Receipt Of Guideline-concordant Treatment Research Articles

Racial Comparisons in Treatment of Rectal Adenocarcinoma and Survival in the Military Health System.

Racial disparities in treatment and outcomes of rectal cancer have been attributed to patients' differential access to care. We aimed to study treatment and outcomes of rectal cancer in the equal access Military Health System (MHS) to better understand potential racial disparities. We accessed the MilCanEpi database to study a cohort of patients aged 18 and older who were diagnosed with rectal adenocarcinoma between 1998 and 2014. Receipt of guideline recommended treatment per tumor stage, cancer recurrence, and all-cause death were compared between Non-Hispanic White and Black patients using multivariable regression models with associations expressed as odds (AORs) or hazard ratios (AHRs) and their 95% confidence intervals (CIs). The study included 171 Black and 845 White patients with rectal adenocarcinoma. Overall, there were no differences in receipt of guideline concordant treatment (AOR = 0.76, 95% CI = 0.45, 1.29), recurrence (AHR = 1.34, 95% CI = 0.85, 2.12), or survival (AHR = 1.08, 95% CI = 0.77, 1.54) for Black patients compared to White patients. However, Black patients aged <50 years at diagnosis (AOR = 0.34, 95% CI 0.13, 0.90) or with stage III or IV tumors (AOR = 0.28, 95% CI = 0.12, 0.64) were less likely to receive guideline recommended treatment than White patients in stratified analysis. In the equal access MHS, while there were no overall racial disparities in rectal cancer treatment or clinical outcomes between Black and White patients, disparities among those with early-onset or late-stage rectal cancers were noted. This suggests factors other than access to care may play a role in the observed disparities and warrants further research.

Social Genomic Determinants of Health: Understanding the Molecular Pathways by Which Neighborhood Disadvantage Affects Cancer Outcomes.

Neighborhoods represent complex environments with unique social, cultural, physical, and economic attributes that have major impacts on disparities in health, disease, and survival. Neighborhood disadvantage is associated with shorter breast cancer recurrence-free survival (RFS) independent of individual-level (race, ethnicity, socioeconomic status, insurance, tumor characteristics) and health system-level determinants of health (receipt of guideline-concordant treatment). This persistent disparity in RFS suggests unaccounted mechanisms such as more aggressive tumor biology among women living in disadvantaged neighborhoods compared with advantaged neighborhoods. The objective of this article was to provide a clear framework and biological mechanistic explanation for how neighborhood disadvantage affects cancer survival. Development of a translational epidemiological framework that takes a translational disparities approach to study cancer outcome disparities through the lens of social genomics and social epigenomics. The social genomic determinants of health, defined as the physiological gene regulatory pathways (ie, neural/endocrine control of gene expression and epigenetic processes) through which contextual factors, particularly one's neighborhood, can affect activity of the cancer genome and the surrounding tumor microenvironment to alter disease progression and treatment outcomes. We propose a novel, multilevel determinants of health model that takes a translational epidemiological approach to evaluate the interplay between political, health system, social, psychosocial, individual, and social genomic determinants of health to understand social disparities in oncologic outcomes. In doing so, we provide a concrete biological pathway through which the effects of social processes and social epidemiology come to affect the basic biology of cancer and ultimately clinical outcomes and survival.

Understanding barriers to guideline-concordant treatment in foregut cancer: From data to solutions.

e13521 Background: Receipt of guideline concordant treatment (GCT) is associated with improved prognosis in foregut (gastric, pancreatic, and hepatobiliary) cancers. However, a large proportion of patients with foregut cancers do not receive GCT. This single institution study from the Deep South sought to understand barriers to receipt of GCT using a root cause analysis (RCA) approach. Methods: A retrospective review of 498 patients with foregut adenocarcinoma diagnosed between 2018-2022 was performed. GCT was defined using National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-receipt of GCT. Results: Overall, 170 patients (34.1%) did not receive GCT. Median (Interquartile range [IQR] time from symptoms to start of workup was 8.8 weeks (4.3-16.4); time from diagnosis to first oncology appointment was 4.6 weeks (1.6- 6.6), and time from oncology appointment to start of treatment was 11 weeks (3.7- 18.2). Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. Non-GCT was often a function of multiple intersecting patient, physician, and institutional factors. Barriers to receipt of GCT along the cancer care continuum included: receipt of incomplete therapy due lack of follow-up with surgical oncologist after initial appointment (16.5%), deconditioning on chemotherapy resulting in non-receipt of surgical therapy (15.3%), multiple delays in care due to patient resource constraints resulting in loss to follow-up after receipt of some therapy (11.2%), physician factors including provider knowledge (leading to delayed or non-diagnosis) or specialist non- adherence to GCT (11.2%), lack of documented treatment plan after referral to oncologist (11.2%), loss to follow up before oncology referral without record of health system attempt to re-establish care (10%), non-referral to oncologist (9.4%), non-referral to surgical oncologist in patients with resectable disease (8.8%), and complications during treatment preventing completion of treatment (6.5%). Findings from this study will allow us to propose targeted solutions to improve receipt of GCT, such as development of automated systems to improve patient follow-up and compliance with GCT; institutional prioritization of resources to enhance staffing for navigation, physical therapy, social services, and care coordination; financial counselling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways. Conclusions: A substantial percentage of patients with foregut cancer do not receive GCT due to multiple barriers along the cancer care continuum. This RCA approach allows us to propose and develop solutions that may improve receipt of GCT.

