Recent Year Of Diagnosis Research Articles

Predictors of palliative treatment in stage IV colorectal cancer.

Palliative treatment may be associated with prolonged survival and improved quality of life, but remains underutilized in stage IV colorectal (CRC). We examined a national cohort of stage IV CRC patients to determine the factors associated with palliative treatment. Stage IV CRC patients, classified based on their survival length (<6 months, 6-24 months, and 24+months), were analyzed using the American College of Surgeons National Cancer Data Base (2004-2013). Multivariable analysis was performed to evaluate factors associated with palliative treatment. Of 85,981 patients analyzed, 10.9% received palliative treatment. For 6-24 months survival, a more recent year of diagnosis, Medicaid, uninsured status, Mountain and Pacific regions were associated with higher odds of palliative treatment. For those who survived < 6months, older patients had lower odds, while academic centers and residence > 20 miles from treating institutions were associated with increased likelihood of palliative treatment. Palliative treatment in stage IV CRC is associated with a more recent year of diagnosis, Medicaid, academic centers, Mountain and Pacific regions of the US.

Immediate intravesical chemotherapy for low-grade bladder tumors in California: An underutilized practice and its impact on recurrence

To demonstrate patterns of uptake and impact on recurrence of intravesical chemotherapy (IC) immediately following transurethral resection of bladder tumor (TURBT) for low-grade non-muscle-invasive bladder cancer (NMIBC) at a population level. Incident cases of low-grade (LG) Ta or T1 NMIBC from 2005 to 2012 were identified from the California Cancer Registry. We determined rates of IC utilization following TURBT. Multivariable logistic regression models were utilized to assess predictors of IC utilization. Multivariable Cox proportional hazards regression was used to assess the association of IC utilization with recurrence-free survival, bladder cancer-specific survival, and overall survival. Ten thousand thirty-one patients with LG NMIBC diagnosed in California between 2005 and 2012. The overall rate of IC utilization was 5.1%, and increased from 1.7% (2005-2006) to 9.6% (2011-2012). More recent year of diagnosis (Odds ratio 1.74, confidence interval 1.60-1.90 for 2-year increments) was associated with an increased likelihood of undergoing immediate postoperative IC. The cumulative incidence of recurrence at 24 months for patients who received IC was 25.2% compared to 30.2% among those who did not receive IC. Use of IC was significantly associated with improved recurrence-free survival (Hazards ratio 0.82, confidence interval 0.70-0.97). Utilization of IC for LG NMIBC remains dismally low, with less than 10% of patients receiving this standard of care. Low utilization is associated with increased rates of recurrence. We demonstrate a major shortcoming in quality of care with potential widespread impact on outcomes and cost of care.

Comparative Effectiveness of Abdominal versus Laparoscopic Radical Hysterectomy for Cervical Cancer in the Postdissemination Era.

PurposeDespite the benefits of minimally invasive surgery for cervical cancer, there are a lack of randomized trials comparing laparoscopic radical hysterectomy and abdominal radical hysterectomy. We compared morbidity, cost of care, and survival between abdominal radical hysterectomy and laparoscopic radical hysterectomy for cervical cancer.Materials and MethodsWe used the Korean nationwide database to identify women with cervical cancer who underwent radical hysterectomy from January 1, 2011 to December 31, 2014. Patients who underwent abdominal radical hysterectomy were compared to those who underwent laparoscopic radical hysterectomy. Perioperative morbidity, the use of adjuvant therapy, and survival were evaluated after propensity score balancing.ResultsWe identified 6,335 patients, including 3,235 who underwent abdominal radical hysterectomy and 3,100 who underwent laparoscopic radical hysterectomy. The use of laparoscopic radical hysterectomy increased from 46.1% in 2011 to 51.8% in 2014. Patients who were younger, had a more recent year of diagnosis, and were treated in the metropolitan area were more likely to undergo a laparoscopic procedure (p < 0.001). Compared to abdominal radical hysterectomy, laparoscopic radical hysterectomy was associated with lower rates of complication, fewertransfusions, a shorter hospital stay, less adjuvant therapy, and reduced total medical costs (p < 0.001). Laparoscopic surgery was associated with a better overall survival than abdominal operation (hazard ratio, 0.74; 95% confidence interval, 0.64 to 0.85).ConclusionIn the postdissemination era, laparoscopic radical hysterectomy was associated with more favorable morbidity profiles, a lower cost of care, and comparable survival than abdominal radical hysterectomy.

