Recent Year Of Diagnosis Research Articles

Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer

Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT. The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression. We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01). Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.

Survival of Older Adults With Newly Diagnosed Acute Myeloid Leukemia: Effect of Using Multiagent Versus Single-agent Chemotherapy

BackgroundControversy exists regarding the optimal chemotherapy regimen for older adults with acute myeloid leukemia (AML). Patients and MethodsWe analyzed data from the US National Cancer Data Base of 25,621 patients aged 60 to 79 years, with a diagnosis of AML from 2004 to 2014, who had received single-agent versus multiagent chemotherapy. A Cox proportional hazard model was used for overall survival (OS) analysis for the entire study cohort and separately for patients who had received single-agent (n = 6743) versus multiagent (n = 6743) chemotherapy, matched for age, Charlson comorbidity index, and AML subtype. ResultsThe use of multiagent chemotherapy was high overall (70%) but declined with factors, such as increasing age, Charlson comorbidity index, AML subtype other than good risk, academic center, lower rate of high school graduation, and more recent year of diagnosis. Patients treated with multiagent chemotherapy had greater 1-year OS (43% vs. 28%), especially for patients aged 60 to 69 years and those with good-risk AML or Charlson comorbidity index of 0 to 1. OS (hazard ratio, 1.32; 95% confidence interval, 1.28-1.36) remained more favorable for the multiagent chemotherapy group on multivariable analysis. This was confirmed in a matched cohort analysis. ConclusionsTo the best of our knowledge, this is the largest real-world study that has demonstrated an association between factors such as age, comorbidity, and AML subtype and the use of multiagent chemotherapy. The use of multiagent chemotherapy was associated with improved OS, especially for patients aged <70 years, those with good-risk AML, and those with a low Charlson comorbidity index.

Clinicopathologic Features and Survival Trends for Acinic Cell Carcinoma of the Major Salivary Glands: A Surveillance, Epidemiology, and End Results Population Analysis.

BackgroundWe analyzed a population-based national registry to identify the most influential patient pretreatment and treatment factors affecting overall survival (OS) and cause-specific survival (CSS) in patients diagnosed with acinic cell carcinoma (ACC) of the major salivary glands.MethodsUsing the Surveillance, Epidemiology, and End Results (SEER) database of the US National Cancer Institute (NCI) related to survival, a total of 1,254 patients with diagnosed ACC of the major salivary glands from 1975 to 2016 met inclusion criteria. Factors significant for OS and CSS were determined using univariate and multivariate analysis with the Cox proportional hazards model.ResultsUnivariate OS analysis demonstrated that surgery favorably influenced longer survival compared to no surgery (hazard ratio (HR) 2.35, P < 0.05). Patient age was found to be highly predictive of superior OS (divided into 10-year age bands, P < 0.0001, younger age better). In multivariate OS analysis, there were statistically significant worse outcomes for men (HR 1.54, P < 0.05), grades III/IV (HR 2.5, P < 0.05), and distant disease (HR 3.55, P < 0.05) or regional disease (HR 1.22, P < 0.05). Patients diagnosed during years 1996 - 2016 had better OS when compared to earlier decades 1975 - 1995 (HR 1.38, P < 0.05). In univariate analysis, the mean CSS for grades I, II, and III/IV were 429 months (95% confidence interval (CI), ± 38.39), 426 months (95% CI, ± 25.73) and 198 months (95% CI, ± 66.38). Multivariate analysis of CSS further demonstrated that there were statistically significant worse outcomes for men (HR 1.68, P < 0.05), grade III/IV (HR 3.2, P < 0.05), tumor size greater than 40 mm (P < 0.001), and distant disease (HR 4.48, P < 0.05) or regional disease (HR 1.84, P < 0.05).ConclusionsTo our knowledge, this is the largest population-based study of OS and CSS of major salivary gland ACC. We found that the patient pretreatment and treatment factors including younger age at diagnosis, female sex, early stage, lower grade, surgical excision, and recent year of diagnosis are associated with improved survival in patients diagnosed with ACC of the major salivary glands. We hope that this information will aid in construction of further research projects that better refine optimal treatment protocol of individualized patient care.

Trends in the Number of Lymph Nodes Evaluated Among Patients with Pancreatic Neuroendocrine Tumors in the United States: A Multi-Institutional and National Database Analysis.

