Predictors Of Chemotherapy Use Research Articles

Abstract 3822: Oncotype DX testing and differences in use of chemotherapy by age in an integrated system

Abstract Introduction: Oncotype DX (ODX) identifies breast cancer patients who are less likely to benefit from chemotherapy. We investigated patient factors associated with clinical application of ODX testing and chemotherapy use. Methods: We identified a cohort of adult breast cancer patients with stage I-IIA, estrogen receptor positive, human epidermal growth factor receptor 2 negative, lymph node negative disease diagnosed within Kaiser Permanente Northern California between 2015 - 2021 eligible for ODX testing. Chi-square tests were used for bivariate analysis of categorical variables. Multivariable logistic regression was used to identify independent predictors of chemotherapy use in female patients with high risk ODX scores (>25). Results: 8017 patients were eligible for ODX testing; of which 5,136 received testing (64%) and 576 patients (7%) had high risk ODX. ODX testing increased over the years (45% of eligible patients in 2015; 79% of eligible patients in 2021). Testing was frequent in larger lesions (74%), poorly differentiated tumors (73%), and younger patients (83% in patients <40 years at diagnosis; 12% in patients > 80 years). Chemotherapy was frequently administered in younger patient, and for larger, poorly differentiated tumors. For patients who possessed a high risk ODX score, chemotherapy administration differed by age. In comparison with the 90% of high risk patients <45 years who received chemotherapy, 58% of patients 60+ years at diagnosis with high risk ODX received chemotherapy. Comorbidity index and chemotherapy administration was not statistically significant (Table 1). Conclusion: Oncologists frequently use ODX testing to guide chemotherapy management. Despite high risk ODX scores, older patients received less chemotherapy compared to their younger counterparts. Further investigation is needed to determine how age impacts clinician decision making and clinical outcomes following ODX testing. Table 1. Multivariable Logistic Regression Analysis of Factors Associated with Chemotherapy Women > 60 years with high risk oncotype DX scores (N=467) Adjusted Odds Ratio (95% Confidence Interval) P-values (Calculated using the Wald χ2 Statistic) Age at Cancer Diagnosis (Reference: 60 - 69 years old) 70-79 0.62 (0.40-0.96) 0.03 >79 0.11 (0.02-0.55) 0.01 Charlson Comorbidity Index (Reference = 0) 1 0.76 (0.48-1.22) 0.26 2 0.62 (0.30-1.29) 0.20 3 0.65 (0.26-1.60) 0.35 4 0.54 (0.20-1.44) 0.22 5+ 0.37 (0.10-1.35) 0.13 Citation Format: Ashley Aller, Liisa Lyon, Laurel Habel, Aida Shirazi, Raymond Liu. Oncotype DX testing and differences in use of chemotherapy by age in an integrated system [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3822.

Patterns of treatment in older patients with newly diagnosed advanced bladder cancer: A SEER dataset analysis.

Bladder cancer is one of the top 10 cancers diagnosed in Americans with a median age of 73. This is the patient population that tends to be older with multiple medical conditions, and previously described variability in treatment in the earlier stages of the disease. This study aimed to evaluate the first-line therapeutic choices for older adults newly diagnosed with advanced bladder cancer. In addition, this work evaluated predictors of response as well as the role of events of functional importance in relation to treatment assignment. A population-based cohort study was conducted using the SEER-Medicare database of patients with advanced stage bladder cancer not eligible for curative intent therapy between 2010 and 2013. Patient groups of interest were compared via univariate and multivariate associations. Additionally, a latent class analysis was applied to identify classes with similar features in reference to events of functional importance-events linked to the maintenance or improvement of physical function status. Within the sample, we noted that a minority of patients received a standard cisplatin-containing regimen (14.77%) and a majority did not receive any chemotherapy (59.69%). Most patients were over age 75. The adjusted odds ratio of no chemo versus cisplatin in patients aged 76 and older compared to patients 66-75 was 6.61 (4.79-9.13; p < 0.0001). We applied latent class analysis methods to the dataset, and three classes demonstrated very low and moderate levels of functional events in the 12 months prior to a person's first outpatient visit for advanced bladder cancer care. Patients with new diagnosis of advanced bladder cancer largely do not receive the recommended first-line systemic therapy of cisplatin chemotherapy, and a significant majority does not receive any treatment. When evaluating the association between class assignment and predictors of chemotherapy use, such as comorbidity and age, patients with "low usage overall" were more likely to receive chemotherapy. Yet even patients who received chemotherapy had some events of functional importance.

