National Cancer Institute-designated Center Research Articles

Health Disparities in Young Adults: A Direct Comparison of Distress and Unmet Needs Across Cancer Centers.

Information on concerns that young adults (YAs) with cancer face when receiving care outside of specialized treatment centers is needed to increase equitable care to YAs at greater risk of marginalization by the health care system. The current study compared distress and unmet needs at the time of clinic visit between YAs receiving care from three different cancer clinics: (1) a National Cancer Institute-designated center, (2) a community-based clinic, and (3) a county hospital outpatient clinic. The Adolescent and Young Adult Psycho-Oncology Screening Tool (AYA-POST) was administered to measure distress and cancer-related concerns of YAs in active treatment. A one-way analysis of variance (ANOVA) compared distress scores by treatment site. A Fisher's exact test compared the number of participants endorsing each item on the Needs Assessment Checklist from each site. A simple linear regression determined the association between distress and number of items endorsed on the Needs Assessment Checklist. Ninety-seven participants completed the AYA-POST, endorsing, on average, 11 concerns. Fisher's exact test showed significant differences between sites in the proportion of participants endorsing eight items: boredom (P < .001), eating/appetite (P < .001), nausea/vomiting (P < .001), financial concern (P = .002), hopelessness/helplessness (P = .03), confidentiality (P = .04), sibling concern (P = .04), and insurance (P = .05). The simple linear regression model was significant (F(1, 94) = 39.772, P < .001, R2 = 0.297), indicating the number of unmet needs accounted for almost 30% of the variance in distress. The one-way ANOVA was not significant (F(2, 93) = 1.34, P = .267). Social determinants of health can influence the number and type of unmet needs experienced, affecting distress and other outcomes and underscoring the importance of timely, effective, age-appropriate screening and intervention for distress and unmet needs in YAs with cancer.

Cannabis Perceptions and Patterns of Use Among Older Adult Cancer Survivors.

Objectives: To descriptively assess cannabis perceptions and patterns of use among older adult cancer survivors in a state without a legal cannabis marketplace. Methods: This study used weighted prevalence estimates to cross-sectionally describe cannabis perceptions and patterns of use among older (65+) adults (N = 524) in a National Cancer Institute-designated center in a state without legal cannabis access. Results: Half (46%) had ever used cannabis (18% following diagnosis and 10% currently). Only 8% had discussed cannabis with their provider. For those using post-diagnosis, the most common reason was for pain (44%), followed by insomnia (43%), with smoking being the most common (40%) mode of use. Few (<3%) reported that cannabis had worsened any of their symptoms. Discussion: Even within a state without a legal cannabis marketplace, older cancer survivors might commonly use cannabis to alleviate health concerns but unlikely to discuss this with their providers.

Paging Dr. Google: Characterizing Direct to Consumer Internet Advertisements from Oncology Treatment Centers

Patients increasingly use internet searches to compare treatment options and decide on oncology treatment centers. The objective of this study is to examine the type of oncology treatment centers that were advertised on web-based searches. A series of keyword searches were conducted using the Google search engine. Based on search trends, 3 of the top relevant search phrases were used ("best cancer doctor", "best cancer treatment", and "cancer treatment near me"). Modifiers were added to each search term to reflect the cancer categories with the highest prevalence: "breast", "prostate", and "lung". This yielded 12 search phrases that were used on a search hub that simulates Google searches from different geographic locations. The 30 most populous city locations were used. Of the four paid advertisements at the top of each search, the cancer treatment centers were categorized into centers that are National Cancer Institute-Designated (NCIs), Commission on Cancer (CoC) accredited, non-CoC accredited, and non-traditional treatment centers. Advertisements that weren't for cancer treatment centers were excluded. Of the 360 searches and 817 subsequent cancer treatment center advertisements, 51.2% were for NCI, 12.2% were CoC accredited, 26.9% were non-CoC accredited, and 9.7% were non-traditional treatment centers. The search phrase that yielded the highest ratio of NCI results was "best cancer doctor" at 74.4% and the phrase that yielded the lowest was "prostate cancer treatment near me" at 37.1%. Of the known 71 NCI centers in the country, 42 (59.2%) did not have any advertisements. Of the 35 NCI centers located in one of the target cities, 12 (34.3%) did not have any advertisements. Notably, two specific NCI centers accounted for 49.5% of the NCI advertisements. Similarly, one specific non-traditional treatment center accounted for 48.1% of the non-traditional center advertisements. Regarding non-traditional treatment centers, there was geographic variation with Boston having 38.1% of searches yielding non-traditional treatment center advertisements as opposed to six cities having 0%. The ratio of non-traditional treatment center advertisements by region were as follows: Northeast with 13.6%, West with 12.6%, South with 7.7%, and Midwest with 5.0%. These results indicate that most direct-to-consumer cancer advertisements come from CoC or NCI centers. Among advertisements coming from NCI centers, relatively few centers account for the majority of advertisements with most NCI centers having no advertising presence. Future research is needed to evaluate claims, costs, and the ethical considerations of direct-to-consumer marketing, where the potential for mischaracterizing the strength of the scientific evidence to vulnerable cancer populations requires more scrutiny.

