United States National Cancer Database Research Articles

Geographic disparities in access to glioblastoma treatment based on Hispanic ethnicity in the United States: Insights from a national database.

Access to treatment for glioblastoma (GBM) can be impacted by multiple demographic parameters. Barriers specific to the Hispanic population of the United States (US) are not fully understood. Therefore, the aim of this study was to elucidate geographic disparities for access to GBM treatment in the US Hispanic population. All GBM patients with known Hispanic ethnicity status (and Caucasian race) in the US National Cancer Database (NCDB) between the years 2005-2016 were retrospectively reviewed. Treatment statuses of surgical resection, chemotherapy, radiation therapy and triple therapy (resection, chemotherapy and radiation) were summarized, and analyzed by comparison and regression analyses over US Census regions. A total cohort size of 40,232 Caucasian GBM patients were included, with 3,111 (8%) identifying as Hispanic. The odds of treatment by chemotherapy (OR 0.78, P < 0.01), radiation therapy (OR 0.82, P < 0.01) and triple therapy (OR 0.84, P < 0.01) were all significantly lower in the Hispanic group versus non-Hispanic group. The odds of being treated in the Hispanic group were significantly lower in multiple Census regions with respect to surgical resection (New England, OR 0.51; Mountain, OR 0.68), chemotherapy (East North Central, OR 0.77; Middle Atlantic, OR 0.71; Pacific, OR 0.77), radiation therapy (Middle Atlantic, OR 0.77) and triple therapy (New England, OR 0.49; Middle Atlantic, OR 0.87; Pacific, OR 0.84). Significant barriers to triple therapy in the Hispanic group within these regions were older age (OR 0.97; P < 0.01), treatment in a community facility (OR 0.85, P = 0.03), lack of insurance (OR 0.71, P = 0.03), yearly income < $40,227 (OR 0.69, P < 0.01), low education levels (OR 0.75, P = 0.03) and presence of co-morbidity (OR 0.82; P < 0.01). Currently in the US, there exists heterogenous geographic disparities for Hispanic GBM patients to access different treatments compared to non-Hispanic patients. Multiple circumstances can influence access to treatment within the Hispanic community of these regions, and greater investigation with more granularity required to reveal mechanisms in which these disparities may be addressed in the future.

Clinical impact of celiac ganglia metastasis upon pancreatic ductal adenocarcinoma

BackgroundPre-operative staging of pancreatic adenocarcinoma guides clinical decision making. Limited data indicate that metastasis to celiac ganglia (CG) correlates with poor prognosis. We investigated feasibility and safety of endoscopic ultrasound fine needle aspiration (EUS-FNA) detection of CG metastasis and its impact upon tumor stage, resectability, and survival in pancreatic ductal adenocarcinoma (PDAC). PatientsWe reviewed our prospectively maintained EUS and cytopathology databases to identify patients with FNA proven CG metastasis in patients with PDAC from 2004 to 2017. Clinical demographics, EUS, CT, MRI, cytopathology, cancer stage, and resectability data were analyzed. Survival of PDAC patients with CG metastasis was compared to the expected survival of PDAC patients of similar stage as reported by the United States National Cancer Database. ResultsTwenty-one patients with PDAC [median age 73 (IQR63-78); 14 (67%) female)], had CG metastasis confirmed by cytopathologic assessment. CG metastasis resulted in tumor upstaging relative to other EUS findings and cross sectional imaging findings in 12 (57%) and 15 (71%) patients, and converted cancers from resectable to unresectable relative to EUS and cross sectional imaging in 7 (37%) and 7 (37%) patients, respectively. In patients with PDAC, the survival of patients with CG metastasis was not significantly different from the overall survival (hazard ratio 0.71; 95% confidence interval 0.44, 1.13; p = 0.15). ConclusionsEUS-FNA may safely identify CG metastases. While CG metastasis upstaged and altered the resectability status among this cohort of patients with PDAC, the survival data with regard to PDAC suggest that this may be misguided.

Charlson comorbidity score is associated with readmission to the index operative hospital after radical cystectomy and correlates with 90-day mortality risk.