The role of adjuvant chemotherapy in FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma treated with surgery and postoperative radiotherapy

Objectives: The optimal treatment of FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma remains unknown. It is unclear if adjuvant chemotherapy (CHT) in addition to adjuvant radiotherapy enhances survival in this subgroup of endometrial cancer patients. The goals of the present study were to perform a National Cancer Database (NCDB) analysis in this cohort of patients to 1) compare overall survival following treatment with a hysterectomy and adjuvant radiotherapy with or without CHT, 2) evaluate CHT utilization in the United States, and 3) investigate which factors are associated with survival in stage IB grade 3 endometrioid adenocarcinoma patients. Methods: Patients diagnosed between 2004 and 2015 with FIGO stage IB grade 3 endometrial endometrioid adenocarcinoma treated with hysterectomy and postoperative radiotherapy with or without adjuvant systemic CHT were identified in the NCDB. Overall survival (OS) was assessed with Kaplan-Meier curves, and differences between groups were compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders, and logistic regression was used to reveal predictors of CHT use. Results: While the receipt of CHT was associated with a trend toward increased 5-year OS from 68.1% to 74.7% (p=0.059), this association did not reach statistical significance on propensity score weighted (p=0.073) and multivariate analyses (adjusted HR (aHR) 0.86; CI: 0.70-1.06; p=0.15) as shown in the figure. Moreover, there was some evidence of a differential CHT effect in patients who did not undergo a lymphadenectomy (LND; p=0.056); CHT was associated with a trend toward reduced hazard of death in patients with LND (aHR=0.82, CI: 0.66-1.01, p=0.0634) but not in patients who did not undergo LND (aHR=1.70, CI: 0.86-3.35, p=0.1255). Patients who underwent brachytherapy as opposed to external beam radiotherapy, had lymphovascular space invasion (LVSI), were 59 years or younger, were diagnosed in the more recent years of the study and treated in higher facility case volume centers were more likely to: receive adjuvant chemotherapy. No LND (HR 1.51; CI: 1.13-2.03; p=0.0057), positive LVSI (HR 1.71; CI: 1.36-2.16; p 70 (HR 2.61; CI: 2.03-3.36; p Download : Download high-res image (275KB) Download : Download full-size image Conclusions: Adjuvant CHT plus radiotherapy was associated with a non-statistically significant increase in OS in FIGO stage IB grade 3 endometrioid adenocarcinoma patients compared to those treated with adjuvant radiotherapy alone. This potential effect is most apparent in patients who underwent LND.

Evaluation of whether adjuvant chemotherapy can be safely omitted for older female patients with ER-positive, HER2-negative N1 breast cancer: a study based on the SEER database.

BackgroundThis study evaluated the trends and practice patterns associated with adjuvant chemotherapy (CT) use for patients aged ≥70 years with estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative (HER2–) N1 (1–3 positive lymph nodes) breast cancer (BC). Furthermore, the relationship between adjuvant CT and survival in this set of patients was determined.MethodsThe Surveillance, Epidemiology, and End Results (SEER) database was used to identify 6,711 women with ER+, HER2– N1 BC who were aged ≥70 years between 2010 and 2015. Demographic, clinical, and pathological predictors of CT use were identified using logistic regression. Multivariable Cox regression was used to identify variables that correlated with overall survival (OS), before and after propensity score matching (PSM).ResultsYounger age at diagnosis, other histological types, higher tumor grade, larger tumor size, breast reconstruction surgery, progesterone receptor-negative (PR–), and increased nodal involvement were associated with an increased probability of receiving CT. CT use was associated with improved 5-year OS, both before and after PSM [hazard ratio (HR): 0.66, 95% confidence interval (CI): 0.58–0.75 and HR: 0.81, 95% CI: 0.68–0.96, respectively]. The exploratory subgroup analysis showed that although the benefit of CT was significant in the grade III subgroup, it was not significant in the grades I–II subgroups.ConclusionsAdjuvant CT improved 5-year OS in patients with ER+, HER2– N1 BC who were aged ≥70 years; however, the benefit of CT was more significant in the grade III subgroup than in the grades I–II subgroups.

Chemotherapy use in early-stage anal canal squamous cell carcinoma and its impact on outcome.

