Patients In National Cancer Database Research Articles

Lepidic-Type Lung Adenocarcinomas: Is It Safe to Observe for Growth Before Treating?

BackgroundLepidic-type adenocarcinomas (LPAs) can be multifocal, and treatment is often deferred until growth is observed. This study investigated the potential downside of that strategy by evaluating the relationship of nodal involvement with tumor size and survival. MethodsThe impact of tumor size on lymph node involvement and survival was evaluated for National Cancer Database patients who underwent surgery without induction therapy as primary treatment for cT1-3 N0 M0 histologically confirmed LPA from 2006 to 2019 by using logistic regression, Kaplan-Meier, and Cox analyses. ResultsPositive nodes occurred in 442 of 8286 patients (5.3%). The incidence of having positive nodes approximately doubled with each 1-cm increment increase in size. Patients with positive nodes were more likely to have larger tumors (27 mm vs 20 mm, P < .001) and clinical ≥T2 disease (40.7% vs 26.8%, P < .001) compared with node-negative patients. However, tumor size was the only significant independent predictor of having positive nodal disease in logistic regression analysis, and this association grew stronger with each incremental centimeter increase in size. Patients with positive nodes were more likely to undergo adjuvant radiotherapy (23.5% vs 1.1%, P < .001) and chemotherapy (72.9% vs 7.9%, P < .001), and expectedly, had worse survival compared with the node-negative group in univariate (5-year overall survival, 50.9% vs 81.1%, P < .001) and multivariable (hazard ratio, 2.56; 95% CI, 2.14-3.05; P < .001) analyses. ConclusionsNodal involvement is relatively uncommon in early-stage LPAs but steadily increases with tumor size and is associated with dramatically worse survival. These data can be used to inform treatment decisions when evaluating LPA patients.

Disparities in Clinical Trial Enrollment and Reporting in Rectal Cancer: A Systematic Review and Demographic Comparison to the National Cancer Database.

Cancer care guidelines based on clinical trial data in homogenous populations may not be applicable to all rectal cancer patients. The aim of this study was to evaluate whether patients enrolled in rectal cancer clinical trials (CTs) are representative of United States (U.S.) rectal cancer patients. Prospective rectal cancer CTs from 2010 to 2019 in the United States were systematically reviewed. In trials with multiple arms reporting separate demographic variables, each arm was considered a separate CT group in the analysis. Demographic variables considered in the analysis were age, sex, race/ethnicity, facility location throughout the United States, rural vs urban geography, and facility type. Participant demographics from trial and the National Cancer Database (NCDB) participants were compared using chi-squared goodness of fit and one-sample t-test where applicable. Of 50 CT groups identified, 42 (82%) studies reported mean or median age. Trial participants were younger compared to NCDB patients (P < .001 all studies). All but three trials had fewer female patients than NCDB (48.2% female, P < .001). Less than half the CT groups reported on race or ethnicity. Eighteen out of 22 trials (82%) had a smaller percentage of Black patients and 4 out of 8 (50%) trials had fewer Hispanic or Spanish origin patients than the NCDB. No CTs reported comorbidities, socioeconomic factors, or education. CT primary sites were largely at academic centers and in urban areas. The present study supports the need for improved demographic representation and transparency in rectal cancer clinical trials.

Robotic chest wall resection for primary benign chest wall tumors and locally advanced lung cancer: an institutional case series and national report.

Limited data exists for robotic chest wall resection; we report institutional and national experience of robotic chest wall resection. In this comparative retrospective case series we describe patients who underwent robotic chest wall resection at our institution and enrich this case series with data from the National Cancer Database (NCDB). We describe our preoperative workup, operative technique, and postoperative care. Outcomes included conversion to open, length of stay, readmissions, and 30- and 90-day mortality. The results are descriptively reported and compared. We describe 6 patients institutionally and 96 NCDB patients. At our institution 66.7% were males, median age was 70.0 (range, 39-91) years, and 50% were primary chest wall tumors. Median tumor size was 5.25 (range, 2.3-8.3) cm. Outcomes were as follows: no open conversions, median length of stay 3 (range, 1-6) days, no unplanned 30-day readmissions or 90-day mortality. In the NCDB, 55.2% were males with median age of 68.5 (range, 30-89) years. Median tumor size was 3.90 (range, 2.4-6.0) cm. NCDB outcomes were as follows: 18.8% open conversion, median length of stay 7 (range, 5-10) days, 3.1% unplanned 30-day readmission, and 8.3% 90-day mortality. Our institutional case series had 18.0 months median follow-up (range, 6-54 months) with no functional deficits. Median survival in NCDB was 49.6 months. Robotic chest wall resection is feasible and is performed nationally with acceptable short- and long-term outcomes. Our institutional experience reports our technique, resultant short hospital stay, and excellent functional outcomes.