Incidence and Risk of Celiac Disease in Individuals with Type 1 Diabetes over the Lifespan—A Population-Based Cohort Study Using the Health Improvement Network Database

Objective: Individuals with type 1 diabetes (T1D) are at increased risk for celiac disease (CD), though the incidence for those diagnosed with T1D beyond childhood is unknown. We used survival analysis to investigate the incidence and risk factors for diagnosis of CD over time in a population-based cohort of children and adults with T1D. Methods: Retrospective cohort study using The Health Improvement Network (THIN), a primary care electronic medical records database of &amp;gt;13 million people in the United Kingdom. Subjects were 1-35 years old at T1D diagnosis; subjects with type 2 diabetes or prevalent CD were excluded. We used Cox proportional hazards regression to identify factors associated with diagnosis of CD during follow-up. Risk factors assessed included age at T1D, sex, year of T1D diagnosis, and time-varying covariates of thyroid disease and adrenal insufficiency. Results: Subjects (n=11,537; 43% female) had a median follow-up time of 6.8 years (IQR 2.5-14.1). CD was diagnosed in 234 (2%), with median time to diagnosis of 2.9 years (IQR 1.2-7.8); 37% were diagnosed &amp;gt; 5 years after T1D. Incidence (per 10,000 person-years) was greater in females than males (26.9 [95% CI 22.4-31.9] vs. 16.4 [95% CI 13.4-19.9]) and in subjects &amp;lt;10 years at T1D diagnosis (50.1 [95% CI 41.4-60.2] vs. 13.3 [95% CI 11.0-15.9]). In multivariable Cox regression, the hazard of CD was higher with younger age (HR 0.88 per year of age at T1D diagnosis, 95% CI 0.80-0.96, p=0.006), in females (HR 1.50, 95% CI 1.16-1.94, p=0.002), and with more recent year of diagnosis (HR 1.09, 95% CI 1.07-1.12, p &amp;lt; 0.001). Conclusions: A significant proportion of CD cases were diagnosed more than 5 years after T1D diagnosis, the time frame currently recommended for screening. A more personalized approach to CD screening, accounting for the greater risk for younger-onset and female patients with T1D, may be warranted to minimize over-testing while limiting missed diagnoses. Disclosure M. Vajravelu: None. D. De Leon: Employee; Spouse/Partner; Merck &amp; Co., Inc.. Research Support; Self; Zealand Pharma A/S. Consultant; Self; XOMA Corporation, ProSciento. Research Support; Self; Biomarin Corporation. D.R. Weber: None. R. Keren: None. M.R. Denburg: Research Support; Self; Mallinckrodt Pharmaceuticals. R. Verma: None.

Distribution of 21-Gene Recurrence Scores in Male Breast Cancer in the United States.

The 21-gene recurrence score (RS) is a RT-PCR assay estimating risk of distant recurrence in estrogen receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2) breast cancer (BC). Studies validating RS are limited to women. Our objective was to assess RS distribution and factors associated with high-risk RS in male BC. Using the Surveillance, Epidemiology, and End Results database, we identified men and women with ER+/HER2- BC from 2010 to 2013. Patients were categorized into risk groups using the traditional and the Trial Assigning Individualized Options for Treatment (TAILORx) cutoffs. Multivariable logistic regression determined factors associated with testing and high-risk TAILORx RS. We identified 1388 men and 154,196 women with ER+/HER2- BC. Twenty-five percent of men and 30% of women had RS testing. Mean age of tested men was 63; most were white (81%), had grade I or II tumors (67%), and had stage I or II (95%) BC. Factors associated with increased RS testing were younger age, recent year of diagnosis, lymph node negativity, and lower-stage tumors (p ≤ 0.05). By TAILORx, 21% of men had high-risk RS compared with 14% of tested women. Men with grade III and PR negative tumors were more likely to have a high-risk RS (p ≤ 0.05). Chemotherapy utilization was correlated with RS. Using a large population-based dataset, we found that compared with women, men were significantly more likely to have high-risk RS. Grade III and PR-negative BC were significantly associated with high-risk RS. Higher RS in men correlated with increased chemotherapy utilization.

Surgical Management of Lobular Carcinoma In Situ: Analysis of the National Cancer Database.