Our objective was to determine perioperative variables associated with 30-day readmission to the index operative hospital after radical cystectomy for bladder cancer and subsequent survival outcomes. Retrospective cohort study utilizing the United States National Cancer Database from 2004-2015. All clinical stages undergoing radical cystectomy were analyzed. Exclusion criteria included clinical suspicion of nodal disease, metastasis, or preoperative radiation therapy. Multivariable logistic regression was used for 30-day readmission risk to the index hospital. Kaplan-Meier analysis and multivariable Cox regressions were used for survival outcomes. 31,147 patients were identified and stratified by 30-day readmission (n = 2628) or no readmission (n = 28,519). Thirty-day readmission to the index surgery hospital was 8.4%. Groups were comparable in terms of age, gender, race, income, facility type, insurance, length of hospital stay, and pathologic stage. There were significantly more patients with higher Charlson comorbidity score in the readmission cohort. On logistic regression analysis, increasing Charlson score was the only predictor of 30-day readmission (OR 1.39-1.73, p < 0.001). The 90-day mortality rate was 7.2% overall (7.0% no readmission vs 9.9% 30-day readmission, p < 0.001). Cox regression analysis for mortality revealed increasing age (HR 1.04), higher Charlson score (HR 1.42-1.85), readmission within 30days (HR 1.38) and pathologic stage pT ≥ 2 (HR 1.88-7.09, all p < 0.001) as independent predictors of 90-day mortality. Increasing comorbidity is a strong predictor of readmission to the index surgery hospital after radical cystectomy. Readmission is associated with worsened mortality at 90days.

Trends in the initial management of vestibular schwannoma in the United States

IntroductionVestibular schwannomas are benign tumors of the 8th cranial nerve. Initial treatment options include active surveillance, surgery, and/or radiation therapy. We analyzed the United States National Cancer Database (NCDB) for patients with vestibular schwannomas and evaluated the initial management trends after diagnosis. MethodsWe queried the NCDB for patients with vestibular schwannomas, excluding patients who did not have schwannomas of the vestibulocochlear nerve. Categorical and continuous variables were analyzed, and multivariate Cox regression analyses were performed to investigate for predictors of initial local therapy at diagnosis. All statistical analyses were performed using commercially available software (SPSS, Version 22; SPSS Inc., Chicago, IL). ResultsA total of 28,446 patients met the inclusion criteria. In this cohort, 7351 (25.8%) underwent observation, 12,362 (43.5%) underwent surgical resection, 7785 (27.4%) underwent SRS, 824 (2.9%) underwent EBRT, and 124 (0.4%) underwent RT NOS. On multivariate analysis, younger age, increased distance to treating facility, Charlson/Deyo score of 1, primary payer insurance, facility location and facility type (academic or cancer center) (p < 0.001) were all factors that predicted patients undergoing initial definitive treatment. ConclusionAge, distance to treating facility, Charlson/Deyo score, primary payer, facility location, and facility type are factors that influence initial treatment for patients with vestibular schwannoma. Clinical stratification systems are needed to identify which patients would benefit most from initial local therapy versus active surveillance.

Stereotactic radiotherapy for stage I renal cell carcinoma: Overall survival and treatment trends compared to thermal ablation and surgical resection.

e16111 Background: Stereotactic radiotherapy (SRT) is a non-invasive treatment modality that is currently evaluated for use in renal cell cancer (RCC). We aimed to evaluate current utilization of SRT for stage I RCC and compare associated overall survival with thermal ablation (TA) and partial nephrectomy (PN). Methods: The 2004-2015 United States National Cancer Database was searched for histopathologically approved stage I RCC treated with PN, cryoablation (CRA), radiofrequency- or microwave-ablation (RFA/MWA) or SRT. Patients were propensity score matched to account for potential confounders. Overall survival (OS) was evaluated with Kaplan-Meier plots, log-rank tests and Cox proportional hazards models. Results: A total of 91,965 patients were included (SRT n = 174; PN n = 82,913; CRA n = 5,446; RFA/MWA n = 3,432).Stage I SRT patients tended to be older females with fewer comorbidities and treated at non-academic centers in New England states. After propensity score matching, a cohort of n = 660 patients was obtained with well-balanced distribution of confounders between the different treatment strategies. In the matched cohort, OS following SRT was inferior to PN and thermal ablation (PN vs. SRT HR = 0.33, 95% CI: 0.22-0.50, p &lt; 0.001; CRA vs. SRT HR = 0.44, 95% CI: 0.30 – 0.66, p &lt; 0.001; RFA/MWA vs. SRT HR = 0.53, 95% CI: 0.36-0.77, p &lt; 0.001). OS following CRA was comparable to PN (HR = 1.35, 95% CI: 0.84-2.18, p = 0.216), while OS following RFA/MWA was inferior to PN (HR = 1.61, 95% CI: 1.01-2.56, p = 0.046). OS rates are summarized in table 1. Conclusions: Only a minority of RCC patients receive SRT. In stage I RCC, current renal SRT protocols yield lower overall survival compared to thermal ablation and resection, while CRA and PN show comparable outcomes. Based on the current body of evidence, SRT for RCC should be reserved for clinical trials or exceptional clinical circumstances.[Table: see text]