Abstract IA008: Racial disparities in guideline-concordant endometrial cancer treatment

Abstract Mortality associated with endometrial cancer is 98% higher among Black as compared with White women. A large body of literature has evaluated differential treatment patterns as a potential determinant of increased mortality among Black women. In most studies, receipt of individual endometrial cancer treatment components (i.e., surgery, radiation, chemotherapy) is compared between Black and White women. Moreover, individual treatment components are typically considered binary variables (received vs. not received) with the received category reflecting a wide spectrum of treatments received. For example, women who receive one vs. six cycles of chemotherapy would be similarly labeled as receiving chemotherapy, despite a clear difference in treatment intensity. In contrast, recent studies have begun to evaluate racial and ethnic differences in the complete course of treatment as a unit, within the context of established guidelines. The National Comprehensive Cancer Network guidelines provide evidence-based endometrial cancer treatment recommendations based on clinical trials and observational research. Surgery is the first step of guideline-concordant treatment and pathology factors captured from surgery inform adjuvant treatment recommendations. Since the distribution of tumor characteristics that guide treatment recommendations varies between Black and White women, we should expect racial differences in use of adjuvant radiation and chemotherapy. However, when conceptualizing treatment as guideline-concordant vs. discordant, racial and ethnic differences clearly signal disparate quality of care. In this presentation, we will discuss the need for research on endometrial cancer treatment disparities to shift from a paradigm of exploring individual treatment components to one in which receipt of guideline-concordant treatment is the focus. Moreover, through the lens of a recently funded grant, we will discuss the value of using an explicit disparities definition in analyses of guideline-concordant treatment, which allows for decomposition of the sources of racial and ethnic disparities. Differences in healthcare related to clinical need or preference are not considered sources of disparities, reflecting the normative view that these differences are acceptable, and therefore, just. On the other hand, unjust sources of disparities include the operation of healthcare systems, the legal and regulatory climate, and discrimination, among other factors. In addition to the selection of a rigorous and nuanced disparities definition, future research on guideline-concordant treatment disparities should investigate the role of multilevel factors that reflect the social determinants of health. Cancer health disparities are entrenched in the social determinants of health, which cannot be effectively addressed at the individual-level alone. Citation Format: Ashley S. Felix. Racial disparities in guideline-concordant endometrial cancer treatment [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr IA008.

Abstract A129: Association of concordance with guidelines of the National Comprehensive Cancer Network and overall survival in Puerto Rican women with endometrial cancer

Abstract Background: Endometrial cancer represents a significant burden in Puerto Rico, as it is one of the most common cancers among women. Although it has a favorable prognosis when diagnosed early, it remains the fifth leading cause of cancer-related deaths among women living in Puerto Rico. This highlights the need to address healthcare disparities and improve the quality of the healthcare system. Treatment guidelines are designed to assist healthcare professionals in offering the best possible care to patients by providing evidence-based suggestions. Implementing standardized practices is crucial to enhancing healthcare quality outcomes. Our objective was to assess the concordance of National Comprehensive Cancer Network (NCCN) guidelines for endometrial cancer treatment and its association with overall survival. Methods: Data on endometrial cancer patients aged 18 years and older diagnosed between 2009 and 2015 was obtained from the Puerto Rico Central Cancer Registry, linked to the Puerto Rico Health Insurance Administration database (n=2,114). The association between clinical aspects, health system, and socioeconomic factors with receipt of guideline-concordant treatment was evaluated using logistic regression. Overall survival (OS) was calculated using the Kaplan-Meier method. Univariate and multivariate-adjusted Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between guideline-concordant treatment and OS. Results: In our cohort, 53.9% of patients received guideline-concordant treatment. Patients receiving treatment at a Commission on Cancer (CoC)-accredited facility are twice as likely to receive guideline-concordant treatment than non-accredited facilities (95% CI: 1.71-2.98). Individuals who received an assessment from a gynecologist oncologist are 90.0% more likely to receive treatment based on NCCN guidelines than those who did not (95% CI: 1.56-2.32). Private insured patients are 28.0% more likely to receive guideline-concordant treatment than Medicaid patients (95% CI: 1.02-1.61). In Cox regression models, guideline-concordant treatment was associated with a lower mortality risk compared to women who did not receive guideline-concordant treatment (95% CI: 0.59- 0.89). Conclusion: Receiving guideline-concordant treatment is a strong predictor of improved survival rates in endometrial cancer patients. Additionally, patients treated at CoC-accredited hospitals and by gynecologic oncologists tend to receive higher-quality care. Given that guidelines based on effective treatment standards have been demonstrated to enhance cancer patient outcomes, we must encourage and support factors contributing to their increased adoption. By doing so, we can strive to improve the prognosis and overall well-being of individuals affected by endometrial cancer in Puerto Rico. Citation Format: Yisel Pagan-Santana, Karen J. Ortiz-Ortiz, Maira Castañeda-Avila, Ruth Rios-Motta. Association of concordance with guidelines of the National Comprehensive Cancer Network and overall survival in Puerto Rican women with endometrial cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A129.