Trends in utilization of first-line palliative care in non-metastatic hepatocellular carcinoma.

e16234 Background: Palliative care therapies are known to improve the quality of life and even the survival of some patients. Although non-metastatic (stages I-III) hepatocellular carcinoma (HCC) patients often present with significant symptoms, first-line palliative care treatment is uncommon in this setting. Here we characterized rates of palliative care utilization among non-metastatic HCC patients and determined factors associated with palliative care receipt. Methods: We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2019. We used descriptive analysis for determining palliative care utilization, including palliative chemotherapy, surgery, radiotherapy, and pain management. We performed multivariable logistic regression analysis to assess the association of characteristics with palliative treatment utilization. Results: Among 121,151 patients diagnosed with stage I-III HCC, the utilization of first-line palliative care subsets was only a small portion of 3966 (3.3%). The most commonly used palliative care treatment was pain management (37.4%), followed by systemic chemotherapy (31.1%), radiotherapy (13%), surgery (9.9%), and combination therapies (8.6%). The higher stage, high comorbidity score, and decreased life expectancy were more likely to be associated with received PC. Stage 2 and 3 diseases were associated with increased odds of PC receipt compared to stage 1 disease (odds ratio [OR] = 1.63 [1.45-1.83] and OR = 3.57 [3.22-3.95]; respectively). Comorbidity score 3 was significantly more likely to receive PC than comorbidity score 0 (OR = 1.54 [1.41–1.69]). In addition, life expectancy &gt;24 months was significantly less associated with PC receipt compared to life expectancy &lt; 6 months (OR: 0.23 [0.20-0.26]). Conclusions: First-line palliative care subsets are underutilized to control symptoms among patients with non-metastatic HCC. Targeted efforts should be focused on increasing palliative care delivery in this group which has a vast potential to benefit.

Understanding Factors Leading to Surgical Attrition for "Resectable" Gastric Cancer.

We used a novel combined analysis to evaluate various factors associated with failure to surgical resection in non-metastatic gastric cancer. We identified factors associated with the receipt of surgery in publicly available clinical trial data for gastric cancer and in the National Cancer Database (NCDB) for patients with stages I-III gastric adenocarcinoma. Next, we evaluated variable importance in predicting the receipt of surgery in the NCDB. In published clinical trial data, 10% of patients in surgery-first arms did not undergo surgery, mostly due to disease progression and 15% of patients in neoadjuvant therapy arms failed to reach surgery. Effects related to neoadjuvant administration explained the increased attrition (5%). In the NCDB, 61.7% of patients underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (younger, healthier, and privately insured patients treated at high-volume and academic centers) the rate of surgery was 79.2%. Decreased likelihood of surgery was associated with advanced age (OR 0.97, p < 0.01), Charlson-Deyo score of 2+ (OR 0.90, p < 0.01), T4 tumors (OR 0.39, p < 0.01), N+ disease (OR 0.84, p < 0.01), low socioeconomic status (OR 0.86, p = 0.01), uninsured or on Medicaid (OR 0.58 and 0.69, respectively, p < 0.01), low facility volume (OR 0.64, p < 0.01), and non-academic cancer programs (OR 0.79, p < 0.01). Review of clinical trials shows attrition due to unavoidable tumor and treatment factors (~ 15%). The NCDB indicates non-medical patient and provider characteristics (i.e., age, insurance status, facility volume) associated with attrition. This combined analysis highlights specific opportunities for improving potentially curative surgery rates.

The Role of Post-Mastectomy Radiation Therapy in Patients with pT3N0 Breast Cancer and Low Genomic Recurrence Score

