National Cancer Institute-designated Research Articles

Trends in the use of evidence-based therapy for resectable gastric cancer.

Two pivotal randomized controlled trials (RCTs), the Intergroup (INT-0116) and Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trials, demonstrated a survival benefit of multimodality therapy in patients with resectable gastric cancer. The purpose of this study was to determine utilization rates of these treatment regimens in the United States and to identify factors associated with receipt of evidence-based care. We performed a retrospective cohort study of patients with Stage IB-IV (M0) gastric adenocarcinoma who underwent resection from 1991 to 2009 using the linked SEER-Medicare database. Only 19.1% of patients received post-operative chemoradiation therapy (CRT), and 1.9% received peri-operative chemotherapy; most patients underwent surgery alone (60.9%). Patients with more advanced stage, younger age, and fewer comorbidities were more likely to receive evidence-based care. We found no association between National Cancer Institute (NCI) designation and delivery of multimodality therapy. However, patients who underwent medical oncology consultation were much more likely to receive evidence-based treatment (OR 3.10, 95% CI 2.35-4.09). Rates of peri-operative chemotherapy and post-operative CRT in patients with resected gastric cancer remain remarkably low, despite high-quality RCT evidence demonstrating their benefit. Furthermore, NCI designation does not appear to be associated with administration of evidence-based treatment.

Patient survival after surgical treatment of rectal cancer: impact of surgeon and hospital characteristics.

Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood. We used data from the Surveillance, Epidemiology, and End Results-Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board-certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute-designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long-term survival. Our data source yielded 6432 patients. Initial analysis demonstrated improved long-term survival in patients treated by higher-volume colorectal surgeons, higher-volume hospitals, teaching hospitals, and National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long-term survival. Patients treated for rectal cancer by board-certified colorectal surgeons in centers that are higher volume and/or NCI-designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable.

How Effective Are Clinical Pathways With and Without Online Peer-Review? An Analysis of Bone Metastases Pathway in a Large, Integrated National Cancer Institute–Designated Comprehensive Cancer Center Network

Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network. In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10-14 fractions for certain clinical situations. The data were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010. In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1-5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1-5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1-1.4) for community and 1.3 (confidence interval, 1.1-1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001). This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice.

Patient Resources Available to Bladder Cancer Patients: A Pilot Study of Healthcare Providers

To survey thought leaders attending an annual bladder cancer conference about resources available to survivors at, primarily, large academic centers treating a high volume of patients. Bladder cancer is a disease with high treatment burden. Support groups and survivorship programs are effective at managing physical and psychosocial impairments experienced by patients. The Institute of Medicine recommends increased resources for cancer survivorship, but no description of current resources exists for bladder cancer patients. Preceding the 4th annual Bladder Cancer Think Tank meeting in August 2009, we carried out an Internet-based survey of registrants that queried respondents about institutional resources and support systems devoted to bladder cancer survivors. Data were collected using SurveyMonkey.com, and descriptive statistics were computed. A total of 43 eligible respondents included urologists (77%), medical oncologists (16%), and other physicians or health professionals (7%). Physician respondents represented 22 academic centers and 2 private groups. Although 63% of respondent institutions had a National Cancer Institute designation, only 33% had an active bladder cancer support group. Survivorship clinics were available in 29% of institutions, and peer support networks, community resources for education, and patient navigation were available in 58%, 13%, and 25% of respondent institutions, respectively. Resources for bladder cancer survivors vary widely and are lacking at several academic centers with high-volume bladder cancer populations. Bladder cancer providers are often unaware of available institutional resources for patients. Urologists need to advocate for additional survivor resources and partner with other disciplines to provide appropriate care.

National Cancer Institute Cancer Center Designation and 30-Day Mortality for Hospitalized, Immunocompromised Cancer Patients

ABSTRACTPurpose: To examine 30-day mortality and National Cancer Institute (NCI) designation for cancer patients who are immunocompromised and hospitalized. Method: Secondary analysis of 1998 and 1999 hospital claims, cancer registry, and vital statistics (n = 10,370) linked to survey and administrative data from 160 Pennsylvania hospitals. Logistic regression models estimated the effects of NCI designation on the likelihood of 30-day mortality. Results: NCI-designated centers were associated with a 33% reduction in the likelihood of death, after adjusting for patient, hospital, and nursing characteristics. Conclusions: Immunocompromised cancer patients have lower mortality in NCI-designated hospitals. Identification and adoption of care processes from these institutions may improve mortality.