Current guidelines recommend counseling on risk-reduction strategies, including lifestyle modification, endocrine therapy, and bilateral mastectomy, for patients with classic-type lobular carcinoma in situ (LCIS) detected on core biopsy or surgical excision. Importantly, current diagnosis and treatment guidelines for classic-type LCIS do not include unilateral mastectomy for primary treatment or risk reduction. Prior studies reporting national practice patterns suggest increasing use of mastectomy for management of LCIS, with considerable variation by geographic region. However, these studies did not distinguish between uni- and bilateral mastectomies. This study aimed to investigate national practice patterns and factors associated with unilateral mastectomy. The study used the National Cancer Database to identify women with a diagnosis of LCIS from 2004 to 2013. Descriptive statistics were used to describe surgical treatment, and multinomial logistic regression was used to identify temporal, patient, and facility-level factors associated with receipt of uni- and bilateral mastectomy. The study identified 30,105 women with LCIS. Of these woman, 5.4% received no surgery, 84.8% had surgical excision, 4% underwent unilateral mastectomy, and 5.1% underwent bilateral mastectomy. Adjusted analysis showed that young age, white race, insurance coverage, greater comorbidity, and geographic region (p < 0.001) were associated with receipt of both uni- and bilateral mastectomy. Additionally, more recent year of diagnosis was associated with receipt of bilateral mastectomy. Unilateral mastectomy rates within geographic regions ranged from 2.7% in New England to 8% in the South. Nearly as many patients underwent unilateral (4%) as bilateral mastectomy (5.1%), representing inappropriate care. These findings highlight an opportunity to reduce unnecessary care through improved provider and patient education regarding optimal management of LCIS.

Trends and Patterns of Proton Therapy Utilization Among Patients With Head and Neck Cancer: Analysis from the National Cancer Database (2005-2014)

To analyze national trends and patterns of proton therapy use among patients with head and neck cancer. Using the National Cancer Database, we identified patients diagnosed with any head and neck primary malignancy of all stages between 2005 and 2014. Patients treated with radiation therapy and proton therapy directed specifically to the primary site were selected. Distribution of patient/clinical factors, socioeconomic status, demographic factors, and treatment facility type were evaluated. Univariable and multivariable logistic regression was used to correlate factors associated with proton therapy use compared to other modalities of radiation therapy. There were 245,859 who received any radiation therapy as part of their initial treatment course and 468 (0.2%) who received proton therapy. The use of protons underwent a small increase in utilization from 0.1% in 2005 to 0.4% by 2014 (OR 3.041, P<.001). The most common primary sites treated with proton therapy were the nasal cavity/nasopharynx (n=174, 37.2%) and the oral cavity (n=107, 22.9%). On multivariate logistic regression, treatment at an academic facility (OR 2.345, P<.001), income >$63,000 (OR 1.606, P<.001) and most recent years of diagnosis (2013-2014, OR 3.050, P<.001) were associated with increased likelihood of receiving proton therapy. In addition, patients who received proton therapy were more likely to travel a longer distance for treatment (OR 1.918, P<.001) compared to those receiving other modalities of radiation. Higher Charlson/Deyo comorbidity score (OR 0.729, P=.033), non-white race (OR 0.605, P=.004), geographic regions in the south (OR 0.320, P<.001) or mid-west (OR 0.488, P<.001), and urban locations (OR 0.447, P=.001) compared to metropolitan areas were associated with decreased likelihood of receiving proton therapy. There were no differences in utilization with age or with history of second primary cancers. Protons have undergone an incremental increase in utilization in the United States, but remains an uncommon modality for treatment of head and neck cancer. As the indications and benefits of proton therapy in head and neck cancer continue to emerge, decreasing the cost of its use and increasing its availability is necessary to reduce disparities in the provision of proton therapy.

Treatment Outcomes in Male Breast Cancer: A Retrospective Analysis of 161 Patients

Male breast cancer is a rare disease with limited evidence-based guidelines for treatment. This study aimed to identify demographic, pathological and clinical factors associated with its prognosis. A retrospective review of 161 male breast cancer patients diagnosed at a single institution from 1987 to June 2017 was conducted. Patient demographics, disease characteristics, treatment and outcome were extracted and included in competing-risk analysis and the univariate Cox proportional hazard model for univariate analysis. Factors with P<0.10 were included in multivariable analysis. The mean age at diagnosis was 67 years (standard deviation=11.2) and the median follow-up duration was 5.3 years (range 0-25 years). There were 48 deaths, including 23 cancer-specific deaths. The actuarial median survival was 19.9 years. In multivariable analysis, factors associated with overall survival were size of tumours (hazard ratio 2.0; 95% confidence interval 1.4-2.7, P<0.0001) and diagnosis of metastatic disease (hazard ratio 8.7; 95% confidence interval 1.9-40.6; P=0.006). Of 138 patients without metastases at diagnoses, 11 had local-regional recurrence and 26 had distant metastases. In the multivariable model for local-regional recurrence, a more recent year of diagnosis was associated with reduced risk (hazard ratio 0.9, 95% confidence interval 0.8-1.0, P=0.008), whereas more positive lymph nodes was associated with higher risk (hazard ratio 2.2, 95% confidence interval 1.2-4.0, P=0.01). A higher risk of metastases was associated with more positive lymph nodes (hazard ratio 1.9; 95% confidence interval 1.1-3.3; P=0.03) and tumour size (hazard ratio 1.8; 95% confidence interval 1.1-2.9; P=0.01). A higher risk of any recurrence or metastases was associated with the number of positive nodes (hazard ratio 1.9; 95% confidence interval 1.2-3.0; P=0.005) and tumour size (hazard ratio 1.6; 95% confidence interval 1.1-2.2; P=0.01). In general, tumour size and more positive lymph nodes were associated with worse prognosis. Larger powered studies are needed to identify prognostic factors with smaller effect sizes.