<h3>Purpose/Objective(s)</h3> The role of post-mastectomy radiotherapy (PMRT) in patients with pT3 pN0 breast cancer remains controversial. We previously showed a correlation between PMRT and improved overall survival (OS) in pT3N0 patients who do not receive chemotherapy. However, it is unknown whether this correlation extends to patients with low genomic recurrence score (RS). In this analysis, we used the National Cancer Database (NCDB) to investigate the benefit of PMRT in pT3N0 patients with low RS. <h3>Materials/Methods</h3> We performed an analysis of NCDB patients with pT3N0 breast cancer who had low Oncotype DX RS (ORS) (< 25) and did not receive systemic chemotherapy. Patients were matched for baseline patient, tumor, and treatment characteristics using inverse probability of treatment weighting to minimize the impact of potential confounding variables. We stratified patients based on receipt of PMRT and compared OS using Kaplan-Meier estimates. Univariate and doubly-robust multivariable analyses were used to correlate PMRT and various baseline characteristics with OS. <h3>Results</h3> We identified 444 patients with pT3N0 breast cancer who had undergone mastectomy and had low-risk genomic assay scores who did not receive systemic chemotherapy. After IPTW matching, there were no significant differences in baseline patient characteristics. In the PMRT group, 44% received treatment to the chest-wall only, and 66% patients received chest wall and regional nodal irradiation. PMRT was associated with improved overall survival on both the univariate (HR=0.201; 95% CI=0.05-0.78; p=0.021) and doubly-robust multivariable analyses (HR=0.128; 95% CI=0.02-0.66; p=0.014). Receipt of endocrine therapy was also found to significantly improve overall survival (p=0.02). We attempted to repeat the analysis in patients with RS >25 who received chemotherapy, but we only identified a total of 78 such patients and could not perform a robust analysis. <h3>Conclusion</h3> This cohort analysis shows a strong correlation between PMRT and improved OS in pT3N0 patients with low ORS who do not receive chemotherapy. It is possible that with the de-escalation of chemotherapy and axillary surgery in this patient population in the modern era, the benefit of locoregional treatment with radiotherapy is magnified. Our analysis suggests that prospective data are needed before de-escalation of radiotherapy for these patients based on ORS.

Proposed Risk Stratification and Patterns of Radioactive Iodine Therapy in Malignant Struma Ovarii.

Introduction: Malignant struma ovarii (MSO) is a rare thyroid cancer arising within an ovarian teratoma. While surgical excision of the primary tumor is widely accepted as standard of care, recommendations for adjuvant treatment of MSO-whether or not to administer radioactive iodine (RAI)-are based largely on case reports and remain debated. In this study, we aimed to propose a risk stratification and analyze RAI utilization patterns in MSO cases. Methods: The National Cancer Database (NCDB) was queried for patients with MSO between 2004 and 2016. Demographic, oncological, and clinicopathologic data were compared between groups using Fisher's exact test. Kaplan-Meier curves were used to estimate overall survival (OS), and variables associated with OS were assessed via univariate Cox regression. We adapted the 2015 American Thyroid Association risk guidelines for MSO patients. We stratified patients into low-, intermediate-, and high-risk groups using metastasis, extraovarian extension, lymphovascular invasion, lymph node status, surgical margins, tumor size, and grade. Risk stratification, demographic, oncological, and clinicopathologic data were compared between the groups receiving and not receiving RAI therapy. We then queried the Surveillance, Epidemiology, and End Results (SEER) 18 registry for patients with MSO between 2000 and 2018 to confirm our risk stratification analysis. Results: In the NCDB analysis, a total of 158 patients were identified, and 19 received RAI. RAI therapy was associated with distant metastasis (p = 0.005) and lymph node status (p = 0.012). Twenty-one NCDB patients were stratified as high risk, and 30% of high-risk patients received RAI. High-risk stratification was associated with decreased OS via univariate Cox regression (hazard ratio = 4.0 [95% confidence interval 1.11-14.26], p = 0.034). In our subsequent analysis using the SEER registry, there were 95 MSO patients, and 18 received RAI. Again, the majority of high-risk patients did not receive RAI, with only 41% of high-risk patients receiving RAI. Conclusions: MSO is a rare malignancy with apparently variable and inconsistent patterns of postoperative RAI administration. The risk stratification described here provides a framework to identify patients potentially at risk for mortality, and utilization of RAI in this group should be studied further.

Sentinel Lymph Node Biopsy Alone is Adequate for Chemotherapy Decisions in Postmenopausal Early-Stage Hormone-Receptor-Positive, HER2-Negative Breast Cancer with One to Three Positive Sentinel Lymph Nodes.

