead of initial surgery and adjuvant chemotherapy. Conclusions Hospital ovarian cancer surgical volume ≥ 21 cases/year is associated with a higher likelihood of patients with Stage IIIC/IV epithelial ovarian cancer receiving standard treatment (surgery followed by adjuvant chemotherapy). Even after adjusting for treatment paradigm and other factors, hospital volume ≥ 21 cases/year was significantly predictive of improved overall survival outcome.

National Cancer Database report on cancer of the head and neck: 10‐Year update

We sought to examine the current state of cancer care for head and neck tumors in the United States. We therefore performed a retrospective, longitudinal study of the approximately 822,000 head and neck cancer cases included in the National Cancer Data Base (NCDB) for 1990 through 2004, representing approximately 75% of the estimated incident diagnoses in the United States. All cases of head and neck cancer diagnosed and reported to the NCDB during this interval were reviewed, and descriptive statistics, grouped by disease and host factors, were analyzed over time and compared with a prior similar analysis done 10 years ago. Although many similarities persist, several major changes in head and neck cancer have occurred, most notably (1) a decrease in the number of the older-aged patients who have mucosally derived squamous cell carcinomas coupled with an increase in the number of younger-aged patients who have thyroid-origin adenocarcinomas and (2) a decrease in the use of radiation therapy alone for treatment in favor of chemotherapy enhanced radiation therapy. Head and neck cancers include a heterogeneous group of tumors whose precise composition changes over time and whose therapy evolves as well. The NCDB is well suited to capture this information and provide both an analysis of the current state of cancer care for head and neck tumors and a longitudinal view over time.

Variations in Axillary Staging: Much Ado About Nothing?

The debate regarding the role of lymphadenectomy in breast cancer persists despite the availability of 25-year follow-up data from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B04 trial comparing radical mastectomy, total mastectomy with regional nodal irradiation, and total mastectomy with no nodal treatment, a study that was designed to address this question. This trial failed to show a survival benefit attributable to regional nodal surgery or radiation; however, critical review revealed that the trial was likely too underpowered to show this difference, and axillary lymph node dissection (ALND) remained an important component of surgical therapy to accurately stage the axilla, guide systemic therapy decisions, and minimize regional recurrence. Sentinel lymph node (SLN) biopsy, an accurate and less invasive alternative to axillary node dissection, has become the new standard of care for axillary staging, and adoption of this technique has allowed surgeons to avoid axillary dissection and many of its attendant morbidities in node-negative patients. Questions still remain, however, as to whether ALND is always necessary in patients with positive SLNs and considerable effort has gone into the development of nomograms and predictive models to identify a subset of patients with a sufficiently low probability of having additional non-SLN metastases for whom completion node dissection may be avoided. With the early closure of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial, it is unlikely that we will have ever have definitive evidence as to whether ALND improves survival in patients with positive lymph nodes; yet axillary lymph node staging remains an integral component of breast cancer treatment, and axillary lymph node status remains the most significant prognostic factor for disease recurrence and survival. All current guidelines for the management of invasive breast cancer include the performance of an axillary staging procedure to guide further treatment decisions, and the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology state that SLN biopsy (SLNB) is the preferred method of axillary sampling when available. NCCN guidelines further state that the performance of ALND is considered optional in patients with ‘‘particularly favorable tumors, patients for whom the selection of adjuvant systemic therapy is likely to be unaffected, for the elderly, and for those with serious comorbid conditions.’’ These caveats allow physicians to balance the risks and the benefits of the procedure for an individual patient, i.e., the art of medicine, but should not result in lesser-quality care for any particular group of patients. In this issue, Halpern et al. have found that significant variation exists in the performance of axillary staging procedures with respect to age, race, and socioeconomic class. Although there is a growing body of literature citing disparities in breast cancer care across race and socioeconomic class, the most significant finding in this analysis of the National Cancer Database (NCDB) is the omission of lymph node biopsy (LNB) in the older population. Patients in the oldest quartile C 73) were more than three times as likely not to receive an axillary staging procedure compared to their younger counterparts (age 51 years). Such variation in axillary surgery in the elderly should not come as a surprise. In the era before SLNB (1985–1995), a NCDB report identified that women older than 70 were more than twice as likely not to receive ALND when undergoing breast-conserving surgery (BCS) for early-stage breast cancer, and after the introduction of SLNB (1998–2005), the authors of the current paper previously reported that among all patients undergoing axillary surgery for earlystage breast cancer, older patients were less likely to receive SLNB (odds ratio, 0.8; 95% confidence interval, 0.78– 0.82). Halpern et al. also cite other published reports of variations in the surgical management of breast cancer for Society of Surgical Oncology 2008