The role of routine lymphadenectomy in the surgical treatment of pancreatic neuroendocrine tumors (pNET) remains poorly defined. The objective of the current study was to investigate trends in the number of lymph nodes (LN) evaluated for pNET treatment at a nationwide level. Patients undergoing surgery for pNET between 2000 and 2016 were identified in the U.S. Neuroendocrine Tumor Study Group (US-NETSG) database as well as the Surveillance, Epidemiology, and End Results (SEER) database. The number of LNs examined was evaluated over time. The median number of evaluated LNs increased roughly fourfold over the study period (US-NETSG, 2000: 3 LNs vs. 2016: 13 LNs; SEER, 2000: 3 LNs vs. 2016: 11 LNs, both p < 0.001). While no difference in 5-year OS and RFS was noted among patients who had 1-3 lymph node metastases (LNM) vs. ≥ 4 LNM between 2000-2007 (OS 73.5% vs. 69.9%, p = 0.12; RFS: 64.9% vs. 40.1%, p = 0.39), patients who underwent resection and LN evaluation during the period 2008-2016 had an incrementally worse survival if the patient had node negative disease, 1-3 LNM and ≥ 4 LNM (OS 86.8% vs. 82.7% vs. 74.9%, p < 0.001; RFS: 86.3% vs. 64.7% vs. 50.4%, p < 0.001). On multivariable analysis, a more recent year of diagnosis, pancreatic head tumor location, and tumor size > 2cm were associated with 12 or more LNs evaluated in both US-NETSG and SEER databases. The number of LNs examined nearly quadrupled over the last decade. The increased number of LNs examined suggested a growing adoption of the AJCC staging manual recommendations regarding LN evaluation in the treatment of pNET.

Effect of Using Multiagent Versus Single Agent Chemotherapy on Overall Survival (OS) of Older Adults with Acute Myeloid Leukemia (AML)

Introduction: Whether adults aged ≥60 years with AML benefit from multiagent (or intensive) chemotherapy is a matter of controversy. Prior studies have demonstrated conflicting results. We performed analysis of a large National Cancer Data Base (NCDB) to determine the value of multiagent vs. single agent chemotherapy. Methods: NCDB captures approximately 70% of all cancer diagnoses in US, and undergoes rigorous quality monitoring. We utilized NCDB to identify patients aged 60-79 years, who were newly diagnosed with AML (other than APL) between the years 2004-2014. Logistic regression model was used to determine factors associated with the use of multiagent chemotherapy. Kaplan-Meier curves were generated and compared using the log rank test. Logistic regression model and Cox Proportional Hazard model were used for one-month mortality and OS analyses, respectively. In a separate analysis, patients who received single agent (n=6743) vs. multiagent chemotherapy (n=6743) were matched based on the variables age, Charlson comorbidity score, and AML subtypes (good-risk AML, therapy-related AML/AML with myelodysplasia related changes, and other intermediate/high-risk AML). A Cox Proportional Hazard model was used for OS analysis of the matched cohort. Results: Of a total of 25,621 patients, 70% received multiagent chemotherapy. The receipt of multiagent chemotherapy declined with increasing age, Charlson comorbidity score, AML subtypes other than good-risk, female, non-academic center, shorter distance traveled to receive care, lower rate of high school graduation, and more recent year of diagnosis. Patients treated with multiagent chemotherapy had higher likelihood of receiving hematopoietic cell transplant (HCT) (9% vs. 1%); lower one-month mortality (11% vs. 19%); and greater 1-year OS (43% vs. 28%) (Figure 1). The use of multiagent chemotherapy had particularly higher 1-year OS in patients aged 60-64 and 65-69 years, in good-risk AML, patients with Charlson comorbidity score of 0-1 and those who did not receive upfront HCT consolidation (Table 1). One-month mortality (odds ratio 1.64, 95% confidence interval, CI 1.51-1.78) and OS (hazard ratio, HR 1.32, 95% CI 1.28-1.36) remained more favorable for multiagent chemotherapy group in multivariable analyses. Other factors that affected OS included age, comorbidity, AML subtypes, median household income, insurance, use of HCT, academic status of facility, distance traveled to receive care, sex and year of diagnosis. In a matched analysis of 13,486 patients, the use of single agent vs. multiagent chemotherapy resulted in a higher risk of mortality (HR 1.28, 95% CI 1.23-1.32). Conclusions: In one of the largest real-world studies, we demonstrate an association between factors such as age, comorbidity and AML subtypes and the use of multiagent chemotherapy. After adjusting for covariates, the use of multiagent chemotherapy among older adults was associated with higher receipt of HCT, and improved one-month mortality and OS. Improved OS was confirmed in a matched analysis. Certain groups such as patients younger than 70 years, good-risk AML and those with low Charlson comorbidity score had the greater OS benefit with the use of multiagent chemotherapy. Further studies to determine the role of multiagent or intensive chemotherapy are particularly important with approvals of several new drugs in the recent years and integration of many novel drugs in both low-intensity and intensive chemotherapy regimens. Disclosures Bhatt: Tolero Pharmaceuticals: Research Funding; Incyte: Consultancy, Research Funding; Partner therapeutics: Consultancy; Abbvie: Consultancy; Agios: Consultancy; CSL Behring: Consultancy; National Marrow Donor Program: Consultancy; Pfizer: Consultancy. Holstein:Celgene: Consultancy; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; GSK: Consultancy; Genentech: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Sorrento: Consultancy. Al-Kadhimi:Celldex Biotech: Other: Stocks; Seattle Genetics: Other: Stocks. Armitage:Union Pacific: Consultancy; Tesaro bio: Membership on an entity's Board of Directors or advisory committees; Ascentage: Consultancy; Samus Therapeutics: Consultancy; Oncology Analytics: Consultancy; Partner Therapeutics: Consultancy. Gundabolu:Pfizer: Consultancy; Novartis: Consultancy; Jazz pharmaceuticals: Consultancy; Samus Therapeutics: Research Funding.