Association of Medicaid expansion with timely receipt of treatment and survival among patients with HER2-enriched breast cancer.

6539 Background: HER2-enriched breast cancer (estrogen and progesterone receptors negative and HER2-positive) has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its impact on care for HER2-enriched breast cancer is unknown. To fill this gap, we examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment, and survival among newly diagnosed nonelderly women with HER2-enriched breast cancer. Methods: Women aged 18-62 years newly diagnosed with HER2-enriched breast cancer between 2010 and 2018 were identified from the National Cancer Database. Our primary outcomes included receipt of stage-based guideline-concordant treatment, initiation of treatment &lt;60 days, and stage-specific 2-year overall survival. A difference-in-differences (DD) approach compared outcome changes following the expansion in Medicaid expansion vs. non-expansion states. A linear probability model estimated treatment outcome, and a flexible parametric survival model evaluated survival. All models were clustered at the state level and adjusted for age group, race/ethnicity, rurality of residence, zip code-level income, comorbidity, and diagnosis year. Results: A total of 31,354 patients with HER2-enriched breast cancer were included, including 19,255 in expansion states and 12,099 in non-expansion states. Compared to patients in expansion states, patients in non-expansion states were more likely to be racial/ethnic minorities, uninsured, and diagnosed at late-stage. Medicaid expansion was not significantly associated with changes in receipt of surgery for stage I-III disease but was associated with an increase of 4.42 percentage points (ppt, 95% CI: 0.09, 8.74) in receipt of chemotherapy/targeted therapy for stage IV disease, with an increase from 90.4% pre-expansion to 92.8% post-expansion in expansion states and a decrease from 93.7% to 91.9% in non-expansion states. Medicaid expansion was also significantly associated with a 2.41 ppt increase in initiating guideline-concordant treatment within 60 days (95% CI: 0.66, 4.17; 83.5% to 82.5% in expansion states vs. 86.6% to 83.7% in non-expansion states), and a 1.18 ppt increase in two-year survival rate (95% CI: 0.03, 2.33; 94.0% to 94.9% in expansion states vs. 94.3% to 94.1% in non-expansion states). The increase in two-year survival associated with Medicaid expansion was most prominent for stage III patients (DD=3.63 ppt; 95% CI: 0.64, 6.62). Conclusions: Medicaid expansion was associated with increased receipt of timely treatment and improved 2-year survival among nonelderly women newly diagnosed with HER2-enriched breast cancer.

Association of Medicaid expansion with treatment receipt, delays in treatment initiation, and survival among young adult women with breast cancer.

1509 Background: Medicaid expansion under the Affordable Care Act has been shown to increase insurance coverage and early-stage cancer diagnoses for young adults (YAs), the age group with the highest uninsured rate. We examined whether Medicaid expansion was associated with increased receipt of timely, guideline-concordant treatment and survival among YA women newly diagnosed with breast cancer, the most common YA cancer diagnosis. Methods: Using the National Cancer Database, we identified 51,675 women aged 18-39 years who were diagnosed with breast cancer in 2011-2018. We applied the difference-in-differences (DD) method to estimate outcome changes pre vs. post Medicaid expansion, in expansion- vs. non-expansion states. Linear probability models estimated associations of Medicaid expansion with receipt of guideline-concordant treatment – including any endocrine therapy among women with ER-positive or PR-positive breast cancer, and any chemotherapy or targeted therapy among women with ER-negative and PR-negative breast cancer – and initiation of guideline-concordant treatment (surgery, chemotherapy, or targeted therapy for stage I-III diagnoses, and systemic therapy for stage IV diagnoses) &lt;60 days after diagnosis. Flexible parametric survival models were used to estimate 2-year overall survival. DD models also adjusted for age, race/ethnicity, rurality, zip code-level income, comorbidity, and diagnosis year, with standard errors clustered at the state level. Analyses were stratified by stage at diagnosis (stage I-III vs. IV). Results: Of the subset of women with stage I-III ER-positive or PR-positive breast cancer, the percentage receiving endocrine therapy increased in expansion states (85.20% pre-expansion to 86.46% post-expansion), but decreased in non-expansion states (84.32% to 82.79%), resulting in a net increase of 2.42 percentage points (ppt; 95% CI = 0.56 to 4.28) associated with Medicaid expansion in the adjusted DD model. Among all women with stage I-III breast cancer, the percentage with treatment initiation &lt;60 days after diagnosis decreased less in expansion states (84.10% pre-expansion to 82.36% post-expansion) than in non-expansion states (86.95% to 83.98%), resulting in a net reduction of 1.61 ppt (95% CI = 0.05 to 3.18) in treatment delays associated with Medicaid expansion. Notably, the 2-year overall survival increased in expansion states (96.84% pre-expansion to 96.99% post-expansion), but decreased in non-expansion states (97.24% to 96.30%), resulting in a net survival increase of 1.00 ppt (95% CI = 0.21 to 1.79) associated with Medicaid expansion. Conclusions: Among YA women with stage I-III breast cancer, Medicaid expansion was associated with increased receipt of guideline-concordant treatment, reduced delays in treatment initiation, and improved 2-year survival.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital.