The RxPONDER trial randomized patients with cT1-3N0 hormone receptor-positive, HER2-negative (HR+HER2-) breast cancer and one to three positive nodes and Recurrence Score (RS) < 26 to endocrine therapy (ET) or chemoendocrine therapy (CET) with equivalent survival in postmenopausal women. In current practice, cN0 patients with one or two positive sentinel lymph nodes (SLN) do not undergo axillary lymph node dissection (ALND), raising concerns about applying these data in patients who may have additional nodal disease. We identified institutional [Dana-Farber Brigham Cancer Center (DF/BCC), 2016-2020] and national [National Cancer Database (NCDB), 2012-2017] cohorts of women aged 50-75 years with cT1-3N0 HR+HER2- breast cancer and RS < 26 treated with upfront surgery with one to three positive SLN. Axillary nodal burden and outcomes were assessed on the basis of the number of positive nodes and CET use. A total of 197 and 13,499 HR+HER2- eligible patients with one to three positive SLN and RS < 26 were identified in the DF/BCC and NCDB databases, respectively, and 12.7% of DF/BCC and 32.4% of NCDB patients had ALND. Of these, only 12.0 and 4.9% had more than three total positive nodes, respectively. Rates of CET were 6.6% in DF/BCC and 20.9% in NCDB patients. In the NCDB, similar adjusted 4-year overall survival was seen between patients treated with CET or ET for any number of positive nodes (98.1-99.9%, all p > 0.05). Postmenopausal women with cT1-3N0 HR+HER2- breast cancer and RS < 26 with one to three positive SLN are unlikely to have more than three total positive nodes. CET decisions should continue to be based on SLN biopsy as ALND is unlikely to change treatment recommendations or outcomes.

Is Medicaid Expansion Associated with Improved Nonmetastatic Colon Cancer Survival? An Analysis of the National Cancer Database.

This retrospective study of 86413 patients (40-64years old) undergoing surgical resection for a new diagnosis of invasive, nonmetastatic colon cancer included in the National Cancer Database (NCDB) from 2010 to 2015 compared overall survival (OS) in MES to NES. Cox proportional hazard models, fit for OS, and propensity score-matching (PSM) analysis were performed. In this sample, 51297 cases (59.2%) lived in MES and 35116 (40.8%) in NES. Medicaid expansion states had earlier pathological stage compared to NES (stage I 25.38% vs 24.17%, stage II 32.93 vs 33.4%, and stage III 41.69 vs 42.43%; P < .001). 5-year OS in MES was higher than NES (79.1% vs 77.3%; P < .001); however, on both multivariable analysis (MVA) and PSM analysis, MES did not have significantly different OS from NES (hazard ratio (HR), .99, 95% confidence interval (CI), .95-1.03; P = .570; HR, .99, 95% CI, .95-1.03; P = .68). Among NCDB patients with invasive, nonmetastatic colon cancer residing in MES at time of diagnosis was associated with earlier pathological stage. However, on both MVA and PSM analysis, OS was not significantly different in MES vs NES. Research on patient outcomes, such as receipt of guideline concordant care, can further inform the impact of insurance coverage expansion efforts on cancer outcomes.

Evaluation of Survival and Postoperative Radiation Among Patients with Advanced Medullary Thyroid Carcinoma: An Analysis of the National Cancer Database.

This study compared survival between patients who had medullary thyroid cancer (MTC) treated with surgery alone and patients who underwent surgery and radiation (SRT). Patients from the National Cancer Database (NCDB) with a diagnosis of stage 3 or 4 MTC, lymph node disease, and no distant metastases between 2008 and 2016 were studied. Kaplan-Meier analyses and log-rank statistics were used to estimate and compare overall survival between patients treated with surgery alone and those treated with SRT. Mutlivariable Cox proportional hazards models and propensity-matching were used to adjust for confounding and selection bias. Among 1370 patients, 1112 (81%) received surgery alone, and 258 (19%) received SRT. The hazard ratio for mortality in the SRT group was 1.784 (95% confidence interval [CI] 1.313-2.43) after multivariable adjustment for confounding variables. Furthermore, SRT remained associated with a higher mortality rate (p<0.008) after propensity-matching in an effort to adjust for selection bias. This analysis of NCDB patients showed that SRT is associated with a significantly higher mortality rate among patients treated for stage 3 or 4 IV MTC with positive lymph node disease. Although this observation can be attributed to unmeasured confounders or selection bias, the cause for the profound survival differences deserves prospective evaluation, especially as adjuvant therapies for this disease continue to evolve.

Surgical Outcomes in the National Lung Screening Trial Compared With Contemporary Practice