Radiofrequency ablation versus surgical resection of hepatocellular carcinoma: contemporary treatment trends and outcomes from the United States National Cancer Database.

To compare utilization and effectiveness of radiofrequency ablation (RFA) and surgical resection for hepatocellular carcinoma (HCC). The 2004-2015 United States National Cancer Database was queried for HCC patients treated by RFA and surgical resection. Patients were 1:1 propensity score matched. Duration of hospital stay, unplanned readmission rates, and overall survival (OS) were compared in the matched cohort via multivariable regression models. Eighteen thousand two hundred ninety-six patients were included (RFA, n = 8211; surgical resection, n = 10,085). RFA was more likely in young male whites with high degree of hepatic fibrosis, high bilirubin levels, high INR, and multifocal HCC; resection was more likely in those with private insurance, high income, high cancer grade and stage, and larger HCC. RFA rates varied between 32.3% (East South Central) and 58.5% (New England). Post-treatment outcomes were superior for RFA versus resection regarding duration of hospital stay (median 1 vs. 5d, p < 0.001), 30-day unplanned hospital readmission rates (3.1% vs. 4.5%, p < 0.001), and 30-/90-day mortality (0% vs. 4.6%/8%, p < 0.001). Overall survival was comparable for RFA and resection for severe hepatic fibrosis/cirrhosis (5-year OS 37.3% vs. 39.4%, p = 0.07), for patients > 65 years old (5-year OS 21.9% vs. 26.5%, p = 0.47), and for HCC < 15mm (5-year OS 49.7% vs. 52.3%, p = 0.78). OS in the full cohort was superior for surgical resection (5-year OS 29.9% vs. 45.7%, p < 0.01). RFA for HCC shows substantial variation by geography, socioeconomic factors, liver function, and tumor extent. RFA offers superior post-treatment outcomes versus surgical resection and may be an alternative for older patients with cirrhosis and/or small HCC. • Duration of hospital stay, unplanned readmissions, and 30-/90-day mortality are lower for RFA versus surgical resection. • RFA and surgical resection show similar survival in severe hepatic fibrosis. • In HCC < 15mm, RFA and surgical resection yield similar survival.

The prevalence of human papillomavirus in oropharyngeal cancer is increasing regardless of sex or race, and the influence of sex and race on survival is modified by human papillomavirus tumor status.

The purpose of this study was to evaluate the influence of sex and race/ethnicity upon prevalence trends of human papillomavirus (HPV) in oropharyngeal cancer (OPC) and survival after OPC. This was a cohort study of patients included in the United States National Cancer Database who had been diagnosed with OPC between 2010 and 2015. Outcomes were HPV status of tumor specimens and overall survival. Sex- and race-stratified trends in HPV prevalence were estimated using generalized linear modeling. The influence of sex, race, and HPV tumor status on overall survival was compared by Kaplan-Meier method and Cox Proportional Hazards models. This analysis included 20,886 HPV-positive and 10,364 HPV-negative OPC patients. The prevalence of HPV-positive tumors was higher among men (70.6%) than women (56.3%) and increased significantly over time at a rate of 3.5% and 3.2% per year among men and women, respectively. The prevalence of HPV-positive tumors was highest among whites (70.2%), followed by Hispanics (61.3%), Asians (55.8%), and blacks (46.3%). Blacks and Hispanics experienced significantly more rapid increases in prevalence of HPV-positive tumors over time compared with whites (6.5% vs 5.6% vs 3.2% per year, respectively). In HPV-positive OPC, neither sex nor race/ethnicity was associated with survival among patients with HPV-positive OPC. In contrast, for HPV-negative OPC, risk of death was significantly higher for women versus men (adjusted hazard ratio [aHR], 1.17; 95% confidence interval [CI], 1.08-1.26) and blacks versus whites (aHR, 1.21; 95% CI, 1.10-1.33). The prevalence of HPV-positive tumors is increasing for all sex and race/ethnicity groups in the United States. Sex and race are independently associated with survival for HPV-negative but not HPV-positive OPC.