Institutional barriers to clinical trial exploration experienced by the Latinx community

This study evaluated two types of barriers that the authors deemed important to resolve during the early stage of cancer clinical trial exploration by Latinx community members. One was the accessibility of information provided on cancer centers’ websites. The other was the telephone responders’ clinical trial knowledge and their conveyance of a warm welcome to Latinx callers inquiring about the centers’ clinical trials. Simulated clinical trial inquiry calls were made to 17 National Cancer Institute-designated centers in this study. The centers were located in cities where the Latinx community accounted for at least 25% of the population, thereby justifying center-wide efforts to encourage the Latinx community to explore clinical trial participation. A rubric was developed to determine and quantify a Total Score that was partially composed of the accessibility of clinical trial information displayed on each cancer center’s website. A research assistant gathered information by posing as a person calling the cancer center to inquire about clinical trials on behalf of a family member with limited English proficiency and evaluated their response using a “mystery shopper” method of data collection. The warmth and sense of welcome conveyed by the telephone responder was also quantified and included in the rubric’s Total Score. A perfect Total Score reflected the likely existence of an environment that would encourage Latinx community members to continue exploring clinical trials, i.e., removed or diminished possible barriers. Welcoming characteristics, such as those elements included in the scoring rubric, can be monitored regularly to assure that centers are consistently conveying an optimal sense of welcome to the Latinx community, while also providing accessible clinical trial information. Among the 17 cancer centers, no correlation was found between the size of the Latinx population served and each center’s Total Score.

Development and Assessment of a Model for Predicting Individualized Outcomes in Patients With Oropharyngeal Cancer

Recent insights into the biologic characteristics and treatment of oropharyngeal cancer may help inform improvements in prognostic modeling. A bayesian multistate model incorporates sophisticated statistical techniques to provide individualized predictions of survival and recurrence outcomes for patients with newly diagnosed oropharyngeal cancer. To develop a model for individualized survival, locoregional recurrence, and distant metastasis prognostication for patients with newly diagnosed oropharyngeal cancer, incorporating clinical, oncologic, and imaging data. In this prognostic study, a data set was used comprising 840 patients with newly diagnosed oropharyngeal cancer treated at a National Cancer Institute-designated center between January 2003 and August 2016; analysis was performed between January 2019 and June 2020. Using these data, a bayesian multistate model was developed that can be used to obtain individualized predictions. The prognostic performance of the model was validated using data from 447 patients treated for oropharyngeal cancer at Erasmus Medical Center in the Netherlands. Clinical/oncologic factors and imaging biomarkers collected at or before initiation of first-line therapy. Overall survival, locoregional recurrence, and distant metastasis after first-line cancer treatment. Of the 840 patients included in the National Cancer Institute-designated center, 715 (85.1%) were men and 268 (31.9%) were current smokers. The Erasmus Medical Center cohort comprised 300 (67.1%) men, with 350 (78.3%) current smokers. Model predictions for 5-year overall survival demonstrated good discrimination, with area under the curve values of 0.81 for the model with and 0.78 for the model without imaging variables. Application of the model without imaging data in the independent Dutch validation cohort resulted in an area under the curve of 0.75. This model possesses good calibration and stratifies patients well in terms of likely outcomes among many competing events. In this prognostic study, a multistate model of oropharyngeal cancer incorporating imaging biomarkers appeared to estimate and discriminate locoregional recurrence from distant metastases. Providing personalized predictions of multiple outcomes increases the information available for patients and clinicians. The web-based application designed in this study may serve as a useful tool for generating predictions and visualizing likely outcomes for a specific patient.