Trends in the risk of second primary malignancies among survivors of chronic lymphocytic leukemia

With improving survivorship in chronic lymphocytic leukemia (CLL), the risk of second primary malignancies (SPMs) has not been systematically addressed. Differences in risk for SPMs among CLL survivors from the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) were compared to risk of individual malignancies expected in the general population. In ~270,000 person-year follow-up, 6487 new SPMs were diagnosed with a standardized incidence ratio (SIR) of 1.2 (95% CI:1.17–1.23). The higher risk was for both solid (SIR 1.15; 95% CI:1.12–1.18) and hematological malignancies (SIR 1.61; 95% CI:1.5–1.73). The highest risk for SPMs was noted between 2 and 5 months after CLL diagnosis (SIR 1.57; 95% CI:1.41–1.74) and for CLL patients between 50- and 79-years-old. There was a significant increase in SPMs in years 2003–2015 (SIR 1.36; 95% CI:1.3–1.42) as compared to 1973–1982 (SIR 1.19; 95% CI:1.12–1.26). The risk of SPMs was higher in CLL patients who had received prior chemotherapy (SIR 1.38 95% CI:1.31–1.44) as compared to those untreated/treatment status unknown (SIR 1.16, 95% CI:1.13–1.19, p < 0.001). In a multivariate analysis, the hazard of developing SPMs was higher among men, post-chemotherapy, recent years of diagnosis, advanced age, and non-Whites. Active survivorship plans and long-term surveillance for SPMs is crucial for improved outcomes of patients with a history of CLL.

Stereotactic body radiotherapy versus percutaneous local tumor ablation for early-stage non-small cell lung cancer