Testis Cancer

No AccessJournal of UrologyUrologic diseases in America Project1 Jun 2007Testis Cancer Mitchell H. Sokoloff, Geoffrey F. Joyce, Matthew Wise, and Urologic Diseases in America Project Mitchell H. SokoloffMitchell H. Sokoloff More articles by this author , Geoffrey F. JoyceGeoffrey F. Joyce More articles by this author , Matthew WiseMatthew Wise More articles by this author , and Urologic Diseases in America Project More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2007.01.127AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We quantified the burden of testis cancer in the United States by identifying trends in its incidence, its treatment and the use of health care resources to estimate the economic impact of the disease. Materials and Methods: The analytical methods used to generate these results were described previously. Results: The overall incidence of testis cancer in the United States increased 46% between 1975 and 2001. During the same period the ratio of seminoma to nonseminoma increased and there were fewer men presenting with stage II and III tumors. Survival rates increased successively, attaining the current level of 95.9%. Treatment patterns changed and active surveillance increased as a primary treatment modality. Overall hospitalization rates for men with testis cancer decreased from 1.8/100,000 in 1994 and 1.4/100,000 in 2000. Care for white men shifted to the outpatient setting, which did not occur for black men. The estimated annual expenditure for testis cancer for privately insured individuals between ages 18 and 54 years was $6,236. National estimates of annual medical expenditures placed the total cost of treatment at $21.8 million in 2000, representing an increase of 10% over the total in 1994. Of men with testis cancer 16% missed work for treatment of the disease with an average of 8.4 total hours of work missed. Conclusions: The cost of testis cancer is estimated at almost $21.8 million annually. It appears to be increasing with time despite a shift to active surveillance treatments and less hospitalization. References 1 : Cancer statistics, 2005. CA Cancer J Clin2005; 55: 10. Google Scholar 2 : Urologic Diseases in America Project: analytical methods and principal findings. J Urol2005; 173: 933. Link, Google Scholar 3 : Urologic Diseases in America Interim Compendium. Washington, D. C: United States Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases2004. Google Scholar 4 : Rising risk of testicular cancer by birth cohort in the United States from 1973 to 1995. J Urol1999; 162: 361. Link, Google Scholar 5 : Trends in the incidence of testicular germ cell tumors in the United States. Cancer2003; 97: 63. Google Scholar 6 : Differences in testis cancer survival by race and ethnicity: a population-based study, 1973–1999 (United States). Cancer Causes Control2004; 15: 437. Google Scholar 7 : The National Cancer Data Base report on patterns of care for testicular carcinoma, 1985–1996. Cancer1999; 86: 2171. Google Scholar 8 : Concentrations of polychlorinated biphenyls in blood and the risk for testicular cancer. Int J Androl2004; 27: 282. Google Scholar Section of Urologic Oncology, Division of Urology and Renal Transplantation, Department of Surgery, Oregon Health and Sciences University, Portland, Oregon© 2007 by American Urological AssociationFiguresReferencesRelatedDetailsCited byCooper D, L'Esperance J, Christman M and Auge B (2008) Testis Cancer: A 20-Year Epidemiological Review of the Experience at a Regional Military Medical FacilityJournal of Urology, VOL. 180, NO. 2, (577-582), Online publication date: 1-Aug-2008. Volume 177Issue 6June 2007Page: 2030-2041 Advertisement Copyright & Permissions© 2007 by American Urological AssociationKeywordsprevalencetesticular neoplasmshealth care costshospitalizationtestisMetricsAuthor Information Mitchell H. Sokoloff More articles by this author Geoffrey F. Joyce More articles by this author Matthew Wise More articles by this author Urologic Diseases in America Project More articles by this author Expand All Advertisement PDF downloadLoading ...

The national cancer data base report on squamous cell carcinoma of the base of tongue

Background. This study provides the largest contemporary overview of presentation, care, and outcome for base of tongue squamous cell carcinoma (SCC). Methods. We extracted 16,188 cases from the National Cancer Data Base (NCDB). Chi-square analyses were performed on selected cross-tabulations. Observed and disease-specific survival were used to analyze outcome. Results. Three-quarters had advanced-stage (III–IV) disease. Radiation therapy alone (24.5%) and combined with surgery (26.9%) were the most common treatments. Five-year observed and disease-specific survival rates were 27.8% and 40.3%, respectively. Poorer survival was significantly associated with older age, low income, and advanced-stage disease. For early-stage disease, surgery with or without irradiation had higher survival than irradiation alone. For advanced-stage disease, surgery with irradiation had the highest survival. Conclusions. Survival rates were low for base of tongue SCC, with most deaths occurring within the first 2 years. Income, stage, and age were significant prognostic factors. In this nonrandomized series, surgery with radiation therapy offered patients with advanced-stage disease the best survival. © 2004 Wiley Periodicals, Inc. Head Neck 26: 660–674, 2004

The National Cancer Data Base report on squamous cell carcinoma of the base of tongue.