BackgroundThe National Lung Screening Trial (NLST) established a role for lung cancer screening. Mortality benefits with screening are predicated on successful treatment with low surgical mortality. Given variations observed in perioperative outcomes after lung cancer resection, it remains unknown whether benefits observed in the NLST are generalizable to a broader population. We sought to determine whether NLST perioperative outcomes are reflective of contemporary practice in a national cohort. MethodsWe identified patients diagnosed with non-small cell lung cancer who underwent lung resection in the 2014 to 2015 National Cancer Database (NCDB) and the NLST. We compared demographic and cancer characteristics in both datasets. We used hierarchical logistic regression to compare 30-day and 90-day postoperative mortality across facilities in both datasets. ResultsIn all, 65054 patients in NCDB and 1003 patients in the NLST treated across 1119 NCDB hospitals and 33 NLST hospitals were included. After risk and reliability adjustment, mean 30-day and 90-day mortality were significantly higher among NCDB hospitals (mean 30-day, 2.2 [95% confidence interval (CI), 2.2 to 2.2] vs 1.8 [95% CI, 1.8 to 1.8], P < .001; mean 90-day, 4.2 [95% CI, 4.2 to 4.3] vs 2.9 [95% CI, 2.9 to 2.9], P < .001). Variation in risk- and reliability-adjusted 30-day mortality (95% CI, 1.1% to 4.9%) and 90-day mortality (95% CI, 2.6% to 9.7%) was observed among NCDB hospitals. Adjusted mortality was similar among NLST facilities (30 days, 1.8% to 1.8%; 90 days, 2.9% to 2.9%). ConclusionsRisk- and reliability-adjusted postoperative mortality varies widely in a national cohort compared with outcomes observed in the NLST. Efforts to minimize this variation are needed to ensure that benefits of lung cancer screening are fully realized in the United States.

Trends in Guideline-Adherent Chemoradiation Therapy for Locally Advanced Cervical Cancer Before and After the Affordable Care Act

This study assessed trends in guideline-adherent chemoradiation therapy (GA-RT) for advanced-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation in the year 2010.National Cancer Database patients treated with definitive chemoradiation for locally advanced cervical cancer (FIGO 2018 Stage IB3-IVA) from 2004-2016 were included. GA-RT was defined according to NCCN guidelines and included: 1) delivery of external beam radiation, 2) brachytherapy, and 3) chemotherapy, 4) no radical hysterectomy. Univariable and multivariable logistic regression were used to determine trends in GA-RT relative to the ACA and identify patient factors independently associated with GA-RT. Survival of GA-RT was also estimated using Kaplan-Meier analysis.Thirty-seven thousand seven hundred and seventy-two patients met inclusion criteria (Pre-ACA: 16,169; Post-ACA: 21,673). A total of 33,116 patients had squamous cell carcinoma, and 4,626 patients had other histologies. Forty-five percent of patients were node positive. A total of 14.6% of patients were Stage I, 41.8% were Stage II, 36.4% were Stage III, and 7.9% were Stage IVA. Compared to commercial insurance, patients with Medicare had decreased odds of receiving GA-RT (OR = 0.65; 95% CI:0.61-0.69). Black patients (OR = 0.9; 95% CI:0.85-0.95) were associated with decreased odds of receiving GA-RT. Compared to squamous cell carcinoma, adenocarcinoma and carcinoma NOS were associated with decreased receipt of GA-RT (OR = 0.87; 95% CI: 0.80-0.93 and OR = 0.64; 95% CI: 0.55-0.75, respectively). Increasing T-stage was associated with greater receipt of GA-RT (stages 1B2 [OR = 1.89, 95% CI: 1.53-2.37], 2A2 [OR = 2.29, 95% CI: 1.81-2.92], 2B [OR = 2.1, 95% CI: 1.71-2.61], and 3B [OR = 1.47, 95% CI: 1.19-1.83]). Patients with nodal stage NX were less likely to receive GA-RT compared to N0 (OR = 0.6, 95% CI: 0.52-0.68). Increasing Charlson-Deyo score was associated with decreased receipt of GA-RT (OR = 0.86, 95% CI: 0.82-0.89). In multivariate analysis, all factors remained statistically significant except for race. The percentage of population that was guideline adherent significantly increased post-ACA (pre-ACA 28%; post-ACA 34%; P < 0.001). On univariate analysis, patients were 34% more likely to receive GA-RT after the ACA compared to before the ACA. In the multivariate model, receipt of GA-RT increased by 30% (P < 0.001). Adherence to treatment guidelines increased 2-year overall survival by 15% (GA 76%; Not GA 61%; P < 0.001). The post-ACA cohort was associated with increased 2-year overall survival compared to the pre-ACA cohort (pre-ACA 62%; post-ACA 69%; P < 0.001).Patients were more likely to be guideline adherent and receive GA-RT after the implementation of the ACA. This increase in guideline adherence was also associated with an increase in 2-year survival, indicating implementation of the ACA may have improved patient outcomes.R.J. Thomas: None. D. Provenzano: None. S. Goyal: Partner; Center for Rheumatic Diseases. M. Loew: None. B. Long: None. M. Lopez-Acevedo: None. Y.J. Rao: None.

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.