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital. We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status. 520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years. Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Abstract B126: Examining Medicaid-serving primary care teams and delivery context on quality of care transitions to oncology: Implications for health equity

Abstract Purpose: Care transitions, from primary care to oncology, for Medicaid enrollees are understudied and likely contribute to quality and outcome disparities. We explore multi-team systems (MTS) (care coordination tasks and teamwork) to understand variations in breast and colorectal cancer care transitions in Medicaid-serving clinics. Methods and Materials: We conducted a comparative case study of three purposively recruited primary care clinics in New Jersey, based on clinic-level care transition performance (Medicaid enrollees’ receipt of guideline-concordant treatment). Site evaluations, conducted in 2019-2020, included observation (2-3 days) and interviews. Insights into performance variation emerged from a two-phase analytic approach. Results: Performance variations may stem from adaptations of MTS inputs and processes based on contextual factors (i.e., business model, clinic culture). Clinic 1 (average performer), part of a multi-site safety-net clinic system, mainly teamed outside of their organization, relying on designated roles, protocol-based care, and quality improvement informed by within team metrics. Clinic 2 (high performer), part of a for-profit health system, remained mission driven to improve urban health, teamed exclusively with internal teams with electronically enabled between team information exchange, and health system wide quality improvement efforts. Clinic 3, (low performer), a physician-owned private practice with minimal teaming, accepted Medicaid enrollees to diversify their payer mix and relied on referral-based care with limited consideration of social barriers. Conclusion: MTS’s adapt their care coordination in response to context. Addressing disparities in cancer care coordination for Medicaid populations should prioritize the implementation of policy that leverage clinic attributes and the boundary status of interdependent teams. Citation Format: Denalee M. O'Malley, Michelle Doose, Jenna Howard, Joel C. Cantor, Benjamin F. Crabtree, Jennifer Tsui. Examining Medicaid-serving primary care teams and delivery context on quality of care transitions to oncology: Implications for health equity [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B126.

Understanding the Impact of Medicaid-Serving Primary Care Team Functioning and Clinical Context on Cancer Care Treatment Quality: Implications for Addressing Structural Inequities.

Primary care factors related to Medicaid enrollees' receipt of guideline concordant cancer treatment is understudied; however, team structure and processes likely affect care disparities. We explore Medicaid-serving primary care teams functioning within multiteam systems to understand performance variations in quality of breast and colorectal cancer care. We conducted a comparative case study, using critical case sampling of primary care clinics in New Jersey, to provide maximum variation on clinic-level care performance rates (Medicaid enrollees' receipt of guideline-concordant treatment). Site evaluations, conducted from 2019 to 2020, included observation (2-3 days) and interviews. Using a multistep analytic process, we explored contextual factors within primary care that may contribute to cancer care performance variations. We identified performance variations stemming from adaptations of multiteam system inputs and processes on the basis of contextual factors (ie, business model, clinic culture). Team 1 (average performer), part of a multisite safety-net clinic system, mainly teamed outside their organization, relying on designated roles, protocol-based care, and quality improvement informed by within-team metrics. Team 2 (high performer), part of a for-profit health system, remained mission-driven to improve urban health, teamed exclusively with internal teams through electronically enabled information exchange and health system-wide quality improvement efforts. Team 3 (low performer), a physician-owned private practice with minimal teaming, accepted Medicaid enrollees to diversify their payer mix and relied on referral-based care with limited consideration of social barriers. Primary care team structures and processes variations may (in part) explain performance variations. Future research aiming to improve care quality for Medicaid populations should consider primary care teams' capacity and context in relation to composite teams to support care quality improvements in subsequent prospective trials.

The impact of patient travel time on disparities in treatment for early stage lung cancer in California.