MP34-15 PROSTATE CANCER QUALITY OF CARE DISPARITIES AND THEIR IMPACT ON PATIENT OUTCOMES

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II1 Apr 2018MP34-15 PROSTATE CANCER QUALITY OF CARE DISPARITIES AND THEIR IMPACT ON PATIENT OUTCOMES Keith Lawson, Katherine Daignault, Olli Saarela, Robert Abouassaly, and Antonio Finelli Keith LawsonKeith Lawson More articles by this author , Katherine DaignaultKatherine Daignault More articles by this author , Olli SaarelaOlli Saarela More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , and Antonio FinelliAntonio Finelli More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1107AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The ability to rigorously measure disparities in care that drive poor patient outcomes is essential for developing effective strategies for quality improvement. As real-world case-mix adjusted quality variations have yet to be reported in prostate cancer, our objective was to apply a data-driven analytical framework to determine the validity of expert-defined quality indicators (QIs) in order to reveal true disparities in prostate cancer care and their impact on patient outcomes. METHODS Hospital-level quality of care was assessed according to 10 published, expert-defined QIs utilizing data derived from the United States National Cancer Database (NCDB). Case-mix adjusted hospital benchmarking was performed using indirect standardization methodology and multivariable regression models as previously described by our group [1]. In a training set of hospitals, a composite measure of hospital quality, the Prostate Cancer Quality Score (PC-QS), was derived from those individual QIs that discriminated hospital performance in a manner associated with poor patient outcomes; including the need for salvage therapy, initiation of androgen deprivation therapy, 30- and 90-day mortality, and overall mortality. Subsequently, associations between the PC-QS and hospital volume, academic affiliation, and patient outcomes (as above) were determined in a separate validation set of hospitals. RESULTS Collectively, data from over 1100 hospitals were analyzed, with widespread variation observed across all QIs. In the training set, between 3-36% of hospitals were identified as poor outliers compared to the national average level of care for a given QI. Based on associations between outlier status and the aforementioned patient outcomes, 5 individual QIs were incorporated into the PC-QS. In the validation set, lower PC-QS hospitals displayed smaller referral volumes and were less likely to be academic hospitals than those with higher PC-QS (p < 0.001). Higher PC-QS was associated with lower rates of salvage therapy, ADT initiation and 30-day mortality (adjusted hazard ratio [confidence interval]: 0.85 [0.79-0.91], 0.94 [0.91-0.98], adjusted odds ratio 0.92 [0.87-0.97] per PC-QS unit increase, respectively). CONCLUSIONS Data-driven benchmarking of hospital-level quality performance reveals the widespread disparities that exist in prostate cancer care. This data supports the use of our novel PC-QS composite metric as a benchmarking tool for quality improvement. 1. Lawson KA et. al. Eur Urol 2017; 72: 379-386. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e443 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Keith Lawson More articles by this author Katherine Daignault More articles by this author Olli Saarela More articles by this author Robert Abouassaly More articles by this author Antonio Finelli More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

3A.02 Major Drivers of Combined Modality Therapy for Limited-Stage Small Cell Lung Cancer in the United States National Cancer Database: Topic: Radiation Oncology

3A.02 Major Drivers of Combined Modality Therapy for Limited-Stage Small Cell Lung Cancer in the United States National Cancer Database: Topic: Radiation Oncology

(P036) Implementation of Hypofractionated Prostate Radiotherapy in the United States: A National Cancer Database Analysis