2 Background: The standard of care for non-metastatic squamous cell carcinoma of the anal canal (SCCA) is concurrent chemoradiotherapy with high rates of local control. There is some thought that perhaps chemotherapy can be omitted for the earliest stages without worse outcomes. We used the National Cancer Database (NCDB) to identify predictors of chemotherapy receipt or omission to assess the impact on outcomes. Methods: We queried the NCDB from 2004-2016 for patients with cT1N0M0 SCCA treated non-operatively with radiation with and without chemotherapy and at least 2 months of follow-up. Logistic regression was used to generate predictors of chemotherapy use. Cox regression identified predictors of survival. Propensity matching was done to help account for indication bias. Results: We identified 2,959 patients meeting eligibility, of which 8% (n = 237) were treated without chemotherapy. The vast majority (n = 2722, 92%) were recorded as having multi-agent chemotherapy. Median radiation dose was 50.4 Gy (IQR 45-54) in 28 fractions (IQR 49.4-59.4) with chemotherapy and 54.0 Gy (IQR 49.4-59.4) in 30 fractions (IQR 25-33) in those who had chemotherapy omitted. Predictors of omission of chemotherapy were older age (OR 0.66, 95% CI [0.49-0.90], P = 0.0087), higher comorbidity score (OR 0.62, 95% CI [0.38-0.99], P = 0.0442), African American race (OR 0.57, 95% CI [0.36-0.90], P = 0.0156) and more remote year of treatment (OR 1 1 for years 2004-2006). Predictors of survival were younger age (HR 1.73 for age &gt; 58 years, 95% CI [1.41-2.11], P &lt; 0.001), multi-agent chemotherapy use (HR 0.48, 95% CI [0.38-0.62], P &lt; 0.0001), higher income (HR 0.57, 95% CI [0.40-0.81], P = 0.0016), female gender (HR 0.68, 95% CI [0.57-0.82], P = 0.0016), and private insurance (HR 0.54, 95% CI [0.34-0.87], P = 0.0104). After propensity matching, overall survival at 120 months for patients treated with and without chemotherapy was 86% and 65%, respectively (p &lt; 0.0001). Conclusions: Chemotherapy is utilized the majority of the time in early stage SCCA. Being mindful of the limitations of a retrospective database analysis, our results suggest an association with worse survival outcomes when chemotherapy is omitted.

Adjuvant chemotherapy for intrahepatic cholangiocarcinoma: approaching clinical practice consensus?

Intrahepatic cholangiocarcinoma (ICC) is rare with limited evidence-based guidelines. This retrospective study evaluates the use of chemotherapy in patients with resected ICC. The Surveillance Epidemiology and End Results (SEER) program database was used to identify patients with resected ICC. Patients were stratified by date of diagnosis (2000-2004, 2005-2009, 2010-2014), T, and N stage. Multivariable logistic regression models identified predictors of chemotherapy use. Kaplan-Meier and Cox proportional hazard models were used to identify survival trends. One thousand and two hundred twenty-three patients met inclusion criteria. Chemotherapy utilization increased over time (33% to 41%, P≤0.05). Chemotherapy use increased in lymph node (LN) positive patients [32% to 60% in 2010-2014; (P≤0.05) and T3/T4 disease (40% to 60% in 2010-2014; P≤0.01], but not in patients with LN negative or T1/T2 disease. LN positivity was associated with utilization of chemotherapy in 2005-2009 and 2010-2014. Overall survival increased from 32 to 41 months (P≤0.05). In LN positive patients, chemotherapy was associated with a decreased hazard ratio of death (P≤0.05) and T3/T4 disease was associated with an increased hazard ratio of death (P≤0.05). Adjuvant chemotherapy use in ICC has increased. More LN positive or patients with T3/T4 tumors are receiving chemotherapy, which may explain the improvement in overall survival.

The Population-based Impact of Adjuvant Chemotherapy on Outcomes in T2N0M0 Non-Small Cell Lung Cancer.