ObjectivesTo compare patterns of care and overall survival (OS) between stereotactic body radiotherapy (SBRT) and percutaneous local tumor ablation (LTA) for non-surgically managed early-stage non-small-cell lung cancer (NSCLC). Materials and methodsThe National Cancer Database (NCDB) was queried from 2004 to 2014 for adults with non-metastatic, node-negative invasive adenocarcinoma or squamous cell carcinoma of the lung with primary tumor size ≤5.0 cm who did not undergo surgery or chemotherapy and received SBRT or LTA. Patterns of care were assessed with multivariate logistic regression. After propensity-score weighting with generalized boosted regression, OS was assessed with univariate and doubly-robust multivariate Cox regression. ResultsOf 15,792 patients, 14,651 (93%) received SBRT and 1141 (7%) received LTA. Increasing age (OR 1.01, p = .035), treatment at an academic institution (OR 2.94, p < .001), increasing tumor size (OR 1.05, p < .001), and more recent year of diagnosis (OR 1.43, p < .001) were predictive of treatment with SBRT, whereas comorbidities (OR 0.74, p = .003) and treatment at a high-volume facility (OR 0.05, p < .001) were predictive for LTA. At a median follow-up of 26.2 months, SBRT was associated with improved OS relative to LTA within a propensity-score weighted doubly-robust multivariate analysis (HR 0.71, p < .001). On weighted subgroup analyses, improved OS was observed with SBRT for tumor sizes >2.0 cm (HR 0.72, p < .001) and for those treated at high-volume facilities (HR 0.71, p < .001). No OS difference was found with SBRT or LTA in tumor sizes ≤2.0 cm (HR 0.90, p = .227). ConclusionWithin the NCDB, SBRT was more commonly utilized and was associated with improved OS when compared to percutaneous LTA for patients with non-surgically managed early-stage NSCLC. Patients with small tumor volumes likely represent an appropriate population for future prospective randomized comparisons between SBRT and LTA.

Overall Survival of Patients With Locoregional and Metastatic Breast Cancer: Is the Influence of Baseline Characteristics the Same?

To compare the overall survival (OS) of patients with locoregional and metastatic breast cancer (BC) considering baseline demographic, clinical and contextual characteristics. A retrospective analysis of a cancer registry was conducted, using the Kaplan-Meier and Mantel-Cox analyses for the calculation of median OS and cumulative survival. The median OS was 112 months, being longer in patients with locoregional versus those with metastatic BC at diagnosis (115 vs. 31 months, p<0.001). The cumulative survival at 1, 3 and 5 years were 94.9%, 85.6% and 76.5%, respectively. More recent year of diagnosis [hazard ratio (HR)=1.09] and age at diagnosis (≥65 vs. 40 years, HR=2.79) and presence of metastatic disease (HR=5.69) were associated with a shorter OS. The region of residence, morphology and topography of the tumor were also associated with survival in patients with BC. Rurality was only associated with lower survival in patients with metastatic BC. This study identified significant differences in the median OS of patients with locoregional and those with metastatic BC considering their baseline characteristics.

Treatment patterns and associated factors in patients with advanced epithelial ovarian cancer: a population-based study

ObjectivesA significant proportion of women with advanced-stage ovarian cancer receive no cancer-directed treatment and limited research has been devoted to this group. This population-based study aimed to gain insight into...

Lymph node count impacts survival following post-chemotherapy retroperitoneal lymphadenectomy for non-seminomatous testicular cancer: a population-based analysis.

To evaluate the prognostic significance of lymph node count (LNC) at post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) in metastatic non-seminomatous germ cell tumour (NSGCT) using the Surveillance, Epidemiology, and End Results (SEER) database and National Cancer Database (NCDB). SEER (2000-2013, n=572) and NCDB (2004-2013, n=731) identified patients undergoing PC-RPLND for Stage II and III NSGCT. Correlation between linear or categorial variables and LNC was conducted using Spearman's rank correlation or Kruskal-Wallis test by ranks. Patients were stratified by ≤20, 21-40, and >40LNs for Kaplan-Meier analysis. Cox proportional hazards models evaluated the association of LNC at PC-RPLND with overall mortality (OM) in the NCDB and cancer-specific mortality (CSM) in the SEER database. The relationship between LNC and OM or CSM was also modelled as a non-linear function to determine a threshold for survival benefit. Amongst all patients, the median (interquartile range) LNC was 17(3-26)LNs in the NCDB, and 18(6-31)LNs in the SEER database. More recent diagnosis year, higher hospital volume, higher median income, private insurance status, and positive LNC were associated with greater total LNC in one or both databases (P<0.05). On Kaplan-Meier analysis, >40LNs was associated with 5-year cancer-specific survival (CSS) of 99% and overall survival (OS) of 96%, whereas ≤20LNs had a 5-year CSS of 91% and OS of 78% (CSS, P=0.04; OS, P<0.01). Risk-adjusted Cox model showed increasing LNC (per node) was inversely associated with OM (hazard ratio [HR] 0.96, 95% confidence interval [CI], 0.94-0.98; P<0.01) and CSM (HR 0.96, 95% CI, 0.94-0.99; P=0.01). Non-linear modelling showed the greatest benefit in OM at between 10 and 20LNs, but continued survival benefit for OM and CSM beyond 20LNs. Greater LNC during PC-RPLND appears to be associated with improved CSS and OS in NSGCT. Our data support the role of thorough RPLND for post-chemotherapy metastatic NSGCT.