Extent of lymph node dissection improves survival in prostate cancer patients treated with radical prostatectomy without lymph node invasion.

To assess the effect of pelvic lymph node dissection (PLND) extent on cancer-specific mortality (CSM) in prostate cancer (PCa) patients without lymph node invasion (LNI) treated with radical prostatectomy (RP). Within the Surveillance, Epidemiology, and End results (SEER) database (2004-2014), we identified patients with D'Amico intermediate- or high-risk characteristics who underwent RP with PLND, without evidence of LNI. First, multivariable logistic regression models tested for predictors of more extensive PLND, defined as removed lymph node count (NRN) ≥75th percentile. Second, Kaplan-Meier analyses and multivariable Cox regression models tested the effect of NRN ≥75th percentile on CSM. Finally, survival analyses were repeated using continuously coded NRN. In 28 147 RP and PLND patients without LNI, 67.3% versus 32.7% exhibited D'Amico intermediate- or high-risk characteristics. The median NRN was 6 (IQR 3-10), the 75th percentile defined patients with NRN ≥11. Patients with NRN ≥11 had higher rate of cT2/3 stage (29.8 vs 26.1%), GS ≥8 (25.7 vs 22.4%), and respectively more frequently exhibited D'Amico high-risk characteristics (34.6 vs 32.1%). In multivariable logistic regression models predicting the probability of more extensive PLND (NRN ≥11), higher biopsy GS, higher cT stage, higher PSA, more recent year of diagnosis, and younger age at diagnosis represented independent predictors. At 72 months after RP, CSM-free rates were 99.5 versus 98.1% for NRN ≥11 and NRN ≤10, respectively and resulted in a HR of 0.50 (P = 0.01), after adjustment for all covariates. Similarly, continuously coded NRN achieved independent predictor status (HR: 0.955, P = 0.01), where each additional removed lymph node reduced CSM risk by 4.5%. More extensive PLND at RP provides improved staging information and consequently is associated with lower CSM in D'Amico intermediate- and high-risk PCa patients without evidence of LNI. Hence, more extensive PLND should be recommended in such individuals.

Abstract P6-08-04: National trends in mastectomy for operable breast cancers treated with neoadjuvant chemotherapy

Abstract Objective: Although neoadjuvant chemotherapy (NAC) has not been shown to improve survival compared with adjuvant therapy for patients with operable invasive breast cancer (IBC), it is often used to allow more limited surgery in the breast and axilla without compromising local control. We sought to evaluate national trends in mastectomy among patients with operable breast cancer treated with NAC and to characterize the contribution of demographic and tumor characteristics to changing trends. Methods: We queried the National Cancer Database (NCDB) 2014 Participant User File for adult women who underwent surgery and received chemotherapy for unilateral T1-3N0-3M0 IBC diagnosed between 2010 and 2014. Surgery was classified as lumpectomy (BCS), unilateral mastectomy (UM) or bilateral mastectomy (BM). Molecular subtype was categorized according to ER, PR, and HER2 status. We used logistic regression to model surgery use (BM or UM vs BCS), adjusting for the following clinical covariates that were selected a priori: age, race/ethnicity, year of diagnosis, comorbidity score, metropolitan vs urban/rural residence, patient distance from treating facility, % with less than high school education (zip code based), insurance type, clinical stage, histology, and molecular subtype. As those who achieved pathologic complete response (pCR) after NAC should be ideal candidates for BCS, we also looked at this group separately. We then performed sensitivity analyses further controlling for region of the country and facility type, and for facility. Results: We identified 235,339 patients who fulfilled our inclusion criteria. Of these patients, 25.3% were treated with NAC. Rates of pCR increased from 33.3% in 2010 to 46.3% in 2014 (p&amp;lt;0.001). Rates of BCS increased from 37.0% in 2010 to 40.8% in 2014 (p&amp;lt;0.001). While rates of UM decreased from 43.3% in 2010 to 34.7% in 2014 (p&amp;lt;0.001), rates of BM with or without reconstruction increased from 19.7% in 2010 to 24.6% in 2014 (p&amp;lt;0.001). Rates of BM without immediate reconstruction remained stable over time, from 11.8% in 2010 to 11.5% in 2014. Among patients who received NAC, factors that were independently associated with both UM and BM (versus BCS) for both the entire cohort and those who achieved pCR included younger age, greater patient distance from facility, and higher clinical stage. Factors that were inversely associated with both UM and BM included black race and ductal histology. More recent year of diagnosis was inversely associated with UM and directly associated with BM. Asian race was associated with UM while non-Hispanic white race was associated with BM. Private or managed care insurance and higher area education were also associated with BM. These results were materially unchanged in sensitivity analyses. Conclusion: Rates of pCR have increased over time among patients with operable IBC treated with NAC. While the rate of UM has declined over time, the rate of BM has increased. Significant sociodemographic differences exist between women who undergo BCS, and women who undergo UM and BM. Further study of factors that influence surgical decision-making in the NAC setting is warranted. Citation Format: Pollom E, Qian Y, Dirbas F, Horst K, Tsai CJ. National trends in mastectomy for operable breast cancers treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-04.