The value of adjuvant chemotherapy in T2N0M0 non-small-cell lung cancer (NSCLC) is unclear. Some current guidelines suggest adjuvant chemotherapy be considered for patients with tumors ≥4 cm. Prior population-based evaluations lacked lung cancer-specific survival (LCSS) and health insurance status. The authors aimed to identify predictors of adjuvant chemotherapy use and assess its real-world benefit in T2N0M0 NSCLC. The authors included patients who underwent surgery for T2N0M0 NSCLC in a large Canadian province with universal health care between 2004 and 2015, grouping cases by adjuvant chemotherapy receipt. They identified predictors of chemotherapy use with logistic regression and correlates of overall survival (OS) and LCSS using Cox regression. The authors analyzed 967 patients. The median age was 68 years (interquartile range, 61 to 74), 455 (47%) were men, and 164 (17%) received adjuvant chemotherapy. Sex, tumor location, and laterality were similar between groups. Younger age, lower Charlson comorbidity score, large cell histology, and tumor size ≥4 cm were associated with a higher likelihood of chemotherapy receipt (all P<0.05). In the entire cohort and in the ≥4 and ≥5 cm subgroups, chemotherapy improved OS but not LCSS on univariate analysis. Chemotherapy was not associated with OS or LCSS in multivariate analysis (OS hazard ratio [HR], 0.925; 95% confidence interval [0.693-1.236], P=0.598, 0.725 [0.454-1.157], P=0.177 in the ≥4 cm group; LCSS HR, 1.196 [0.843-1.695], P=0.316, 0.917 [0.533-1.577], P=0.754 in the ≥4 cm group). Adjuvant chemotherapy was not associated with improved survival in this population-based T2N0M0 NSCLC cohort, even for ≥4 or ≥5 cm tumors, suggesting that it has a limited role in real-world practice.

Predictors of chemotherapy and its effects in early stage squamous cell carcinoma of the larynx.

BackgroundSquamous cell carcinoma (SCC) of larynx is a common head and neck cancer. For cases that are node negative, the role of definitive concurrent chemoradiation is unclear and not supported by guidelines but used at provider discretion. To address this knowledge gap, we examined the oncological outcomes with additional chemotherapy and factors correlated with the chemotherapy administration.MethodsWe queried the National Cancer Database for patients with early stage (T2N0M0) laryngeal SCC treated nonsurgically. Multivariable logistic regression identified predictors of chemotherapy. Multivariable Cox regression evaluated predictors of survival. Propensity matching accounted for indication biases.ResultsWe identified 7181 patients meeting the eligibility criteria, of which 1568 (22%) patients received chemotherapy in addition to radiation. Predictors of chemotherapy use included younger age, Caucasian race, more remote year of treatment, higher grade, sites other than glottis, treatment at a community cancer center, and use of intensity‐modulated radiation therapy. Median overall survival was not significantly different in the two arms analyzed—65 months (95% confidence interval [CI] 60, 72months) with chemotherapy compared to 70 months without chemotherapy (95% CI 66, 75 months, P<.37). Predictors for survival on propensity‐matched multivariable analysis were increased age, male sex, less education, lower income, higher comorbidity score, receipt of treatment at a community center, and nonglottic sites.ConclusionsThis study shows no clear survival benefit with chemotherapy in early stage disease. Although this implies that chemotherapy should not be routinely delivered, individualized judgment and prospective studies are recommended as the biology behind this interesting finding is undefined.Level of Evidence2C (Outcomes Research).

Adherence to Guideline Recommendations for Perioperative Chemotherapy in Patients with pN2-3 M0 Squamous Cell Carcinoma of the Penis: Temporal Trends and Survival Outcomes

AimsTo analyse contemporary perioperative chemotherapy (CHT) guideline adherence rates for pN2-3 M0 squamous cell carcinoma of the penis, as well as CHT association with cancer-specific (CSM) and other-cause mortality (OCM). Materials and methodsWithin the Surveillance, Epidemiology, and End Results databases, 311 pN2-3 M0 squamous cell carcinoma of the penis patients treated with inguinal lymph node dissection were identified. Univariable and multivariable logistic regression analyses focused on CHT rates, whereas cumulative incidence plots and multivariable competing risks regression analyses tested for CSM and OCM rates. ResultsCHT was administered to 140 (45%) patients and rates increased from 37.5 to 62.2% (2004–2015; P = 0.02). Specifically, annual CHT rates increased over time in patients younger or equal to 65 years and in patients older than 65 years (44.4–84.6% versus 28.6–50%, respectively), but this trend was not statistically significant (P = 0.1 and P = 0.2, respectively). The median follow-up was 13 months for both CHT (interquartile range 8.0–32.2) and no-CHT subgroups (interquartile range 5.0–40.0). In multivariable logistic regression analyses, more contemporary year of diagnosis interval (odds ratio 2.08, P < 0.01) and age older than 75 years (odds ratio 0.14, P < 0.001) were independent predictors of CHT use. In multivariable competing risks regression analyses, CHT use did not affect CSM (hazard ratio 1.02; P = 0.7) or OCM (hazard ratio 1.56; P = 0.8). ConclusionsCHT adherence rates sharply increased in the most recent years. Despite this increase over time, the lack of efficacy regarding CSM benefit is disappointing.