National Cancer Institute Designation Predicts Improved Outcomes in Colorectal Cancer Surgery

Although National Cancer Institute (NCI) designation as a cancer center is based almost solely on research activities, it is often viewed, by patients and referring providers, as an indication of clinical excellence. To compare the short- and long-term outcomes of colon and rectal cancer surgery performed at NCI-designated centers to the outcomes after resection at non-NCI-designated hospitals. We performed a retrospective cohort study of Survival, Epidemiology, and End Results (SEER)-Medicare database patients undergoing segmental colectomy (n = 33,969) or proctectomy (n = 8591) for cancer from 1996-2003. Multivariate logistic regression, with and without propensity scores, and matched conditional regression were performed to evaluate the relationship between NCI status and postoperative mortality (in-hospital or 30-day death). The log-rank test, Kaplan-Meier curves, and Cox regression compared survival between hospital types. We evaluated 33,969 colectomy and 8591 proctectomy patients. Postoperative mortality after colectomy was 6.7% at non-NCI and 3.2% at NCI centers. Mortality after proctectomy was 5.0% and 1.9%, respectively. These differences were significant when adjusted for patient and hospital characteristics. For both colon and rectal cancer patients, long-term mortality was significantly improved after resection at NCI centers (HR 0.84, P < 0.001; HR 0.85, P = 0.02, respectively). NCI designation is associated with lower risk of postoperative death and improved long-term survival. Possible factors responsible for these benefits include surgeon training, multidisciplinary care, and adherence to treatment guidelines. Studies are underway to elucidate the factors leading to improved patient outcomes.

A Presidential Blueprint for Success and Change

When the senior editors of our journal asked me to write an editorial as a companion piece to Dr. Nicholas Petrelli’s Society of Surgical Oncology (SSO) presidential address entitled ‘‘I’m in a New York State of Mind’’, I was honored and delighted, but frankly incredulous. For those of us who attended the Society of Surgical Oncology Cancer Symposium in March 2008 in Chicago and were fortunate to have heard Nick’s presentation, to my mind there was no way that the publication of the address could convey the humor, pathos, exuberance, and bluster that emanated from that oration. In addition, no commentary could ever do justice to a well-presented and carefully scripted presidential address – and frankly that is why most representations of this genre rarely are fodder for editorial comment. This presidential address, however, is different – it really contains a strong message and outlines a plan. If I accomplish nothing else in this commentary, I hope that you – those who heard the oral presentation and those who did not – will share my excitement regarding Dr. Petrelli’s message, turn a few pages to the published manuscript and take the time to understand the power, commitment, and superb outcome that a visionary leader working with a good team can accomplish in creating a metamorphosis of both a community-based health care center and the entire cancer care culture in the state of Delaware. Dr. Petrelli and his colleagues, working with support from the National Cancer Institute (NCI), have attacked the critical problem of cancer in their state and, embracing the power of their community/ academic teaching center and its dedicated staff, have transformed the mindset of the community. In addition, they have played a key role in partnering with a state government dedicated to reducing the suffering from cancer within Delaware’s borders. Through hard work and using a blueprint that utilizes the excellence in clinical cancer care demonstrated by community oncologists from all disciplines, Dr. Petrelli and colleagues were successful in their application to the NCI Community Cancer Center Program (NCCCP). The initial group of 14 community cancer centers was chosen for their commitment to clinical trials, transitional research, outstanding data collection, and a goal to reduce healthcare disparities in their community. While barely 1 year into this NCI designation, the group at the Helen F. Graham Cancer Center has achieved 20% accrual to NCI-group trials and will no doubt reach their goal of 30%. Since accrual to adult trials in cancer is generally below 5%, the outstanding commitment to reach these benchmarks is selfevident. All of us who are dedicated to realizing excellence in cancer care through the power of our community hospital cancer programs will gain much insight from reviewing Dr. Petrelli’s blueprint. In my role as chairman of the Commission on Cancer of the American College of Surgeons, I am particularly heartened to see the heights that a strong community cancer program can achieve. Dr. Petrelli and his colleagues at the Graham Cancer Center have thrown down the gauntlet, challenging the majority of the 1,480 facilities recognized by the Commission on Cancer Approvals Program which are labeled community hospitals. The achievements of our Delaware colleagues can be repeated at our community healthcare facilities if we adhere carefully to their published blueprint. Published online July 15, 2008. Address correspondence and reprint requests to: Frederick L. Greene, MD; E-mail: frederick.greene@carolinashealthcare.org

Not Just Another Article on Cancer Surgery Volume and Patient Outcomes

Not Just Another Article on Cancer Surgery Volume and Patient Outcomes

Survey of the provision of supportive care services at National Cancer Institute-designated cancer centers.

The purpose of this survey was to determine the scope of supportive care services (SCS) designed to promote quality of life during cancer therapies at National Cancer Institute (NCI)-designated cancer centers. A survey was mailed to the medical directors and nursing directors of 52 NCI-designated comprehensive (n = 26), clinical (n = 11), and planning cancer centers (n = 15) in the United States. Only one survey was completed from each institution. Survey questions identified services provided such as pain management, terminal care, psychosocial programs, and spiritual care. Thirty-nine questionnaires were received for a total response rate of 75%. Of the respondents, 45% were comprehensive cancer centers, 24% clinical cancer centers, and 29% planning centers. One center did not identify their NCI designation. Sixty-one percent of the centers reported research programs in supportive care. Outside funding was reported in 51% of the respondents, with 39% having American Cancer Society (ACS) or National Institutes of Health (NIH) funding and 28% having private industry funding. Overall SCS self-ratings improved from a 21% rating of excellent to very good 5 years ago to the current 54% rating. Survey results provide data on SCS across a representative sample of NCI cancer centers and can be used to develop standards for future cancer control programs.