Utilization of Radiation Therapy in Multiple Myeloma: Trends and Changes in Practice

Background: Radiation therapy (XRT) has been used effectively for the spectrum of plasma cell disorders including plasmacytomas (PLA) and multiple myeloma (MM). Several reports have shown a change in practice for MM therapy including earlier use of combination agent regimens and increased overall utilization of stem cell transplant (SCT) but the role of XRT in the setting of novel therapeutic landscape has not been explored.Methods: The 2016 National Cancer Database (NCDB) for MM with patients diagnosed between 2004-2013 was studied. Cases without information on the selected patient or facility characteristics evaluated in this analysis, including XRT use, race, median income (2008-2012 dats), insurance status or facility type of initial MM diagnosis and/or treatment were excluded. The association between utilization of XRT as part of initial MM therapy and socio-demographic or treating facility characteristics was studied using multivariate logistic regression analysis.Results: Of the 123480 unique MM patients in NCDB diagnosed between 2004-2013, 111281 met the inclusion criteria with 7792 patients having osseous PLA (PLA-O; ICD-O 9731), 101919 having MM (ICD-O 9732) and 1570 having extraosseous PLA (PLA-E; ICD-O 9734). Of these, 28232 patients (25.4%) received XRT as a part of their initial therapy. These included 5399 PLA-O (69.3% of all PLA-O), 21891 MM (21.5% of all MM) and 942 PLA-E (60% of all PLA-E). Significant differences were noted for XRT use by most characteristics analyzed. Decreased XRT use was seen with progressively advancing patient age (≥85 year age OR 0.55, 95% CI 0.51, 0.61; ref=<50 year age). Similarly there was a decrease in XRT utilization over time from 2004-2005 (Ref) to 2012-2013 (OR 0.72, 95% CI0.68, 0.77). Men were more likely to receive XRT than women (OR 1.13, 95% CI 1.09, 1.16). There was a significant difference by race where non-Hispanic Blacks were least likely to receive XRT as part of initial therapy for MM (OR 0.89, 95% CI 0.84, 0.93, Ref=non-Hispanic Whites). Socioeconomic factors associated significantly with XRT use included income, where patients with a high income (median income quartile $63000+) were less likely to receive XRT as compared to lower income levels (OR 0.90, 95% CI 0.83, 0.97, Ref=<$38000) and literacy level, where an increasing literacy was associated with a higher likelihood of receiving XRT (OR for <7% no high-school degree 1.10, 95% CI 1.02, 1.19, Ref=≥21% no high-school degree). Insurance payer type influenced XRT utilization as patients with Medicare were less likely (OR 0.86, 95% CI 0.78, 0.94) while those with “Other Government” payer were more likely (OR 1.34, 95% CI 1.12, 1.60) to receive XRT as compared to the reference group of uninsured. There was an interaction with distance from treating facility as patients living between 10-45 miles away were slightly more likely to receive XRT. Patients with a higher Charlson-Deyo Comorbidity Score (Score 2+) were less likely to get XRT (OR 0.72, 95% CI 0.68, 0.77, Ref=Score 0). Treating facility characteristics significantly associated with increased XRT utilization included geographical location in Mountain (OR 1.17, 95% CI 1.01, 1.35) or Pacific (OR 1.18, 95% CI 1.07, 1.30) regions, while characteristics associated with decreased XRT utilization included high-volume facilities (OR for 50+ MM diagnoses seen/year 0.76, 95% CI 0.64, 0.91, Ref=<5 MM diagnoses seen/year) and facilities performing stem cell transplants (SCT) (OR 0.82, 95% CI 0.76, 0.87). There was no statistical difference in XRT utilization between academic and non-academic facilities.Conclusions: We provide the largest and most comprehensive analysis so far regarding XRT utilization in initial therapy of MM and PLA. We noted an expected higher XRT utilization for PLA as compared to MM and an overall decrease in utilization in recent years, possibly due to advent of highly efficacious systemic agents used as initial MM therapy. Decreased XRT utilization with advancing age may suggest its use as an adjunct to systemic therapy rather than a sole palliative measure since patients with increasing age can now be treated effectively and safely with systemic agents. Centers with higher MM volume and those involved in SCT were less likely to use XRT initially, possibly due to expertise with systemic therapy. Heterogeneity in XRT use based on gender, race and other socioeconomic factors needs to be explored prospectively. DisclosuresAilawadhi:Takeda: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Pharmacyclics: Research Funding. Sher:LAM Therapeutics, Inc: Research Funding.

The Impact of Adjuvant Hemithoracic Radiation on Outcomes in Patients With Stage I-III Malignant Pleural Mesothelioma: A Dual Registry Analysis.