Adjuvant chemotherapy in patients with stage I endometrioid or clear cell ovarian cancer in the platinum era: a Surveillance, Epidemiology, and End Results Cohort Study, 2000–2013

BackgroundWe sought to evaluate the impact of adjuvant chemotherapy on overall survival (OS) in patients with stage I endometrioid epithelial ovarian cancer (EEOC) or ovarian clear cell cancer (OCCC) using a national database. Patients and methodsThe Surveillance, Epidemiology, and End Results database was used to identify patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I EEOC or OCCC from 2000 to 2013. We sought to identify predictors of chemotherapy use and to assess the impact of chemotherapy on OS in these patients. OS was compared using the log-rank test and the Cox proportional hazards model. ResultsIn all, 3552 patients with FIGO stage I EEOC and 1995 patients with stage I OCCC were identified. Of the 1600 patients (45%) with EEOC who underwent adjuvant chemotherapy, the 5-year OS rate was 90%, compared with 89% for those who did not undergo adjuvant chemotherapy (P = 0.807). Of the 1374 (69%) patients with OCCC who underwent adjuvant chemotherapy, the 5-year OS rate was 85%, compared with 83% (P = 0.439) for those who did not undergo adjuvant chemotherapy. Chemotherapy use was associated with younger age, higher substage, and more recent year of diagnosis for both the EEOC and OCCC groups. Only in the subgroup of patients with FIGO substage IC, grade 3 EEOC (n = 282) was chemotherapy associated with an improved 5-year OS—81% compared with 62% (P = 0.003) in untreated patients (HR: 0.583; 95% CI: 0.359–0.949; P = 0.030). In patients with OCCC, there was no significant effect of adjuvant chemotherapy on OS in any substage. ConclusionsAdjuvant chemotherapy was associated with improved OS only in patients with substage IC, grade 3 EEOC. In stage I OCCC, adjuvant chemotherapy was not associated with improved OS.

P1.07-014 Impact of Chemotherapy for Small Cell Lung Cancer in the Third Line and beyond, a SEER-MEDICARE Analysis

While there is no approved third line chemotherapy option for small cell lung cancer (SCLC), empiric use of chemotherapy is common in this setting in the absence of supporting prospective data. In order to assess the potential benefit and predictors of chemotherapy use beyond the second line setting in SCLC, we analyzed the SEER-MEDICARE database. We employed data of SCLC patients diagnosed between 1985 and 2005. Univariate (UVA) association of line of chemotherapies with covariates was examined with Wilcoxon rank-sum test, chi-square or Fisher’s exact test. Multivariable (MVA) logistic regression analysis for line of therapy was conducted using the following covariates: year of diagnosis, age, gender, race, Medicare status, urban/rural location, and radiation. Survival functions were estimated by the Kaplan-Meier method and the log-rank test was used to assess for difference in overall survival (OS) stratified by line of therapy. UVA and MVA survival analyses were carried out using the Cox proportional hazards model. To further balance confounders between patients receiving different lines of therapy, propensity scores were estimated using a MVA logistic regression model to predict the receipt of 3rd line chemotherapy based on relevant covariates. Propensity score analysis was further conducted by including the estimated propensity score as a covariate in a Cox proportional hazards model. All analyses were done using SAS 9.3 with two-sided tests and a significant level of 0.05. There were 47,351 patients with SCLC of which 23,535 (49.7%) received chemotherapy and 10,887 (23%) received platinum-based chemotherapy. Of the platinum-treated patients, 1424 (13.1%) received additional salvage therapy of either topotecan alone (n=801) or topotecan and additional treatments as 3rd line and beyond (n=623). The median OS was 11, 13, 15 and 17 months respectively for patients treated with one, two, three or > 3 lines of chemotherapy respectively. Propensity score analysis showed additional lines of therapy beyond the second line was associated with a reduced risk of death (HR: 0.786; 0.729 - 0.847, p<0.001 and 0.617; 0.564 - 0.675; p<0.001 for 3rd line and > 3 lines of therapy respectively). Age (p=0.043) and year of diagnosis (P<0.001) were significantly associated with treatment beyond 2nd line topotecan on MVA analysis. Salvage chemotherapy is not commonly used following failure of platinum containing chemotherapy in SCLC patients. However, chemotherapy beyond the second line was associated with an incremental survival benefit in US MEDICARE-eligible SCLC patients.