BackgroundTravel time to treatment facilities may impede the receipt of guideline-concordant treatment (GCT) among patients diagnosed with early-stage non-small cell lung cancer (ES-NSCLC). We investigated the relative contribution of travel time in the receipt of GCT among ES-NSCLC patients.MethodsWe included 22,821 ES-NSCLC patients diagnosed in California from 2006–2015. GCT was defined using the 2016 National Comprehensive Cancer Network guidelines, and delayed treatment was defined as treatment initiation >6 versus ≤6 weeks after diagnosis. Mean-centered driving and public transit times were calculated from patients’ residential block group centroid to the treatment facilities. We used logistic regression to estimate risk ratios and 95% confidence intervals (CIs) for the associations between patients’ travel time and receipt of GCT and timely treatment, overall and by race/ethnicity and neighborhood socioeconomic status (nSES).ResultsOverall, a 15-minute increase in travel time was associated with a decreased risk of undertreatment and delayed treatment. Compared to Whites, among Blacks, a 15-minute increase in driving time was associated with a 24% (95%CI = 8%-42%) increased risk of undertreatment, and among Filipinos, a 15-minute increase in public transit time was associated with a 27% (95%CI = 13%-42%) increased risk of delayed treatment. Compared to the highest nSES, among the lowest nSES, 15-minute increases in driving and public transit times were associated with 33% (95%CI = 16%-52%) and 27% (95%CI = 16%-39%) increases in the risk of undertreatment and delayed treatment, respectively.ConclusionThe benefit of GCT observed with increased travel times may be a ‘Travel Time Paradox,’ and may vary across racial/ethnic and socioeconomic groups.

Association between Receipt of Guideline-Concordant Lung Cancer Treatment and Individual- and Area-Level Factors: A Spatio-Temporal Analysis.

Guideline-concordant treatment (GCT) of lung cancer has been observed to vary across geographic regions over the years. However, there is little evidence as to what extent this variation is explained by differences in patients' clinical characteristics versus contextual factors, including socioeconomic inequalities. This study evaluated the independent effects of individual- and area-level risk factors on geographic and temporal variation in receipt of GCT among patients with lung cancer. Receipt of GCT was defined on the basis of the National Comprehensive Cancer Network guidelines. We used Bayesian spatial-temporal multilevel models to combine individual and areal predictors and outcomes while accounting for geographically structured and unstructured correlation and linear and nonlinear trends. Our study included 4,854 non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) cases, reported to the Victorian Lung Cancer Registry between 2011 and 2018. Area-level data comprised socioeconomic disadvantage and remoteness data at the local government area level in Victoria, Australia. Around 60.36% of patients received GCT, and the rates varied across geographic areas over time. This variation was mainly associated with poor performance status, advanced clinical stages, NSCLC types, public hospital insurance, area-level deprivation, and comorbidities. This study highlights the need to address disparities in receipt of GCT among patients with lung cancer with poor performance status, NSCLC, advanced clinical stage, stage I-III SCLC, stage III NSCLC, public hospital insurance, and comorbidities, and living in socioeconomically disadvantaged areas. Two-year mortality outcomes significantly improved with GCT. Interventions aimed at reducing these inequalities could help to improve lung cancer outcomes.

Abstract B101: Race is associated with receipt of guideline-concordant treatment among women with endometrioid endometrial cancer: A National Cancer Database study

Abstract Background: Among women with endometrial cancer (EC), African American women have a 93% higher likelihood of dying compared to white women. This disparity is driven, in part, by the more frequent diagnosis of late stage and non-endometrioid tumors among African American women. However, even among women diagnosed with indolent forms of EC, including early stage or endometrioid histology, African American women are more likely to die. Differential receipt of guideline-based treatment might underlie worse survival among African American women. EC treatment guidelines are based on several randomized clinical trials, which provide consistently strong evidence on treatment regimens for women with early stage, endometrioid EC. Using the National Cancer Database (NCDB), we assessed the hypothesis that among women with less aggressive forms of EC, minority women would have lower odds of receiving guideline-concordant treatment than white women. In addition, we examined whether a survival benefit exists for EC patients who receive guideline-concordant treatment. Methods: We defined receipt of guideline-concordant EC treatment using the National Comprehensive Cancer Network (NCCN) guidelines, which stratify treatment decisions based on tumor characteristics. We used multivariable logistic regression models to compute odds ratios (OR) and 95% confidence intervals (CIs) for the association between race, categorized as non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander (API), and receipt of guideline-concordant treatment. We used multivariable Cox proportional hazards regression models to estimate hazards ratios (HRs) and 95% CIs for relationships between receipt of guideline-concordant treatment and overall survival. Results: A total of 89,976 women diagnosed with stages 1A through 3C, endometrioid EC between the years 2004 and 2014 were included, among whom, 71.5% (n=64,316) received treatment in line with NCCN guidelines. In multivariable adjusted models, NHB (OR=0.91, 95% CI=0.86 – 0.97) and Hispanic women (OR=0.93, 95% CI=0.86 – 0.99) had lower odds of receiving concordant treatment compared to NHW women. Receipt of guideline-concordant treatment did not differ between API and NHW women. During the study period, NHB women had the highest proportion of deaths (28.7%) followed by NHW (22.0%), Hispanic (16.0%), and API women (14.2%). In models adjusted for patient, clinical, and facility characteristics, women not receiving guideline-concordant care were 8% more likely to die (HR=1.08, 95% CI=1.05 – 1.12). Conclusions: Receipt of guideline-concordant treatment differed according to race, with minorities less likely than NHW women to receive guideline-directed therapy. Further, in the overall study population, overall survival was better among those receiving guideline-concordant care. Future studies should evaluate reasons underlying disparate EC treatment. Citation Format: Mara K. Kaspers, Elyse Reamer, Jhalak Dholakia, Ritu Salani, Ashley S. Felix. Race is associated with receipt of guideline-concordant treatment among women with endometrioid endometrial cancer: A National Cancer Database study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B101.