Treatment at high-volume facilities and academic centers in relation to overall survival in patients with locally advanced pancreatic cancer: A National Cancer Database analysis

392 Background: Numerous studies have shown that treatment at a high volume facility (HVF) for patients (pts) with pancreatic cancer is associated with improved outcomes, particularly with pancreatectomy. In fact, a recent study showed that pts undergoing a pancreatectomy at an academic center (AC) is independently associated with improved outcomes. However, the role of chemotherapy (CT) and radiation (RT) in the treatment of locally advanced pancreatic cancer (LAPC) at HVF and AC, to our knowledge, has not been studied. Herein, we investigate the benefit of treatment at HVF and AC compared to low volume facilities (LVF) and non-academic centers (NAC) with CT or chemoradiation (CRT) in pts with LAPC. Methods: The National Cancer Database (NCDB) was utilized to identify LAPC patients treated at all facility types. All patients were treated with CT or CRT. Univariate (UVA) and multivariate (MVA) Cox regression were performed to identify the impact of HVF and AC on overall survival (OS) when compared to LVF and NAC, respectively. HVF was defined as the top 5% of facilities by number of pts treated. Results: From 2004 – 2014, a total of 10139 pts were identified. The median age was 66 years (range 22-90) with median follow up of 48.8 months (46-52.1 months); 49.9% were male and 50.1% female. All pts had clinical stage 3/T4 disease irrespective of nodal metastases. Of these, 4779 pts were treated at an AC and 5260 were treated at a NAC and 588 were treated at HVF and 9551 were treated at LVF. On UVA, age, high median income, high education level, comorbidities, and recent year of diagnosis were associated with improved OS. ACs were associated with improved OS when compared to non-AC (HR 0.92 95% CI 0.88 – 0.96, p = 0.004), as were HVF when compared to LVH (HR 0.84 95% CI 0.76 – 0.92, p &lt; 0.001). Odds ratio for undergoing surgical resection at HVF and AC was 1.68 and 1.37 (p &lt; 0.001), respectively, when compared to LVF and NAC. Conclusions: The treatment of LAPC patients with CT or CRT at an AC led to significantly improved rate of surgical resection and OS. In the absence of prospective data, these results support the referral of pts with LAPC to HVF and/or AC for evaluation and treatment.

Omission of radiotherapy after breast conservation surgery in the postneoadjuvant setting