The outcomes associated with receipt of adjuvant radiation in patients after surgery for MPM are poorly understood. The objective of this study was to use 2 registries to compare the outcomes of patients receiving adjuvant radiation or no radiation after definitive surgery for pathologic stage I-III MPM. Patients with resected pathologic stage I-III MPM were identified from the Duke University registry (1996-2016) and National Cancer Database (NCDB) (2004-2015). The primary outcome was overall survival. Propensity score-matched and landmark subgroup analyses were performed. A total of 212 institutional and 1615 NCDB patients met criteria. In both cohorts, patients who underwent radiation were more likely to have margin-negative resection and more advanced pathologic stage. At a landmark time of 4.4 and 4.7 months from surgery, Duke [hazard ratio (HR) 1.14; 95% confidence interval (CI) 0.62-2.11] and NCDB patients (HR 0.97; 95% CI 0.81-1.17) who received adjuvant radiation did not experience improved survival compared to those who did not receive radiation in multivariable analysis. Duke patients who received radiation had similar incidence of recurrence and time to both overall recurrence and ipsilateral recurrence (HR 0.87; 95% CI 0.43-1.77) compared to those who did not. Duke patients experienced 100 grade 1/2, 21 grade 3/4, and one grade 5 toxicity events during radiation. In this dual registry analysis of patients with resected stage I-III MPM, the receipt of adjuvant hemithoracic radiation was not associated with improved survival compared to no radiation.

Comparison Between Veteran and Non-Veteran Populations With Clinical Stage I Non-small Cell Lung Cancer Undergoing Surgery.

The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC). Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population. We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB). The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001). Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.

Tumor Biology Impacts Survival in Surgically Managed Primary Hepatic Vascular Malignancies

BackgroundHepatic angiosarcoma (AS) and hepatic epithelioid hemangioendothelioma (HEHE) are rare primary hepatic vascular malignancies (PHVM) that remain poorly understood. To guide management, we sought to identify factors and trends predicting survival after surgical intervention using a national database. Materials and methodsIn a retrospective analysis of the National Cancer Database patients with a diagnosis of PHVM were identified. Clinicopathologic factors were extracted and compared. Overall survival (OS) was estimated and predictors of survival were identified. ResultsThree hundred ninty patients with AS and 216 with HEHE were identified. Only 16% of AS and 36% of HEHE patients underwent surgery. The median OS for patients who underwent surgical intervention was 97 months, with 5-year OS of 30% for AS versus 69% for HEHE patients (P< 0.001). Tumor biology strongly impacted OS, with AS histology (Hazard Ratio [HR] of 3.61 [1.55-8.42]), moderate/poor tumor differentiation (HR = 3.86 [1.03-14.46]) and tumor size (HR = 1.01 [1.00-1.01]) conferring worse prognosis. The presence of metastatic disease in the surgically managed cohort (HR = 5.22 [2.01-13.57]) and involved surgical margins (HR = 3.87 [1.59-9.42]), were independently associated with worse survival. ConclusionsIn this national cohort of PHVM, tumor biology, in the form of angiosarcoma histology, tumor differentiation and tumor size, was strongly associated with worse survival after surgery. Additionally, residual tumor burden after resection, in the form of positive surgical margins or the presence of metastasis, was also negatively associated with survival. Long-term clinical outcomes remain poor for patients with the above high-risk features, emphasizing the need to develop effective forms of adjuvant systemic therapies for this group of malignancies.

Abstract PO-177: Cancer burden and survival among transgender patients in the United States