The use of contralateral prophylactic mastectomy among elderly patients in the United States.

Previous studies have reported increased rates of contralateral prophylactic mastectomy (CPM) in the United States among women with unilateral breast cancer. These trends have primarily focused on younger breast cancer patients. Given the growing aging population in the United States, we sought to determine whether CPM use is also increasing in elderly patients. This population-based study identified patients in the surveillance epidemiology and end results (SEER) data. We determined the rate of CPM as a proportion of all surgically treated patients and as a proportion of all mastectomies. We compared the unadjusted CPM rates over the study period using the Cochrane-Armitage test for trend. We used a logistic regression model to test for the factors associated with CPM utilization. We identified 261,281 patients ≥ 65years who underwent surgical treatment for breast cancer. For all patients treated with surgery for invasive breast cancer, the use of CPM increased from 1 in 2004 to 3% in 2014 (200% increase). Among mastectomy patients, the use of CPM increased from 3 in 2004 to 7% in 2014 (133% increase). Young age, non-Hispanic white race, lobular histology, higher grade, increased stage, negative lymph node status, and recent year of diagnosis were significantly associated with increased CPM rates. For elderly patients the use of CPM has continued to increase in the United States. These observations warrant concern in light of increasing evidence that CPM does not improve oncological outcomes and is associated with increased morbidity in older patients.

Cost disparities with age in the treatment of advanced non-small cell lung cancer (NSCLC) in Ontario, Canada.

6629 Background: Previous studies noted an association between age and cost of care in NSCLC. The drivers of these cost disparities have not yet been fully examined. We conducted a cost analysis study examining the differences in, and drivers of, costs of NSCLC care across age groups in Ontario, Canada. Methods: We conducted a retrospective cohort study of patients diagnosed in Ontario from Apr 1, 2007 to Mar 30, 2014, who received palliative chemotherapy for stage IV NSCLC. Variables of interest were extracted from registry data linked by the Institute for Clinical Evaluative Sciences (ICES). The mean total cost of care including systemic therapy and supportive care, was calculated in 2015 CAD dollars by fiscal year of diagnosis. Results: Of all NSCLC cases diagnosed in Ontario (n = 37,786), 17,203 (45.5%) were de novo stage IV, of which 29.7% of patients received any chemotherapy for their disease (n = 5,113), and 281 patients are presumed alive. In this population, median age was 65 to 69 years, 51.9% were male, 43.5% were adenocarcinomas, and 25.1% received second line chemotherapy. After adjusting for comorbidities, income, gender, year of diagnosis, and rural versus urban living, the average lifetime costs per patient remains significantly inversely related to age (p &lt; 0.001). Belonging to the highest income quintile (p = 0.006) and being diagnosed in more recent years (p &lt; 0.001) contributes significantly to increasing overall healthcare costs. Elderly patients (80+) cost less (71%) and have shorter survival time (HR of death 1.28, 95% C.I. 1.10 to 1.50) compared to younger patients (≤45 years old). Accounting for longer survival in younger patients, the youngest group still incur a higher cost per day alive than other age groups ($471/day in ≤45 group, $301/day in &gt; 85 group). Hospitalization accounts for ~30% of total cost in both age groups. Chemotherapy accounts for 1% of total health care costs amongst the elderly (80+) age group and 10% of costs in ≤45 group. Conclusions: Our study shows that, despite everyone receiving systemic therapy in this patient population, younger patients incur significantly higher costs than elderly patients with advanced NSCLC, both before and after adjusting for survival. While hospitalization accounts for the biggest component of total costs, patients with high income and more recent years of diagnosis drive the higher costs of care, and chemotherapy remains a driver of higher costs amongst younger patients.