Trends and Predictors of Chemotherapy Use among Thyroid Cancer Patients in the National Cancer Database (2004-2013)

Background/Aim: Beginning in 2011, the Food and Drug Administration (FDA) approved the use of multikinase inhibitors (MKIs) for medullary thyroid cancers (MTCs), and in 2013 MKIs were approved for metastatic differentiated thyroid cancers (DTCs). However, little is known about the use of chemotherapy in thyroid cancer patients. Thus, the goal of our study was to describe patterns of chemotherapy use, including MKIs, among DTC and MTC patients in the National Cancer Database (NCDB). Methods: Chemotherapy use, along with other treatment types (surgery and radiation), was assessed between 2004 and 2013. The primary predictor was the year of diagnosis (2004-2010 and 2011-2013), based on the FDA's approval of chemotherapy for MTC (2011). Baseline use of MKIs in DTCs in 2013 was also examined. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% CI of receipt of chemotherapy. Results: Overall, 199,654 patients were included in our analytic sample with 194,667 nonmetastatic DTCs, 1,633 metastatic DTCs, and 3,354 MTCs. Among MTCs, chemotherapy use significantly increased from 3.1% in 2004-2010 to 5.0% in 2011-2013 (p = 0.018) in unadjusted and adjusted (OR = 1.54, 95% CI: 1.00, 2.36) analyses. In metastatic DTCs, 4.9% of patients received chemotherapy in 2013, which was not significantly higher than in previous years (p = 0.755). Conclusions: Overall, chemotherapy use among MTCs increased marginally following the FDA's approval of MKIs in 2011, although their use remains very low. MKIs were infrequently used in metastatic DTCs in 2013. Future studies examining patterns of chemotherapy in thyroid cancer patients are warranted.

National patterns of care and predictors of neoadjuvant and concurrent chemotherapy use with definitive radiotherapy in the treatment of patients with oropharyngeal squamous cell carcinoma.

To the authors' knowledge, the patterns of care for the radiotherapy-based treatment of patients with stage III to IVB oropharyngeal squamous cell carcinoma (OPSCC) are poorly defined. The objective of the current study was to characterize the use and predictors of chemotherapy with radiotherapy for this population using the National Cancer Database. Patients in the National Cancer Database with AJCC (American Joint Committee on Cancer) stage III to IV OPSCC who were treated with radiotherapy between 2003 and 2012 were eligible for analysis. Treatment was defined as radiotherapy alone, concurrent chemoradiotherapy, or induction chemotherapy (IC). Multivariable regression with multilevel modeling was used to determine predictors of any chemotherapy use and, among patients receiving chemotherapy, the predictors of IC. The majority (90%) of the 30,875 eligible patients received chemotherapy, the majority of whom (71% of the total) were treated with definitive chemoradiotherapy; a sizeable percentage of patients received IC (19% of total). On multivariable regression, younger age, favorable comorbidity status, and more advanced tumor and lymph node disease were found to be independent predictors of any chemotherapy and IC use. Nonwhite patients (odds ratio [OR], 0.71; P<.0001), women (OR, 0.74; P<.0001), and individuals without private insurance were found to be significantly less likely to receive chemotherapy. Patients treated at higher-volume institutions were significantly less likely to receive IC (OR, 0.69; P = .0006). Human papillomavirus status did not appear to independently influence treatment choice. The vast majority of patients with stage III to IVB OPSCC who were treated with definitive radiotherapy received chemotherapy, which is consistent with high-level data and national recommendations. However, disparities with regard to race, sex, and insurance status emerged thereby requiring additional investigation. The frequent use of IC despite limited supportive evidence warrants research on physician and patient decision making and presents an opportunity to improve evidence-based treatment delivery. Cancer 2017;123:273-282. © 2016 American Cancer Society.

Utilization and Outcomes of Chemotherapy in Women With Intermediate-Risk, Early-Stage Ovarian Cancer.