Abstract Background: Cancer burden among transgender patients is currently unknown due to a paucity of available data. Transgender patients face many barriers to healthcare, including discrimination, stigma, and lack of health insurance. Consequently, there may be delays in cancer diagnoses and treatment, resulting in increased cancer mortality among transgender individuals compared to cisgender persons. We sought to examine cancer stage at diagnosis, cancer treatment, and survival among transgender patients compared to cisgender patients in a large national cancer database. Methods: Data from the National Cancer Database (NCDB) included patients diagnosed with cancer between 2003 – 2016. Gender was recorded by physicians in the medical record and we included individuals categorized as “Male”, “Female”, or “Transsexual” (transgender). We examined primary cancers with ≥10 cases occurring in transgender adults aged ≥18 years. Multivariable logistic regression was used to estimate odds ratios (ORs) for advanced stage at diagnosis (stages III and IV versus stages 0, I, and II) and receipt of cancer treatment (e.g. surgery, chemotherapy, radiotherapy, or a combination) comparing transgender and cisgender patients for each cancer site. Hazard ratios (HRs) were estimated with Cox proportional hazards regression to estimate the associations between physician- recorded gender and all-cause survival for each cancer site. Models were adjusted for age at diagnosis, race/ethnicity, insurance status, year of diagnosis, stage at diagnosis, and treatment receipt as applicable. Results: There were 589 transgender cancer patients among the ≥11 million patients in NCDB. Differences in stage at diagnosis, treatment, and survival between transgender and cisgender cancer patients were not broadly observed across cancer sites. However, transgender patients with lung and bronchus cancer may be more likely to be diagnosed at later stages (OR: 1.76, 95% CI: 0.95, 3.28) than cisgender patients. In addition, compared to cisgender patients, transgender patients were less likely to receive treatment for kidney cancer (OR: 0.22, 95% CI: 0.09, 0.55). Finally, survival was worse in transgender patients compared to cisgender patients with non-Hodgkin lymphoma (HR: 2.36; 95% CI: 1.51, 3.70) and urinary bladder cancer (HR: 2.03, 95% CI: 1.31, 3.14). Conclusion: For specific cancers types, transgender patients may be diagnosed at a later stage, be less likely to receive treatment, and have worse survival. However, this study was hampered by the small number of transgender patients and the lack of self-reported gender identity separate from natal sex. Routine collection of gender identity in cancer registries and patient records will allow for improved estimates of cancer incidence, risk, and more meaningful comparisons between transgender and cisgender cancer patients. There is an urgent need to expand our knowledge of cancer burden among transgender individuals as this population grows and ages. Citation Format: Sarah S. Jackson, Xuesong Han, Ziling Mao, Leticia Nogueria, Gita Suneja, Ahmedin Jemal, Meredith S. Shiels. Cancer burden and survival among transgender patients in the United States [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-177.

Comparative effectiveness of treatment modalities in non-metastatic gastric adenocarcinoma: a propensity score matching analysis of the National Cancer Database

BackgroundWhile addition of chemotherapy and radiation to surgery improves the outcomes of non-metastatic gastric adenocarcinoma (GAC), the best treatment strategy remains controversial.MethodsTo determine the effectiveness of different strategies in patients...

Omission of an Axillary Lymph Node Dissection is Associated with Inferior Survival in Patients with Residual Nodal Disease Following Neoadjuvant Chemotherapy

The appropriateness of substituting a sentinel lymph node biopsy (SLNB) and regional nodal irradiation (RNI) for an axillary lymph node dissection (ALND) in patients with residual lymph node (LN) disease following neoadjuvant chemotherapy (NAC) is unknown, and is currently under investigation in a national randomized clinical trial. Here, we compare overall survival (OS) between these two treatment approaches using the National Cancer Database (NCDB). We performed a retrospective cohort analysis of NCDB patients with non-metastatic, cT1-3, cN1 breast cancer, treated with NAC with residual disease in 1-3 LNs (ypN1), between 2006 and 2014. Patients were grouped into those treated with SLNB (defined as removal of ≤4 LNs) and RNI versus ALND (defined as removal of >4 LNs) and RNI. Patients were matched for all available patient, tumor, and treatment characteristics using propensity scores with inverse probability of treatment weighting (IPTW). OS was compared using Kaplan-Meier estimates. We identified 1377 eligible patients in the ALND group and 318 patients in the SLNB group, with median follow up of 44 and 36 months, respectively. Median number of removed LNs was 13 (IQR 9-17) and 3 (IQR 1-4) in the ALND and SLNB groups, respectively. Compared to the ALND group, patients in the SLNB group were more likely to be treated in the second half of the study period (85% vs 78%), undergo partial mastectomy (57% vs 49%), and have residual disease in a single LN only (69% vs 43%). IPTW-matching achieved adequate balance between the two groups with no significant differences in any of the matched variables. For the matched cohorts, SLNB was associated with significantly lower survival in both univariate and doubly robust multivariable analyses (MVA) (HR 1.7, 95% CI 1.3 – 2.2, P<0.001 for MVA), with estimated 5-year OS of 70% compared to 77% in the ALND group (P = 0.02). Exploratory subgroup analyses showed inferior outcomes for the SLNB group even in patients with a single positive LN. SLNB was comparable to ALND in patients with luminal A/B breast cancer with a single positive LN (HR 1.3, 95% CI 0.9 – 2.1, P = 0.12). To validate our methodology, we compared SLNB to ALND in ∼ 25,000 patients who met the eligibility criteria of ACOSOG Z0011 and found similar survival rates between these two cohorts (HR 1.01, 95% CI 0.9-1.1, P = 0.8). Our analysis suggests that SLNB alone, even when combined with RNI, may be inadequate treatment of the axilla in patients with residual nodal disease following NAC. While exploratory subgroup analyses suggest SLNB might be appropriate in patients with minimal residual nodal disease and favorable tumor biology, an ALND should not be routinely omitted in this patient population until its efficacy is confirmed by prospective trials.