Pre-clinical and clinical research over the past several decades suggests that hypo-fractionated (HFxn) radiotherapy schedules produce similar treatment outcomes compared to conventionally fractionated (CFxn) radiotherapy for definitive treatment of localized prostate cancer (PCa). We sought to evaluate national trends and identify factors associated with HFxn utilization using the United States National Cancer Database (NCDB). We queried the NCDB for men diagnosed with localized (N0, M0) PCa from 2004-2013 treated with external beam radiotherapy. Patients were grouped by dose per fraction (DpF) in Gray: CFxn was defined as DpF ≤2.0, moderate HFxn as DpF >2.0 but <5.0, and extreme HFxn as DpF ≥5.0. Men receiving DpF <1.5 or >15.0 were excluded, as were those receiving <20 or >90 Gray total dose. Multiple logistic regression was performed to identify demographic, clinical, and treatment factor associations. 132,403 men were identified, with 120,055 receiving CFxn, 7,264 moderate HFxn, and 5,084 extreme HFxn. While CFxn was by far the most common approach over the analysis period, HFxn utilization increased from 6.2% in 2004 to 14.2% in 2013 (p<0.01). Extreme HFxn utilization increased the most (from 0.3% to 8.5%) while moderate HFxn utilization was unchanged (from 5.9% to 5.7%). HFxn utilization was independently associated with younger age, later year of diagnosis, non-black race, non-Medicaid insurance, non-Western residence, higher income, academic treatment facility, greater distance from treatment facility, low-risk disease group (by NCCN), and non-receipt of hormone therapy. Although CFxn remains the most common radiotherapy schedule for localized PCa, use of HFxn appears to be increasing in the United States as a result of increased extreme HFxn utilization. Economic and logistical pressures may accelerate adoption of this approach. Considering the multiple demographic and prognostic differences identified between these groups, randomized outcome data comparing extreme HFxn to alternatives is desirable.

OS04.3 Extent of resection and overall survival in risk adjusted and exact matched analyses of 22,928 glioblastoma (all molecular subtypes) patients

Abstract Maximal tumor resection, chemo- and radiotherapy are the standard of care for glioblastoma (GBM), of which robust assessment by clinical trial methodology has been limited by GBM’s severely abridged survival and relatively rare prevalence. The United States National Cancer Database was queried for GBM patients newly-diagnosed from 2004–2014. Overall survival (OS) was assessed by Cox proportional hazards, stratified by extent of resection, and risk adjusted for age, sex, race, Charlson’s comorbidity index, insurance, facility location, facility annual case volume, chemotherapy, radiotherapy, tumor location, tumor laterality, and tumor size; and estimated by Kaplan-Meier methods. Subgroup analyses included MGMT methylation or Karnofsky Performance Score, in the risk adjustment. Coarsened exact matching was used to simulate allocation in an interventional trial. 82,960 adult GBM (all molecular subtypes) patients remained after exclusion, 22,928 with complete data for extent of resection and risk adjustment variables, 83% (n=19,007) of which reached endpoint for OS. Median OS for gross total resection (GTR) was 15.5 mos. (95%CI: 15.2–15.9), compared to 11.7 mos. for subtotal resection (STR; 95%CI: 11.3–12.0; HR 1.29, p<0.001) and 5.9 mos. for those who did not undergo resection (NR; 95%CI: 5.7–6.2; HR 1.56, p<0.001). Estimated 2yr OS rates were GTR 30.7% (95%CI: 29.7–31.8), STR 22.1% (95%CI: 21.1–23.0), and NR 14.8% (95%CI: 14.1–15.5). Notably, in the risk-adjustment adjuvant chemotherapy (HR 0.63, 95%CI: 0.60–0.66), radiotherapy (HR 0.71, 95%CI: 0.68–0.75), unilateral tumor (HR 0.66 vs. bilateral, 95%CI: 0.58–0.76), and supratentorial tumors (HR 0.77 vs. infratentorial, 95%CI: 0.71–0.86) were associated with significantly (p<0.001) improved OS. Additionally, coarsened exact matched (5,867 GTR: 5,867 STR) cohorts demonstrated similar outcomes, (GTR HR vs. STR: 0.74, 95%CI: 0.71–0.78). Median OS for patients with these favorable characteristics was 24.2 mos. vs. 1.5 mos. for those with unfavorable characteristics. In subgroup analyses, GTR significance remained after including MGMT (n=2,776) status in the risk-adjustment (HR vs. STR: 0.74) and MGMT methylation was associated with improved OS (HR 0.66, 95%CI: 0.60–0.72). Compared to STR, GTR was associated with reduced rates of 30- and 90-day mortality (OR 0.71 and 0.64, respectively). In the largest prospectively collected dataset of its kind, GTR for GBM was associated with significantly improved OS compared to STR or NR, in risk adjusted and exact matched analyses. Adjuvant chemotherapy, radiotherapy, unilaterality, supratentorial location, and MGMT methylation in the risk adjusted analysis were also associated with significantly improved OS.