Improved survival in AYAs with NRSTS treated at specialized cancer centers in California.

e23551 Background: Non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) are a heterogeneous group of soft tissue tumors whose management benefits from a multidisciplinary therapeutic approach, especially for patients with metastatic or unresectable disease. Published data suggest that cancer treatment at a specialized cancer center (SCC) can mitigate poor outcomes for other cancers. Therefore, we examined the impact of location of treatment, sociodemographic and clinical factors on survival in adolescents and young adults (AYAs) with NRSTS. Methods: We performed a retrospective, population-based analysis of patients (ages 15-39) hospitalized within one year of diagnosis with first primary NRSTS between 2000–2014 using the California Cancer Registry linked with state hospitalization data. Patients were divided into two groups based on receiving all inpatient treatment at a SCC (Children’s Oncology Group and/or National Cancer Institute-designated center) versus part/none. Multivariable Cox proportional hazards regression identified factors associated with overall and sarcoma-specific survival. Kaplan Meier survival analysis was stratified by location of treatment. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: Of the 1532 AYA patients with NRSTS, 40.4% percent received all their inpatient care at a SCC. Kaplan Meier analysis demonstrated a higher 5-year survival in patients who received all (vs part/none) care at a SCC (60.0% vs 51.8%; p = 0.0002). Multivariable analysis found that having all treatment at a SCC was associated with significantly better overall (HR 0.81, CI 0.68-0.96) and sarcoma-specific (HR 0.73, CI 0.58-0.92) survival. In addition, inferior survival was associated with African American race/ethnicity, nerve sheath tumor, tumor size > 5 cm, non-localized disease, comorbidities and body wall/visceral tumor location (vs extremity). Conclusions: Our findings demonstrate that treatment for NRSTS at a SCC independently predicts better survival in AYAs and confirms other known predictors of outcomes in this patient population. Eliminating barriers to treatment of AYAs with NRSTS at SCCs could improve survival.

Trends in reporting histological subtyping of renal cell carcinoma: association with cancer center type

Histological classification of renal cell carcinoma (RCC) has become increasingly important for clinical management. We identified 295483 RCC diagnosed from 1998-2014 in the National Cancer Database (NCDB) to examine temporal trends in proportions of RCC with unspecified histology and several specific histologies from the 1998 and 2004 World Health Organization classifications of RCC. Further, multivariable log binomial analysis of 101062 RCC diagnosed from 2010 to 2014 was used to determine whether the association of diagnosing/treating facility type and the proportion of unspecified RCC is independent of patient demographic and clinical factors. Between 1998 and 2014, the proportion of histologically unspecified RCC decreased substantially in all facility types, with the decrease smallest in community programs (from 86.0% to 28.1%) and largest in National Cancer Institute-designated centers (from 85.1% to 9.8%). These decreases were offset by increases in percentages of papillary, clear cell, and chromophobe RCC cases. During 2010 to 2014, relative to community programs, RCCs were 21% less likely to be reported as unspecified histology (adjusted prevalence ratio [aPR] = 0.79; 95% CI, 0.68-0.92) in comprehensive community programs, 32% less likely in integrated network programs (aPR = 0.68; 95% CI, 0.57-0.92) and academic programs (aPR = 0.68; 95% CI, 0.54-0.87), and 63% less likely (aPR = 0.37; 95% CI, 0.26-0.52) in National Cancer Institute -designated programs. These results have implications for the optimal selection of targeted systemic therapies for patients with advanced disease, and for the potential value of cancer registry data in pathology quality improvement programs to promote more rapid and consistent adoption of new classifications of RCC and other neoplasms.

Mortality in young adults with Ewing sarcoma treated at specialized cancer centers in California.

10538 Background: Ewing sarcoma is a rare malignancy of the soft tissue or bone that is most frequently seen in children and adolescents. One study suggested that care at specialized cancer centers (SCC) may mitigate survival disparities associated with public insurance in patients with sarcoma, but no large population-based studies have considered how location of care affects survival outcomes. Methods: We performed a retrospective, population-based cohort analysis of patients hospitalized within one year of diagnosis with primary Ewing sarcoma between 2000–2013 using the California Cancer Registry linked with state hospitalization data. Patients were divided into two groups based on whether they received inpatient treatment at a SCC [Children’s Oncology Group (if age ≤25) and/or National Cancer Institute-designated center] or not. We excluded 12 patients whose location of cancer treatment could not be determined. Multivariable Cox proportional hazards regression identified factors associated with mortality. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: Of the 470 patients with newly diagnosed Ewing sarcoma, 40% were female, 52% were non-Hispanic white, and 53% had private health insurance. Sixty-one percent received their inpatient care at a SCC. Multivariable analysis across all ages demonstrated that higher mortality was associated with increasing age, metastatic disease, and large tumors, but mortality was not impacted by treatment at an SCC (HR 0.77, CI: 0.55-1.08; p = 0.134). However, when analyses were stratified by age, treatment at a SCC was associated with lower mortality among patients ages 19–39 years, but not among younger or older patients, and this association was only apparent within 2 years of diagnosis (HR = 0.43, CI: 0.23-0.79; p = 0.007). Conclusions: Our results suggest that treatment for Ewing sarcoma at a SCC significantly improves survival in young adults adjusted for other factors known to be associated with poor prognosis (metastatic disease, larger tumor size and older age). The lower mortality in this age group may be due to access to clinical trials and other specialized services specific to young adults available at SCCs.

Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers.

Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers). A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived > 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors. Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017;123:2516-23. © 2017 American Cancer Society.

Time to Treatment Initiation Predicts Overall Survival in Hospitalized Acute Myeloid Leukemia (AML) Patients: A California Population-Based Study

Background:The impact of time from diagnosis to chemotherapy initiation (time to treatment, TTT) for AML has been a topic of ongoing debate. A prior study reported that TTT ≥5 days adversely impacted overall survival in younger (<60 years of age), but not older (≥60 years of age), patients. However, subsequent studies found either no effect of TTT on overall survival, regardless of age, or an adverse impact of TTT on overall survival for both younger (>10 days) and older patients (>5 days). Prior data also showed no impact of TTT on early mortality. Given these conflicting findings, consensus on the impact of TTT on survival is lacking and warrants further study. Using prospectively collected population-based data, we analyzed a large cohort of adult AML patients to examine the effect of TTT on overall survival.Methods:Using data from the California Cancer Registry and Patient Discharge Dataset between 1999-2012, patients≥15years diagnosed with de novo AML and who received inpatient treatment between 1-90 days from diagnosis were identified (n=5337). Multivariable logistic regression was used to determine factors associated with TTT>5 days vs 1-5 days with data presented as odds ratios (OR) and 95% confidence intervals (CI). The effect of TTT on overall and 60-day survival was estimated using multivariable Cox proportional hazards regression with TTT (1-5, 6-10,>10 days)considered as a time-dependent variable. Patients were stratified by age group (<60,≥60 years) for all analyses.Multivariable models accounted for age, race/ethnicity, sex, number of comorbidities, marital status, neighborhood socioeconomic status, health insurance type, treatment at National Cancer Institute designated (NCI) vs non-NCI designated facility, use ofleukapheresis, and year of diagnosis.Results:Of the 2659 patients <60 years of age, 61.0% were treated within 5 days and 79.7% within 10 days of diagnosis, compared to 43.8% and 65.0%, respectively, of the 2678 patients≥60 years of age. Patients≥60 years were more likely to have 3+ comorbidities compared to the younger age group (43.3% vs 25.9%, P<0.001). The likelihood of TTT>5 days increased with age in both younger and older patients. Across both age groups, patients requiringleukapheresis(age<60: OR 0.19, CI 0.10-0.34; age≥60: OR 0.23, CI 0.12-0.45), treated at a non-NCI (vs NCI) center (age<60: OR 0.62, CI 0.52-0.73; age≥60: OR 0.64, CI 0.52-0.78) and with 1-2 (vs 0) comorbidities (age<60: OR 0.81, CI 0.67-0.98; age≥60: OR 0.69, CI 0.54-0.88) or 3+ (vs 0) comorbidities (age<60: OR 0.77, CI 0.62-0.97; age≥60: OR 0.52, CI 0.41-0.66) had a lower odds of TTT>5 days. Younger (age<60) African Americans (vs non-Hispanic whites) had a higher odds of TTT >5 days (OR 1.43, CI 1.04-1.97). Delaying chemotherapy >10 days (vs 1-5 days) adversely impacted overall survival in both age groups (age<60: HR 1.26, CI 1.11-1.43; age≥60: HR 1.17, CI 1.06-1.28) (Table). However, TTT of 6-10 days (vs 1-5 days) affected overall survival in young (age<60: HR 1.15, CI 1.02-1.31), but not older patients. A TTT of 6-10 days (vs 1-5 days) adversely impacted 60-day survival in both age groups (age<60: HR 1.70, CI 1.24-2.33; age≥60: HR 1.27, CI 1.05-1.54); 60-day survival results were similar for a TTT >10 days (vs 1-5 days) (Table).Conclusions:In a large cohort of patients with de novo AML, TTT of up to 10 days did not have a negative impact on overall survival in patients over the age of 60. In younger patients (<age 60), TTT >5 days was associated with decreased overall survival. Delaying chemotherapy over 5 days adversely impacted 60-day survival in both age groups. Our observation that patients were more likely to have a shorter TTT at non-NCI designated hospitals may relate to delays associated with transfer to or clinical trial enrollment at NCI centers. Our results suggest that waiting to get results of ancillary testing, such as cytogenetic and molecular mutation analyses, in order to inform treatment decisions for AML patients, may be feasible in some patients with AML. In an era of rapidly evolving prognostic and treatment landscapes for AML, our findings may have implications for personalized therapy, including novel targeted therapies, and clinical trial design for patients withAML. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