Abstract A134: Minority women with non-endometrioid endometrial cancer are not less likely to receive guideline-concordant treatment than White women

Abstract Background: Black women with endometrial cancer (EC) experience significant disparities in treatment and survival. They undergo diagnostic evaluation, primary surgical management, and non-surgical treatment at statistically lower rates than non-Hispanic White (NHW) women. Black women are also more likely to present with advanced stage disease and aggressive tumor histology, including non-endometrioid EC subtypes, resulting in a 93% greater overall mortality rate than Whites. Research in other cancers show that Black patients receive guideline-concordant care less often than NHW women. To date, no study has assessed the relationship between race and receipt of comprehensive guideline-concordant therapy, nor have studies examined the impact of guideline- concordant treatment and survival according to race among women with EC. We investigated these associations among women diagnosed with non-endometrioid EC in the National Cancer Database. Methods: Our analysis included 21,696 NHW, 6,859 non-Hispanic Black (NHB), 1,752 Hispanic, and 922 Asian/Pacific Islander (AS/PI) women diagnosed with non-endometrioid EC between 2004 and 2014. We used year-specific National Comprehensive Cancer Network (NCCN) guidelines to classify treatment as guideline-concordant vs. not concordant. We used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for the association between race and receipt of guideline-concordant treatment in models adjusted for age at diagnosis, stage, histology, comorbidity score, insurance type, and facility type. We used multivariable-adjusted Cox proportional hazards models to estimate hazards ratios (HRs) and 95% CIs for relationships between receipt of guideline-concordant treatment and overall survival stratified by race. Results: In the overall study population, 38.2% of women with non-endometrioid EC received NCCN guideline-concordant treatment. Compared to NHW women, NHB women (OR=1.05, 95% CI=0.99 to 1.11), Hispanic women (OR=1.10, 95% CI=0.99 to 1.23) and AS/PI women (OR=1.11, 95% CI=0.97 to 1.28) did not have significantly different odds of receiving guideline-concordant treatment in multivariable-adjusted models. Receipt of guideline-concordant treatment was significantly associated with improved survival among NHW (HR=0.84, 95% CI=0.80 to 0.87), NHB (HR=0.86, 95% CI=0.80 to 0.92), and Hispanic women (HR=0.85, 95% CI=0.72 to 1.00) but not among AS/PI women (HR=0.88, 95% CI=0.71 to 1.10). Conclusions: Almost two-thirds of women with non-endometrioid EC may not receive guideline-concordant treatment. We observed no difference in receipt of concordant care between racial groups. When received, guideline-concordant treatment was associated with improved survival in almost all racial groups. Therefore, instituting interventions to improve adherence to guideline-concordant treatment may contribute to reducing racial disparities in survival for women with non-endometrioid EC. Citation Format: Jhalak Dholakia, Elyse Reamer, Ritu Salani, Ashley Felix. Minority women with non-endometrioid endometrial cancer are not less likely to receive guideline-concordant treatment than White women [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A134.

Abstract A140: Factors associated with receipt of guideline-concordant treatment among Medicaid enrollees with breast and colorectal cancer