Breast conservation therapy (BCT) consists of breast conservation surgery (BCS) and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) can downstage tumors, broadening BCS eligibility in patients requiring mastectomy. However, tumor downstaging does not obviate need for RT. This study evaluated factors that predict RT omission after NACT and BCS. The National Cancer Database was queried for women with unilateral, clinical stage II-III breast cancer, treated with NACT and BCS between 2008 and 2012. Patients not receiving RT after NACT and BCS were identified. A subgroup analysis was performed eliminating patients for whom RT was recommended but not received. Among 10,220 patients meeting study eligibility, 974 (9.53%) did not receive RT after BCS. Predictors of RT omission included older age, insurance status, facility type, facility region, more recent year of diagnosis, receptor status unknown, human epidermal growth factor receptor 2 status positive or unknown, and positive margins. Factors increasing the likelihood of RT receipt included cN3 disease, receptor positivity, and primary downstaging. Race, Hispanicity, education, income, comorbidities, rural versus urban setting, histology, grade, and nodal stage change were not associated with RT omission. When excluding the 314 patients for whom RT was recommended but not received, age, Medicaid insurance, facility type, facility region, receptor status unknown, human epidermal growth factor receptor 2 status unknown, and positive margins were predictors of RT omission. Race, comorbidities, and socioeconomic status were not predictors of RT omission. It remains unclear whether omission of RT in some cases is due to lack of physician knowledge. Further efforts are needed to ensure that physicians and patients recognize that RT is a vital and required part of BCT, even after NACT.

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

We 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. The 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. In 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. Adjuvant 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.

Trends in the San Francisco Human Immunodeficiency Virus Epidemic in the "Getting to Zero" Era.

San Francisco has launched interventions to reduce new human immunodeficiency virus (HIV) infections and HIV-associated morbidity and mortality during the San Francisco "Getting to Zero" era. We measured recent changes in HIV care indicators to assess the success of these interventions. San Francisco residents with newly diagnosed HIV infection, diagnosed from 2009 to 2014, were included. We measured temporal changes from HIV diagnosis to (1) linkage to care in within ≤3 months, (2) initiation of antiretroviral therapy (ART) within ≤12 months, (3) viral suppression within ≤12 months, (4) development of AIDS within ≤3 months, (5) death within ≤12 months, and (6) retention in care 6-12 months after linkage. Kaplan-Meier analyses stratified by year of HIV diagnosis measured time from diagnosis to linkage, ART initiation, viral suppression, AIDS, and death. Overall, the number of new diagnoses declined from 473 in 2009 to 329 in 2014. The proportion of new diagnoses among men (P = .005), Latinos and Asian/Pacific Islanders (P = .02), and men who have sex with men (P = .003) increased. ART initiation and viral suppression ≤12 months after diagnosis increased (P < .001), while the proportion with AIDS diagnosed ≤3 months after HIV diagnosis declined (P < .001). Time to ART initiation and time to viral suppression were significantly shorter in more recent years of diagnosis (P < .001). Time from HIV to AIDS diagnosis was significantly longer in more recent years (P < .001). Retention in care did not significantly change. In San Francisco new HIV diagnoses have declined and HIV care indicators have improved during the Getting to Zero era. Continued success requires attention to vulnerable populations and monitoring to adjust programmatic priorities.

Patterns of care and outcomes for use of concurrent chemoradiotherapy over radiotherapy alone for anaplastic gliomas

The role of concurrent chemoradiotherapy (CRT) for anaplastic gliomas is undefined and patterns of care are under-reported. To address the knowledge gap, we examined use of CRT for grade III gliomas compared to radiotherapy (RT) alone. In an observational study design cohort from the National Cancer Database, we identified 4437 adult patients receiving surgery followed by either CRT or RT for supratentorial anaplastic glioma in 2003-2011. Univariable and multivariable logistic regression analyses were used to assess factors associated with use of CRT. Overall survival (OS) was assessed by the Kaplan-Meier analysis with log-rank tests, Cox proportional hazards regression modeling, and propensity score matching. Receipt of CRT (vs. RT) was associated with recent year of diagnosis (OR for 2011 (vs. 2003) 3.36, 95% CI 2.49-4.54) and having astrocytoma (vs. oligodendroglioma) (OR 1.37, 95% CI 1.15-1.63). Patients receiving CRT had a lower adjusted hazard of death (hazard ratio 0.72, 95% CI 0.65-0.79). Outcomes were worse for patients ≥60 (HR 6.94, 95% CI 6.09-7.91) and astrocytomas (HR 2.08, 95% CI 1.85-2.34). Use of concurrent CRT is associated with more recent year of diagnosis and improved survival relative to RT alone.

Resected irradiated rectal cancers: Are twelve lymph nodes really necessary in the era of neoadjuvant therapy?

Our study aims to identify the minimum number of lymph nodes (LN) associated with improved survival in patients who underwent NRT for stage II-III rectal cancer. Adults with clinical stage II and III rectal adenocarcinoma in the National Cancer Data Base were stratified by NRT. Multivariable Cox regression modeling with restricted cubic splines was used to determine the minimum number of LNs associated with improved survival. Of 38,363 patients, 76% received NRT. After adjustment, a LNY≥12 was associated with improved survival among patients receiving NRT (HR 0.79, p<0.0001) and those without NRT (HR 0.88, p=0.04). Among patients receiving NRT, factors independently associated with LNY≥12 were younger age, private insurance, low comorbidity score, a recent year of diagnosis, higher T stage and grade, APR resection, and academic institution. A minimum LNY of 12 confers a survival benefit for rectal cancer patients regardless of receiving neoadjuvant radiation therapy.