Uptake of sentinel lymph node procedures in women with vulvar cancer over time in a population based study

ObjectivesTo evaluate trends in uptake of sentinel lymph node (SLN) procedures over time and associated factors in women with vulvar cancer. MethodsA retrospective population-based cohort study identified women with invasive squamous cell carcinoma (SCC) of the vulva using health administrative data for the province of Ontario, Canada, between 2008 and 2016. Patients who underwent SLN procedures were compared to those who had groin node dissection (GND). Multivariable analysis was used to identify factors associated with SLN procedures. Results1385 patients with SCC of the vulva were identified; 1079 had a surgical procedure. Only those with groin node assessment were included in the study cohort (n = 732, 68%). SLN procedures were done in 52%. When comparing SLN versus GND, the rate of SLNs was significantly different by year of diagnosis (P < 0.001), associated comorbidity (P < 0.001) and institution (P < 0.0001). The rates of SLNs by institution with gynecologic oncologist were variable and ranged from 32% to 79% among 9 centers. There were no differences in age, income quintile, and urban/rural residence.The proportion of SLN procedures increased from 30.1% (CI 18.9–45.6) in 2008 to 65.2% (CI 36.5–107.6) in 2016. On multivariate analysis, factors significantly associated with SLN procedures were more recent year of diagnosis (OR 7.9, CI 2.7–23.5) associated comorbidities (OR 2.7, CI 1.5–5.0) and institution (Site 5, OR 19.6 [CI 3.6–108.3] and Site 6, [OR 6, CI 1.1–33.4]). ConclusionsThe proportion of SLN procedures in women with vulvar cancer has increased over time, but uptake is not uniform across institutions. Barriers to uptake should be explored.

Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer

BackgroundThe aim of this study was to evaluate the trends of surgical treatments among young patients in T1N0-1M0 stage based on the Surveillance, Epidemiology, and End Results database. Materials and methodsPatients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in T1N0-1M0 stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model. ResultsThe total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy. ConclusionsA trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.

Determinants of Guideline-Based Treatment in Patients With cT1 Bladder Cancer.

Clinical T1 (cT1) bladder cancer is associated with high rates of recurrence, upstaging, and progression. Guidelines recommend that these patients be treated with adjuvant intravesical Bacillus Calmette-Guérin immunotherapy (BCG) or upfront radical cystectomy (RC). We analyzed the National Cancer Database (NCDB) to identify demographic and clinical determinants of guideline-based treatment (GBT) and RC. We identified 47,694 patients in the NCDB with cT1 bladder cancer diagnosed in 2004-2013. Those who did not receive any treatment or underwent primary chemotherapy were excluded. Mixed effects logistic regression adjusted for facility-level variation was used to identify factors associated with receipt of GBT. The median age of the cohort was 72 years (interquartile range, 63-79). Of the patients, 22.4% were female, 5.1% were African American, and 2.7% had variant histology. Nearly one-third of patients received GBT: 11,453 (24%) were initially treated with BCG and 3320 (7%) were initially treated with RC. Recent year of diagnosis (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.52-1.85; P< .001), treatment at an academic center (OR, 2.42; 95% CI, 2.27-2.59; P< .001), and private insurance status (OR, 1.41; 95% CI, 1.19-1.66; P< .001) were associated with increased odds of GBT. Of patients who received GBT, variant histology (OR, 5.89; 95% CI, 4.65-7.47; P< .001), and recent year of diagnosis (OR, 1.89; 95% CI, 1.50-2.39; P< .001) were associated with greater odds of RC. There is low treatment-guideline compliance for patients with cT1 disease. However, there appears to be a temporal trend toward increased use of GBT. Efforts should be made to understand why many cT1 bladder cancer patients do not receive GBT.

Treatment Patterns and Survival of Elderly Patients With Breast Cancer Brain Metastases.

The main objective of this study was to analyze treatment patterns of elderly patients with breast cancer brain metastases (BCBM), evaluate characteristics associated with treatment selection, and to analyze trends in overall survival (OS) over time. We included women with BCBM reported to the Surveillance, Epidemiology, and End Results Medicare Program from 1992 to 2012. Treatments were recorded from Medicare claims from the date of brain metastases diagnosis until 60 days after. Treatments included resection, radiation, and chemotherapy. Cochran-Armitage tests were used for analysis of treatment patterns. Multinomial logistic regression was applied to determine factors associated with treatment selection. Cox regression modelled OS trends within each treatment modality across time. Among 5969 patients included, treatment rates increased from 50% in 1992 to 64.1% in 2012 (P<0.01). Therapy combining radiation, resection, and/or chemotherapy also increased from 8.8% to 18% over the same period (P<0.01). Combined therapy was significantly more likely among patients with extracranial metastases, those with estrogen-negative tumors, younger age at diagnosis, no comorbidities and more recently diagnosed brain metastases. OS improved over time for patients who received a combination of ≥2 treatments (hazard ratio, 0.89 per every 5 more recent diagnosis years; P<0.05). Older patients, those with extracranial metastases, or estrogen/progesterone-negative tumors showed significantly shorter OS. We observed substantial changes in treatment patterns and OS over time in patients with BCBM. We identified several factors associated with specific treatment use. Patients who underwent a combination of ≥2 treatments experienced a significant improvement in OS over time.