Abstract Purpose: Medicaid enrollees with cancer are less likely to receive treatment consistent with established guidelines. It remains unclear what specific factors are associated with non-receipt or delays in guideline-concordant cancer care among Medicaid patients. In this study, we examine receipt of guideline-concordant Medicaid enrollees with breast or colorectal cancer. Methods: We linked data from the New Jersey State Cancer Registry and Medicaid claims and encounter files for patients diagnosed with a first primary breast (BC) or colorectal (CRC) cancer from 2011-2015. We assess guideline-concordant treatment using National Comprehensive Cancer Network and American Society of Clinical Oncology criteria, which include endocrine therapy within 1 year, radiation therapy within 1 year, and adjuvant chemotherapy within 120 days for BC patients; and, postoperative chemotherapy within 9 months, radiation therapy within 6 months, and adjuvant chemotherapy within 4 months for CRC patients that fit the specific clinical criteria for each guideline. For each guideline, patients were placed in one of the three categories: 1.) on-time concordant care, 2.) delayed concordant care, 3.) non-receipt of concordant care. Delayed concordant care included patients with guideline-directed care outside of the indicated timeframe. We used multivariate ordinal logistic regression to determine the independent effects of demographic, health care utilization, and Medicaid enrollment factors on the 3-level concordance measure. Results: Rates of guideline concordant care were: 69.5% for BC endocrine therapy, 63.4% for BC radiation therapy, 76.4% for BC adjuvant chemotherapy, 69.4% for CRC postoperative chemotherapy, 91.9% for CRC radiation therapy, and 68.4% for CRC adjuvant chemotherapy. An additional 10.1% of BC patients received delayed care for endocrine therapy. An additional 14.1% of CRC patients received delayed care for postoperative chemotherapy. Ordinal logit models showed BC patients enrolled through the New Jersey Cancer Education and Early Detection program had a 29.3 percentage point higher probability of on-time care for endocrine therapy compared to women not enrolled through the program (p&amp;lt;0.001). CRC patients enrolled in managed care compared to fee-for-service had a 44 percentage point higher probability for receiving guideline concordant adjuvant chemotherapy (p&amp;lt;0.001). For a subset of BC and CRC guidelines we observed Hispanic patients had lower probably of receiving delayed or non-concordant care compared to NH-White patients (p&amp;lt;0.05). Conclusions: We identified several demographic and enrollment predictors of delayed guideline-concordant treatment for low-income cancer patients. These findings can inform providers to prioritize the targeting of care management resources for patients at high risk for not meeting treatment guidelines and highlight. Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Antoinette Stroup, Dawn L. Hershman, Joel Cantor. Factors associated with receipt of guideline-concordant treatment among Medicaid enrollees with breast and colorectal cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A140.

Abstract D077: Sociodemographic and geographic disparities in treatment for early-stage non-small cell lung cancer (NSCLC) patients in California

Abstract Background: Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the U.S. In 2013, the U.S. Preventive Services Task Force began recommending lung cancer screening, which has resulted in earlier stage diagnosis for many tobacco users. The National Comprehensive Cancer Network (NCCN) provides evidence-based cancer treatment recommendations. Evidence suggests that a patient’s receipt of guideline-concordant treatment (GCT) increases survival, especially for screen-detected, earlier stage cancers. The objective of this study is to describe receipt of timely GCT in California NSCLC patients by sociodemographic characteristics and geography. Methods: We studied 23,080 patients diagnosed with stage I/II NSCLC (2006-2015) in the California Cancer Registry. We classified treatment received as: undertreated, GCT, or over-treated according to NCCN guidelines, and timeliness (treatment began ≤ 45 days after diagnosis) among patients who received GCT. We describe the population according to treatment received, and timeliness by detailed race/ethnicity, stage of diagnosis, sex, age, insurance type, marital status, cancer approved program, and neighborhood socioeconomic status. We calculated absolute and relative inequalities in GCT and timeliness between race/ethnic groups. Hotspot analyses were conducted to identify regions at increased risk for under-treatment/overtreatment, and treatment delay by patient residential census tract. Results: Overall, 69.95% of patients received GCT, 14.53% were undertreated and 15.55% over-treated. Among patients who received GCT, 56.78% began treatment within 45 days of diagnosis. Under-treatment and treatment delay were more frequent in patients who were black or Hispanic, had public insurance, and were of lower socioeconomic status. We detected moderate absolute inequalities in receipt of GCT and timely care; no relative inequalities were observed. Cold and hot spots for under- and over-treatment and timeliness were identified within Metropolitan areas across California. Conclusion: Under-treatment and delayed treatment for early stage lung cancer disproportionately affect priority populations. With rising numbers of early stage lung cancers due to screening smokers, administration of timely proper treatment of lung cancer is critical. Citation Format: Chelsea A Obrochta, Atsushi Nara, James Murphy, Caroline A Thompson. Sociodemographic and geographic disparities in treatment for early-stage non-small cell lung cancer (NSCLC) patients in California [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D077.

Changes in black-white disparity in receipt of guideline concordant treatment for women with early-stage breast tumors.

e19089 Background: Racial disparities are well documented in the treatment of women with breast cancer. Whereas clinical treatment guidelines are established for early stage breast tumors, disparities in guideline-concordant (GC) treatment may influence variation in breast cancer outcomes. As such, we investigated differences in the receipt of GC treatment for black and white women with early-stage breast cancer between 2008 and 2016. Methods: We evaluated the Surveillance, Epidemiology, and End Results Registry (SEER) Incidence database for black and white women aged 20-64 years with stage I / stage II breast tumors. Primary analyses investigated associations between race and receipt of GC treatment in three chronological periods. Potential driving factors for trends in receipt of guideline-concordant treatment were also assessed. Results: Among 145,561 women diagnosed with early stage breast tumors, overall receipt of GC care decreased from 84.58% in 2008 to 83.89% in 2016. In period 1 (2008-2010), there was a prominent disparity between black and white women (81.89% black vs 86.24% white; p &lt; 0.001). By period 3 (2014-2016), GC care increased for black women (84.29%) but decreased for white women (84.82%), eliminating the disparity (p = 0.276). Multivariate logistic regression on changes in the black-white disparity across the study period showed increased receipt of GC treatment for black women relative to white women in period 2 (2011-2013, odds ratio [OR], 1.202; 95% confidence interval [CI], 1.075 – 1.344) and period 3 (OR, 1.376; 95% CI, 1.212 – 1.505). For black women undergoing breast conserving surgery, administration of radiation therapy increased from 44.01% in period 1 to 50.64% in period 3 (p &lt; 0.001) and was a prominent driver for increased GC care. Conclusions: Overall receipt of guideline-concordant treatment decreased from 2008-2016. Black women experienced a substantial increase in receipt of guideline-concordant care in period 2 (2011-2013) and period 3 (2014-2016) relative to white women. Delivery and completion of radiation therapy with breast conserving surgery increased the likelihood of receipt of guideline-concordant treatment.