To examine utilization and efficacy of chemotherapy for stage I ovarian cancer. We conducted a retrospective cohort study using the National Cancer Data Base to identify women with stage I ovarian cancer treated from 1998 to 2012. Patients were classified into three groups based on grade and stage: stage IA or IB grade 1 (low risk); stage IA or IB grade 2 (intermediate risk); and stage IA or IB grade 3 or any stage IC (high risk). Multivariable models were developed to examine predictors of chemotherapy use and survival. We identified 21,758 patients including 4,196 (19.3%) low-risk, 3,777 (17.4%) intermediate-risk, and 13,785 (63.4%) high-risk women. The median follow-up of the cohort was 63.9 months. Use of chemotherapy within the groups was 15.5%, 39.5%, and 69.8%, respectively (P<.001). Among low-risk patients, chemotherapy was not associated with a change in survival (adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.85-1.42), whereas chemotherapy was associated with reduced mortality for high-risk patients (adjusted HR 0.78, 95% CI 0.71-0.85). For intermediate-risk patients (stage IA-IB grade 2), chemotherapy was associated with a 26% reduction in mortality (adjusted HR 0.74, 95% CI 0.62-0.89). The association between chemotherapy and improved survival among intermediate-risk patients remained significant when limited to patients who underwent staging lymphadenectomy (adjusted HR 0.77, 95% CI 0.62-0.97). There is widespread variation in the patterns of care for early-stage ovarian cancer. Chemotherapy was associated with improved survival for stage IA-IB grade 2 patients.

Patterns and Predictors of Chemotherapy Use for Resected Non-Small Cell Lung Cancer

Chemotherapy combined with surgical resection improves survival in patients with stage II to IIIA non-small cell lung cancer (NSCLC) and may benefit selected patients with stage IB disease. We sought to evaluate chemotherapy use in resected stage IB to IIIA NSCLC over time and to identify predictors of perioperative chemotherapy administration. Patients with resected stage IB to IIIA NSCLC were identified from the National Cancer Data Base (2002 to 2011). Administration of chemotherapy was assessed over time. Hierarchical regression models were developed to assess patient, hospital, and tumor-level characteristics predicting perioperative chemotherapy administration. In 55,016 stage IB patients, chemotherapy use significantly increased between 2002 and 2011 from 5.3% to 15.1% (p < 0.001). In 57,033 patients with stage II to IIIA disease, perioperative chemotherapy administration also significantly increased from 29.3% to 58.4% (p < 0.001). Multivariable analyses demonstrated stage IB and II to IIIA patients were less likely to receive chemotherapy if they were older, treated at an academic center (vs community), had more comorbidities, or had lower-grade tumors (all p < 0.05). Stage IB patients with tumors sized 4 cm or larger were more likely to receive chemotherapy (odds ratio, 3.16; 95% confidence interval, 2.73 to 3.65) than those with tumors smaller than 4 cm. Compared with stage IIA patients, stage IIB patients were no more likely to receive perioperative chemotherapy (odds ratio, 1.06; 95% confidence interval, 0.96 to 1.17), whereas stage IIIA patients received chemotherapy significantly more often (odds ratio, 2.82; 95% confidence interval, 2.55 to 3.11). The use of chemotherapy has significantly increased in patients with resected stage IB to IIIA NSCLC. Although clinicians have increasingly adopted evidence-based recommendations, significant treatment gaps persist and represent areas for quality improvement.

Use and duration of chemotherapy and its impact on survival in early-stage ovarian cancer

ObjectiveAlthough 5-year survival for early-stage ovarian cancer is favorable, prognosis at recurrence is poor, necessitating appropriate initial management. We examined the patterns of care and the impact of the duration of chemotherapy on survival for women with early-stage ovarian cancer. MethodsWe used the SEER-Medicare database to identify women ≥65years of age with stage I ovarian cancer diagnosed from 1992 to 2009. Patients were categorized as low-risk (non-clear cell histology, stage IA or IB, grade 1 or 2) or high-risk (clear cell histology, grade 3, or stage IC). We used multivariable logistic regression models to determine predictors of chemotherapy use and duration and Cox proportional hazards models to evaluate the effect of chemotherapy use and duration on survival. ResultsWe identified 1394 patients. Among low-risk patients, 32.9% received adjuvant chemotherapy and the use of chemotherapy increased with time. Among high-risk patients, 71.9% received adjuvant chemotherapy; 44.2% had ≤3months of treatment, and 55.8% had >3months of treatment. Older patients were less likely to receive chemotherapy, while those with higher stage and grade were more likely to receive chemotherapy (P<0.05 for all). Among high-risk patients, the duration of chemotherapy did not impact overall (HR=0.93, 95% CI, 0.67–1.27) or cancer specific (HR=0.93; 95% CI, 0.61–1.42) survival. ConclusionsAmong early-stage ovarian cancer patients, practice patterns are widely divergent. Extended duration chemotherapy does not appear to impact survival for women with high-risk disease.