Short- and Long-Term Survival in Metastatic Pancreatic Adenocarcinoma, 1993-2013.

Background: During the past 2 decades, numerous clinical trials have focused on improving outcomes in patients with metastatic pancreatic cancer (mPDAC). The efficacy of new treatments has been demonstrated among highly selected patients in randomized phase III trials; hence, it is not clear to what extent these advances are reflected within the broader mPDAC population. Materials and Methods: Survival statistics were extracted from the SEER database for patients diagnosed with mPDAC between 1993 and 2013. Survival was analyzed using the Kaplan-Meier method and proportional hazard models. Results: The study population consisted of 57,263 patients diagnosed with mPDAC between 1993 and 2013; 52% were male, with a median age of 69 years (range, 15-104). Superior prognosis correlated with younger age, being married, tumor located within the head of the pancreas, lower grade disease, and more recent year of diagnosis. Median overall survival (OS) remained stable at 2 months between 1993 and 2013. Improvements in OS were seen for younger patients (age <50 years) and those with a more recent year of diagnosis (2009-2013). The percentage of patients who died within 2 months of initial diagnosis decreased between 1993 and 2013 (from 63.5% to 50.6%; P<.0001). The percentage of patients surviving ≥12 months improved from 4.9% in 1993 to 12.7% in 2013 (P<.0001). Conclusions: In recent years a modest improvement in OS has been seen among younger patients with mPDAC. The percentage of patients living beyond 1 year has significantly increased over time; however, the percentage of those dying within 2 months remains substantial.

Prognostic Factors and Outcomes of Adult Lymphoblastic Lymphoma in the United States.

T-lymphoblastic lymphoma (T-LL) and B-lymphoblastic lymphoma (B-LL) are aggressive lymphoid neoplasms accounting for 2% to 4% of adult non-Hodgkin lymphoma. The aim of the present analysis was to characterize the clinical features and histologic subtypes and to assess the clinical prognostic factors for 696 adult patients with LL, the largest epidemiologic sample to date. The present retrospective cohort study used the Surveillance, Epidemiology, and End Results database to identify adult patients (age, > 18 years) with LL with data recorded from 2001 to 2012. We used multivariate Cox regression models to test the clinical prognostic factors, stratified by the histologic subtype. Of 696 patients with LL (median age, 39 years), 367 (53%) had T-LL and 131 (19%) had B-LL. Patients with T-LL tended to be younger (33 years vs. 48 years), male (66% vs. 50.4%), and less likely to have extranodal involvement (6% vs. 32%) compared with those with B-LL. The 5-year survival rate for those with B-LL versus those with T-LL was not significantly different (45% vs. 48%; P= .58), even in a model adjusted for clinical features, disease stage, primary site, radiotherapy, and year of diagnosis (adjusted hazard ratio, 0.93; 95% confidence interval, 0.69-1.25; P= .63). Multivariate analysis identified age, race, and radiotherapy as independent prognostic factors for outcome in T-LL. Limited tumor stage and the most recent year of diagnosis were favorable prognostic factors for B-LL. Adult patients with LL have poor long-term outcomes and novel therapies are needed. Radiotherapy had a positive effect on T-LL outcomes.

Hypofractionated Radiotherapy for Patients with Early-Stage Glottic Cancer: Patterns of Care and Survival

Radiotherapy alone is often used to treat early-stage glottic cancer (ESGC); however, the optimal radiation treatment schedule remains unknown. The National Comprehensive Cancer Network (NCCN) guidelines recommend both hypofractionated radiotherapy (HFX) and conventionally fractionated radiotherapy (CFX). We compared overall survival (OS) and treatment patterns among patients treated with HFX vs CFX for ESGC using a large national database. We identified patients diagnosed with stage I-II (cT1-2N0M0) glottic cancer from 2004 to 2013 within the National Cancer Data Base who were treated with either HFX (2.25 Gy/fraction to 63-65.25 Gy) or CFX (2.0 Gy/fraction to 66-70 Gy). The overall survival of patients receiving HFX vs CFX was compared using the log-rank test, multivariable Cox proportional hazards regression, and propensity score matching. All statistical tests were two-sided. Among 10 212 included patients, 4030 patients (39.5%) received HFX and 6182 patients (60.5%) received CFX. Predictors for receipt of HFX included clinical T1 disease, recent year of diagnosis, and treatment at academic and higher-volume centers (all P < .001). Patients treated with HFX increased from 22.1% in 2004 to 58.0% in 2013. HFX was associated with improved OS compared with CFX on univariate (five-year OS = 77.1%, 95% CI = 75.2% to 78.8%, vs 73.5%, 95% CI = 72.1% to 74.8%, respectively, log-rank P < .001) and multivariable analysis (HR = 0.89, 95% CI = 0.81 to 0.98, P = .02), a finding confirmed on propensity score matching. HFX is associated with improved survival compared with CFX among patients treated with definitive radiotherapy for ESGC, particularly among patients with cT2 disease. HFX utilization increased over the study period; however, 40% of patients in our cohort did not receive HFX in the most recent year of our analysis.