Neighborhood disparities in timeliness of treatment for early stage lung cancer patients.

e19017 Background: Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the United States, accounting for approximately 25% of all cancer deaths. The National Comprehensive Cancer Network (NCCN) provides evidence-based cancer treatment recommendations. Evidence suggests that a patient’s receipt of guideline-concordant treatment (GCT) increases survival, especially for screen-detected, earlier stage cancers. Neighborhoods are key determinants of health and the neighborhood social and built environments can influence cancer treatment and outcomes. Minority segregated neighborhoods often have limited health resource availability. The objective of this study is to estimate the relationship between neighborhood segregation on racial and ethnic disparities in timely receipt of GCT in early-stage lung cancer patients in California. Methods: We studied 22,903 patients diagnosed with stage I/II non-small cell lung cancer (2006-2015) in the California Cancer Registry. The primary outcome of the study is receipt of GCT according to the 2016 NCCN guidelines defined as the administration of proper initial and adjuvant treatment(s) according to cancer site and stage, and measured using surgery type, chemotherapy type, and radiation type. The secondary outcome was timely receipt of care as defined as the initiation of surgery, radiation, or chemotherapy within 45 days of diagnosis for initial treatment and the initiation of chemotherapy +/- radiation within 6 months of initial surgery for N1 patients for adjuvant treatment. Multivariable hierarchical logistic regression will be used to estimate the effect of neighborhood segregation on timely receipt of GCT, adjusting for individual- and neighborhood-level covariates, and stratified by patient race/ethnicity. Results: Overall, 81.39% of patients received GCT; 57.63% of them within 45 days of diagnosis. Under-treatment and treatment delay were more frequent in patients who were black or Hispanic, had public insurance, and were of lower socioeconomic status. We hypothesize that increased neighborhood segregation will decrease a patient’s likelihood of adherence to GCT and timely GCT. Conclusions: This research is vital to improving our understanding of cancer-related health disparities and promoting health in vulnerable neighborhoods. With rising numbers of early stage lung cancers due to screening smokers, administration of timely proper treatment is critical.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BackgroundRacial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2–3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. MethodsTranslating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. ConclusionTRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Guideline-concordant treatment is associated with improved survival among women with non-endometrioid endometrial cancer

BackgroundAmong women diagnosed with non-endometrioid endometrial carcinoma (EC), we investigated associations between race/ethnicity and receipt of guideline-concordant treatment (GCT), as well as relationships between GCT and survival. MethodsWe used the National Cancer Database and identified 21,177 non-Hispanic White (NHW), 6657 non-Hispanic Black (NHB), 1689 Hispanic, and 903 Asian/Pacific Islander (AS/PI) women diagnosed with non-endometrioid EC between 2004 and 2014. Year-specific National Comprehensive Cancer Network (NCCN) guidelines were used to classify GCT. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between race/ethnicity and GCT receipt. Multivariable-adjusted Cox proportional hazards models were used to estimate hazards ratios (HRs) and 95% CIs for relationships between GCT and overall survival in the total study population and stratified by race/ethnicity. ResultsOverall, 43.8% of women with non-endometrioid EC received GCT. Compared to NHW women, NHB (OR = 1.01, 95% CI = 0.95–1.07), Hispanic (OR = 1.01, 95% CI = 0.91–1.12) and AS/PI women (OR = 1.10, 95% CI = 0.96–1.26) did not have significantly different odds of receiving GCT. GCT was significantly associated with improved survival among NHW (HR = 0.84, 95% CI = 0.80–0.87), NHB (HR = 0.85, 95% CI = 0.80–0.91), and Hispanic women (HR = 0.84, 95% CI = 0.72–0.98) but not among AS/PI women (HR = 0.97, 95% CI = 0.78–1.19). ConclusionsWhile more than half of women with non-endometrioid EC did not receive GCT, no difference in GCT receipt by race/ethnicity was observed. When received, GCT was associated with improved survival in almost all racial groups. Interventions to improve GCT adherence may improve survival for most women with non-endometrioid EC.