Biomarker Testing Rates in Patients with Advanced Non-Small Cell Lung Cancer Treated in the Community

Introduction: Over the past few years, molecular targeted therapies have been emerging for the treatment of metastatic non-small cell lung cancer (NSCLC). Targeted therapy is associated with improved outcomes in patients with identified gene alterations, and national guidelines recommend routine biomarker testing. This study evaluated real-world rates of documented epidermal growth factor receptor (EGFR) mutation and other biomarker testing in patients with advanced NSCLC over time. Methods: Adult patients with Stage IV NSCLC were identified between January 1, 2012 and May 31, 2017 from the US Oncology Network iKnowMedTM electronic health records. Patients were examined overall and by histology. Rates of documented EGFR mutation and other biomarker testing were calculated. Multivariable regression analyses were conducted to identify characteristics associated with documented biomarker testing. Results: A total of 14,461 patients were identified: median age was 69.3 years, 52.3% were male, 14.6% were nonsmokers, and 64.7% had non-squamous histology. EGFR mutation testing rates were 35.5% overall, with an increase in rates seen over time: 30.0% in 2012 to 44.0% in 2016 (p 0.001). Anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1), and programmed death-ligand 1 (PD-L1) mutation testing rates were 32.9%, 5.7%, and 5.7%, respectively. More recent diagnosis year, non-squamous histology, larger practice size, and nonsmoking status were strongly associated with higher documented EGFR and ALK mutation testing rates. Conclusions: EGFR mutation testing rates steadily increased over time, but remained less than 50%, with lower mutation testing rates reported for ALK, ROS1, and PD-L1, suggesting that opportunities exist to improve education on testing for biomarkers in NSCLC.

Examination of a paradox: recurrent metastatic breast cancer incidence decline without improved distant disease survival: 1990\u20132011

PurposeDistant relapse metastatic breast cancer (rMBC) incidence and survival are vital measures of breast cancer diagnosis and treatment progress over time.MethodsWe conducted a retrospective cohort study of stage I–III invasive breast cancer, 1990–2011, follow-up through 2016 [N = 8292, rMBC = 964 (12%)] at a community-based institution. Patient and tumor characteristics (treatment, distant recurrence, vital status) from BC registry data were evaluated. Survival analysis and Cox proportional hazards (HzR) with 95% confidence intervals (95% CI) were calculated using distant recurrence and distant disease-specific survival (DDSS) endpoints.ResultsBoth 5- and 10-year distant relapse (rMBC) declined over time from 1990–1998 to 2005–2011 [11% to 5%, 16% to 8% (p < 0.001)]. Proportionately, HER2 + BC distant relapse decreased 9% and triple negative (HR−/HER2−) increased 8% (p = 0.011). In the Cox model, lower stage [stage I: HzR = 0.08 (0.07, 0.10), stage II: 0.29 (0.25, 0.33)], more recent diagnosis years [1999–2004: HzR = 0.60 (0.51, 0.70), 2005–2011: HzR = 0.44 (0.38, 0.52)], HR+ [HzR = 0.62 (0.53, 0.72)], and age 40+ [HzR = 0.81 (0.67, 0.98)] had decreased rMBC risk. Compared to HR+/HER2− BC, triple-negative BC had increased rMBC risk [HzR = 2.02 (1.61, 2.53)] but HER2+ subtypes did not. HR−, age 70+, > 1, or visceral metastases and stage III disease were associated with worse DDSS. DDSS did not improve over time.ConclusionrMBC incidence declined over time with decreased HER2-positive distant recurrence, a shift to more triple-negative BC and consistently poor distant disease survival.

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

ObjectivesTo 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. MethodsIncident 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. ResultsTen 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). ConclusionUtilization 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.