Rates and predictors of chemotherapy use for stage III colon cancer

Despite consensus regarding the benefits of chemotherapy for stage III colon cancer, multiple reports have found significant variations in rates of use. In the current study, the authors attempted to systematically review reports of the community rates at which chemotherapy is administered for stage III colon cancer in the US, and in so doing plan strategies for improving rates of use. A systematic search strategy was undertaken using MEDLINE, Web of Science, and bibliographies to find reports of the rates at which patients with stage III colon cancer receive chemotherapy. A total of 22 studies published since 1990 were identified, with rates of chemotherapy use ranging from 39% to 71%. Age and comorbidity were found to be the most significant patient factors, but studies also found racial/ethnic and socioeconomic disparities in the rates of chemotherapy. Patients treated at teaching hospitals did not clearly receive chemotherapy more often. Oncologists and surgeons who treat a higher volume of colorectal cancer patients were more likely to have chemotherapy initiated in their patients. The authors developed a conceptual model of the process pathway experienced by patients with stage III colon cancer to demonstrate areas of potential underuse of chemotherapy. Nearly half of patients with stage III chemotherapy in the US do not receive chemotherapy. Although many patients are too old or frail to benefit appropriately, for many patients chemotherapy is simply not initiated. Attention needs to be focused on systematic approaches to prevent systems failures that result in underuse. Guidelines regarding chemotherapy use in elderly patients are especially important.

Trends and predictors of first-line chemotherapy use among elderly patients with advanced non-small cell lung cancer in the United States

PurposeThis study assessed first-line chemotherapy treatment patterns over time and identified predictors of chemotherapy use and treatment selection among elderly patients with newly diagnosed Stage IIIB/IV non-small cell lung cancer (NSCLC) in the United States. MethodsPatients aged 65 years and older newly diagnosed with Stage IIIB/IV NSCLC between 1997 and 2002 were identified and followed through 2003 using the Surveillance, Epidemiology and End Results (SEER)-Medicare database to evaluate temporal trends in chemotherapy treatment. Multivariate logistic regression models were estimated to identify predictors of chemotherapy treatment and factors associated with use of cisplatin/carboplatin (platinum) and either a taxane or gemcitabine versus other treatments. ResultsChemotherapy use increased from approximately 28% of Stage IIIB/IV NSCLC patients diagnosed in 1997 to 36% of patients diagnosed in 2002. Doublet therapy was most commonly used as first-line therapy, received by 74% of chemotherapy-treated patients across all study years. Use of doublet therapy with platinum and either a taxane or gemcitabine also increased over time (with the largest increase for gemcitabine combinations from 0.3% in 1997 to 11.8% in 2002). Males were more likely than females to be treated with chemotherapy (odds ratios [95% CI]: 1.14 [1.06–1.22]), as were patients in the Northeast and South relative to patients in the West (1.24 [1.13–1.36] and 1.33 [1.20–1.47], respectively). ConclusionUse of first-line chemotherapy treatment among elderly Stage IIIB/IV NSCLC patients is low, but appears to be increasing, with potential regional and gender differences in treatment. These findings are likely to be of interest to clinicians and policymakers.

Adjuvant Chemotherapy and Survival in Older Women With Hormone Receptor–Negative Breast Cancer: Assessing Outcome in a Population-Based, Observational Cohort

For older breast cancer patients, there is limited evidence of the efficacy of adjuvant chemotherapy from randomized clinical trials. Our goal was to assess the relationship between adjuvant chemotherapy use and survival in a large, population-based cohort of older women with hormone receptor (HR) -negative breast cancer. We identified women age 66 and older diagnosed with HR-negative, nonmetastatic breast cancer from 1992 to 1999 in the Surveillance, Epidemiology and End Results (SEER) cancer registries. Chemotherapy use was identified in Medicare claims linked to SEER records. Clinical and sociodemographic predictors of chemotherapy use were identified using logistic regression. The effect of chemotherapy on survival was evaluated using propensity score methods and multivariable proportional hazards regression. A total of 1,711 (34%) of 5,081 women with HR-negative breast cancer received chemotherapy within 6 months of cancer diagnosis. Chemotherapy use decreased with increasing age and comorbidity, and increased with year of diagnosis, tumor size, number of positive lymph nodes, and higher tumor grade. Adjuvant chemotherapy was associated with a mortality reduction of approximately 15% whether analyzed using propensity scores or standard multivariable methods. The greatest overall survival benefit was observed in patients with node-positive disease and in the node-negative patients most likely to receive chemotherapy. This analysis suggests a survival benefit from adjuvant chemotherapy in older women with HR-negative breast cancer. The benefit of chemotherapy is most pronounced in the patients most likely to be selected for treatment, including those with involved lymph nodes or other high-risk disease characteristics.