This study provides the largest contemporary overview of presentation, care, and outcome for base of tongue squamous cell carcinoma (SCC). We extracted 16,188 cases from the National Cancer Data Base (NCDB). Chi-square analyses were performed on selected cross-tabulations. Observed and disease-specific survival were used to analyze outcome. Three-quarters had advanced-stage (III-IV) disease. Radiation therapy alone (24.5%) and combined with surgery (26.9%) were the most common treatments. Five-year observed and disease-specific survival rates were 27.8% and 40.3%, respectively. Poorer survival was significantly associated with older age, low income, and advanced-stage disease. For early-stage disease, surgery with or without irradiation had higher survival than irradiation alone. For advanced-stage disease, surgery with irradiation had the highest survival. Survival rates were low for base of tongue SCC, with most deaths occurring within the first 2 years. Income, stage, and age were significant prognostic factors. In this nonrandomized series, surgery with radiation therapy offered patients with advanced-stage disease the best survival.

The influence of histologic grade in intraoral squamous cell carcinoma

Statement of the Problem: Advances in adjuvant therapies and refinements in ablative and reconstructive techniques during the last decade have improved functional and aesthetic outcomes of patients with oral squamous cell carcinoma (OSCC). However, there has been little change in the overall survival of these patients. Materials and Methods: The purpose of this retrospective study was to review the outcome of patients with OSCC treated at a single institution by primary surgical resection with or without adjuvant radiotherapy or chemoradiotherapy and to identify factors affecting survival and locoregional control. Method of Data Analysis: The records of 233 patients with OSCC treated at a single institution from 1993 to 2003 were identified from the Legacy Emanuel Hospital and Health Center’s cancer registry. All patients undergoing surgical resection as a primary treatment modality were included in the study. Patients with nonresectable disease, distant metastasis, and those with inadequate follow-up data were excluded from the study. Patients with positive surgical margins, high grade histology, aggressive biologic behavior, or advanced staged disease underwent adjuvant radiotherapy or chemoradiotherapy. The data collected included age, sex, race, tumor site, margin status, grade, TNM stage, cancer therapies, and cancer status. Data were statistically analyzed in an attempt to identify predictors of locoregional control and disease-free survival. Descriptive statistics were calculated for each variable and survival was calculated using the Kaplan-Meier method. Prognostic factors were analyzed using the Cox proportional hazard model. Results: Two hundred fifteen patients consisting of 119 males (48%) and 123 females (52%), with an average age at diagnosis of 66 years (SD ± 14), met the criteria for inclusion in the study. Average tumor size was 23.5mm (SD ± 14.1). Site distribution was as follows; 73 (33.5%) tongue, 40 (18.3%) floor of mouth, 13 (6.0%) palate, 19 (8.7%) cheek, 27 (12.4%) retromolar trigone, 31 (14.2%) upper gingiva and 12 (5.5%) lower gingiva, and 3 (1%) tumor of unspecified location. Seventy patients were identified with grade 1 histology (33%), 117 grade 2 (54%), and 28 grade 3 (13%). There were 106 patients with stage 1 disease (49%), 40 with stage 2 (18%), 17 with stage 3 (8%), and 52 with stage 4 (24%). Positive margins were found in 32 patients (15%). Overall 5-year survival was 56% and disease-free survival at 5 years was 58%. Stage and grade were identified as having a statistically significant effect on survival (P = .0014, likelihood ratio chi-square = 10.7, 3 degrees of freedom and P = .026, likelihood ratio chi-square = 5, 1 degree of freedom, respectively). Neither age, sex, race, tumor site, nor positive margins demonstrated a statistically significant effect on survival (P > .05). Conclusion: Tumor grade and stage are important predictors of survival in patients with oral cavity squamous cell carcinoma. References Funk GF, Karnell LH, Robinson RA, et al: Presentation, treatment, and outcome of oral cavity cancer: A National Cancer Database report. Head Neck 24:165, 2002 Shah JP, Cendron RA, Farr HW, et al: Carcinoma of the oral cavity. Factors affecting treatment failure at the primary site and neck. Am J Surg 132:504, 1976