High-dose Interleukin-2 Therapy for Metastatic Renal Cell Carcinoma: A Contemporary Experience

To present our experience of high-dose interleukin-2 (HDIL-2) in a high-volume National Cancer Institute-designated center for patients with metastatic renal cell carcinoma (mRCC). Patients with mRCC who received HDIL-2 monotherapy as a first- or second-line therapy during 2004-2011 were identified. Demographics, pathologic variables, renal function, time until the start of HDIL-2 therapy, number of cycles (1-3), responses (complete response, partial response, stable disease, and progressive disease), and primary renal cell carcinoma treatment were analyzed. Progression-free survival and overall survival (OS) were determined. Of 906 patients in the kidney cancer database, 91 patients with mRCC were treated with HDIL-2 and 18 patients (20.5%) underwent prior cytoreductive nephrectomy. Median age was 51 years, and 73.9% were men. Median follow-up was 45 months. Pretreatment renal function impairment led to more treatment cycles (2-3) than in those with adequate initial kidney function (92.3% vs 50.6%, respectively; P = .002). Lower tumor stage correlated with a better response (P = .023) and with longer time from diagnosis to initiation of HDIL-2 (P = .011). Complications included hypotension (67.4%), renal impairment (63%), impaired liver function (42.4%), and thrombocytopenia (31.5%). Four patients (4.5%) had a complete response, 10 (11.4%) had a partial response, and 28 (31.8%) had a stable disease. Median progression-free survival and OS were 8.6 and 35.5 months, respectively. The estimated 2-year OS rate was 60.6%. Incorporating HDIL-2 therapy in the treatment strategies for mRCC added to the patients' survival in this series. HDIL-2 therapy is well tolerated in patients with pre-existing renal impairment with no long-term renal toxicity.

Assessment of single-institution HER2 testing patterns, rate of HER2+ disease, and utilization of trastuzumab in early breast cancer.

124 Background: Improved outcomes with HER2-directed therapies highlight the importance of standardized testing for HER2 positivity. This study aimed to assess HER2 testing practices, rate of HER2+ disease, and trastuzumab use in early breast cancer (EBC) at the Huntsman Cancer Institute (HCI) a National Cancer Institute-Designated Center and member of the National Comprehensive Cancer Network. Methods: Included patients’ records from the HCI electronic data warehouse (EDW) and the HCI tumor registry were female, age ≥ 18 years, ≥ 2 visits in the EDW and a stage I to IIIa EBC diagnosis from 2005 to 2012. HER2 testing patterns were identified through chart review of pathology and clinical notes in the EDW. HER2+ was defined as either FISH+ or IHC3+. Patient characteristics, HER2+ rate, and trastuzumab use were evaluated descriptively. Discordance rate associated with reflex testing (IHC 2+ retested by FISH) was also evaluated. Results: A total of 1,459 women were included with stage I (49%, n=720), IIa (26%, n=374), IIb (14%, n=197), and IIIa (12%, n=168) EBC. Mean age was 57 years. HER2+ disease was identified in 243 (17%) tumors. Of HER2+ tumors, 104 (43%) were ER+/PR+, 33 (14%) ER+/PR-, 1 (&lt;1%) ER-/PR+, 79 (32%) ER-/PR-, and 26 (11%) unknown. Tumors were first tested for HER2 using: 1,192 (82%) IHC, 36 (3%) FISH, 227 (15%) unknown and 4 (&lt;1%) other tests. First IHC results were scored 0 (23%), 1+ (33%), 2+ (26%), 3+ (17%), and unknown (&lt;1%). Reflex testing within one month was performed in 301/308 (98%) of IHC 2+ tumors. The discordance rate of IHC/FISH was 10%. Trastuzumab was prescribed for 184/243 (76%) women whose tumors were considered HER2+ based on final interpretation and in 1 HER2 equivocal tumor. Documented reasons for lack of trastuzumab use in HER2+ patients (n=59) included low risk of recurrence based on stage or other treatments (n=18), loss to follow-up (n=13), unknown (n=11), not clinically appropriate due to age or comorbidity (n=10), and patient declined (n=7). Conclusions: This is one of few cancer registries assessing the rate of HER2+ disease in EBC. Reflex testing identified additional HER2+ tumors. The HER2+ rate was within range of previously published studies.