PD19-04 IMMEDIATE INTRAVESICAL CHEMOTHERAPY FOR LOW GRADE BLADDER TUMORS IN CALIFORNIA: AN UNDERUTILIZED PRACTICE AND ITS IMPACT ON RECURRENCE

You have accessJournal of UrologyBladder Cancer: Non-invasive II1 Apr 2017PD19-04 IMMEDIATE INTRAVESICAL CHEMOTHERAPY FOR LOW GRADE BLADDER TUMORS IN CALIFORNIA: AN UNDERUTILIZED PRACTICE AND ITS IMPACT ON RECURRENCE Stanley Yap, Ann Brunson, Neil Pugashetti, Rosemary Cress, Theresa Keegan, Ralph DeVere White, and Ted Wun Stanley YapStanley Yap More articles by this author , Ann BrunsonAnn Brunson More articles by this author , Neil PugashettiNeil Pugashetti More articles by this author , Rosemary CressRosemary Cress More articles by this author , Theresa KeeganTheresa Keegan More articles by this author , Ralph DeVere WhiteRalph DeVere White More articles by this author , and Ted WunTed Wun More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.877AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The use of intravesical chemotherapy (IC) immediately following transurethral resection of bladder tumor (TURBT) for low grade (LG) non muscle invasive bladder cancer (NMIBC) has been well demonstrated to reduce local recurrence and is supported by current guidelines. We sought to demonstrate patterns of uptake for this practice as well as its impact on outcomes at a population level as an initial step in developing quality improvement initiates in NMIBC. METHODS Incident cases of LG Ta or T1 NMIBC diagnosed between 2005 and 2012 were identified from the California Cancer Registry and linked to hospital records of the Office of Statewide Health Planning and Development. Tumor, patient, and hospital characteristics were included in the analysis. We determined rates of IC utilization following TURBT in patients with LG Ta or T1 NMIBC. Multivariable logistic regression models were utilized to determine predictors of IC utilization. Cumulative incidence functions and Cox Proportional Hazards (PH) models were used to determine predictors of recurrence-free survival (RFS), bladder cancer-specific survival (CSS), and overall survival (OS) with utilization of IC as the primary effector variable. RESULTS The final cohort consisted of 10,031 patients with LG NMIBC diagnosed in California between 2005 and 2012, with initial TURBT ≤ 45 days from diagnosis. The overall rate of IC utilization was 5.1%, but demonstrated an increase from 1.7% (2005-2006) to 9.6% (2011-2012). On multivariable logistic regression analysis, variables associated with increased odds of immediate IC instillation included more recent year of diagnosis (OR 1.74, CI 1.60-1.90 for 2 year increments). Factors associated with lower odds of receiving IC included Hispanic race (OR 0.62, CI 0.43-0.88) and Asian/Pacific Islander race (OR 0.58, CI 0.37-0.91). The cumulative incidence of recurrence at 24 months for patients who received IC was 25.2% compared to 30.2% among those that did not receive IC. On multivariable Cox PH analysis, use of IC was significantly associated with an 18% improvement in RFS (HR 0.82, CI 0.70-0.97). CONCLUSIONS Utilization of IC for LG NMIBC remains dismally low in routine practice, with less than 10% of patients receiving this standard of care even in more recent years. Poor utilization of this practice is associated with increased rates of recurrence. Strategies utilizing robust implementation of scientific methods should be studied as a means to overcome a major shortcoming in the quality of care provided to patients with LG NMIBC. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e366 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Stanley Yap More articles by this author Ann Brunson More articles by this author Neil Pugashetti More articles by this author Rosemary Cress More articles by this author Theresa Keegan More articles by this author Ralph DeVere White More articles by this author Ted Wun More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...