Variations In Cancer Treatment Research Articles

Hospital Accreditation Status and Treatment Differences Among Black Patients With Colon Cancer

Hospital-level factors, such as hospital type or volume, have been demonstrated to play a role in treatment disparities for Black patients with cancer. However, data evaluating the association of hospital accreditation status with differences in treatment among Black patients with cancer are lacking. To evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of guideline-concordant care and mortality among non-Hispanic Black patients with colon cancer. This population-based cohort study used the National Program of Cancer Registries, which is a multicenter database with data from all 50 states and the District of Columbia, and covers 97% of the cancer population in the US. The participants included non-Hispanic Black patients aged 18 years or older diagnosed with colon cancer between January 1, 2018, and December 31, 2020. Race and ethnicity were abstracted from medical records as recorded by health care facilities and practitioners. The data were analyzed from December 7, 2023, to January 17, 2024. CoC hospital accreditation. Guideline-concordant care was defined as adequate lymphadenectomy during surgery for patients with stages I to III disease or chemotherapy administration for patients with stage III disease. Multivariable logistic regression models investigated associations with receipt of guideline-concordant care and Cox proportional hazards regression models assessed associations with 3-year cancer-specific mortality. Of 17 249 non-Hispanic Black patients with colon cancer (mean [SD] age, 64.8 [12.8] years; 8724 females [50.6%]), 12 756 (74.0%; mean [SD] age, 64.7 [12.8] years) were treated at a CoC-accredited hospital and 4493 (26.0%; mean [SD] age, 65.1 [12.5] years) at a non-CoC-accredited hospital. Patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals had higher odds of receiving guideline-concordant lymphadenectomy (adjusted odds ratio [AOR], 1.89; 95% CI, 1.69-2.11) and chemotherapy (AOR, 2.31; 95% CI, 1.97-2.72). Treatment at CoC-accredited hospitals was associated with lower cancer-specific mortality for patients with stages I to III disease who received surgery (adjusted hazard ratio [AHR], 0.87; 95% CI, 0.76-0.98) and for patients with stage III disease eligible for chemotherapy (AHR, 0.75; 95% CI, 0.59-0.96). In this cohort study of non-Hispanic Black patients with colon cancer, patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals were more likely to receive guideline-concordant care and have lower mortality risk. These findings suggest that increasing access to high-quality guideline-concordant care at CoC-accredited hospitals may reduce variations in cancer treatment and outcomes for underserved populations.

Cyclophosphamide Pharmacogenomic Variation in Cancer Treatment and Its Effect on Bioactivation and Pharmacokinetics.

Cyclophosphamide (Cy) is a prodrug that is mainly bioactivated by cytochrome P450 (CYP) 2B6 enzyme. Several other enzymes are also involved in its bioactivation and affect its kinetics. Previous studies have shown the effect of the enzymes' genetic polymorphisms on Cy kinetics and its clinical outcome. These results were controversial primarily because of the involvement of several interacting enzymes in the Cy metabolic pathway, which can also be affected by several clinical factors as well as other drug interactions. In this review article, we present the effect of CYP2B6 polymorphisms on Cy kinetics since it is the main bioactivating enzyme, as well as discussing all previously reported enzymes and clinical factors that can alter Cy efficacy. Additionally, we present explanations for key Cy side effects related to the nature and site of its bioactivation. Finally, we discuss the role of busulphan in conditioning regimens in the Cy metabolic pathway as a clinical example of drug-drug interactions involving several enzymes. By the end of this article, our aim is to have provided a comprehensive summary of Cy pharmacogenomics and the effect on its kinetics. The utility of these findings in the development of new strategies for Cy personalized patient dose adjustment will aid in the future optimization of patient specific Cy dosages and ultimately in improving clinical outcomes. In conclusion, CYP2B6 and several other enzyme polymorphisms can alter Cy kinetics and consequently the clinical outcomes. However, the precise quantification of Cy kinetics in any individual patient is complex as it is clearly under multifactorial genetic control. Additionally, other clinical factors such as the patient's age, diagnosis, concomitant medications, and clinical status should also be considered.

Breast cancer treatment and survival differences in women in remote and socioeconomically disadvantaged areas, as demonstrated by linked data from New South Wales (NSW), Australia

IntroductionReducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks. Reducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks.MethodsA retrospective cohort study used linked data for invasive breast cancers, diagnosed in May 2002 to December 2015 from the NSW Cancer Registry, with corresponding inpatient, and medical and pharmaceutical insurance data. Associations between treatment modalities, area socioeconomic status and residential remoteness were explored using logistic regression. Predictors of breast cancer survival were investigated using Kaplan–Meier product-limit estimates and multivariate competing risk regression.ResultsResults indicated a high 5-year disease-specific survival in NSW of 90%. Crude survival was equivalent by residential remoteness and marginally lower in lower socioeconomic areas. Competing risk regression showed equivalent outcomes by area socioeconomic status, except for the least disadvantaged quintile, which showed a higher survival. Higher sub-hazard ratios for death occurred for women with breast cancer aged 70 + years, and more advanced stage. Adjusted analyses indicated more advanced stage in lower socioeconomic areas, with less breast reconstruction and radiotherapy, and marginally less hormone therapy for women from these areas. Conversely, among these women who had breast conserving surgery, there was higher use of chemotherapy. Remoteness of residence was associated in adjusted analyses with less radiotherapy and less immediate breast reconstruction. In these short term data, remoteness of residence was not associated with lower survival.ConclusionThis study provides benchmarks for monitoring future variations in treatment and survival.

Abstract C045: Outcomes of hormone-receptor positive, HER2-negative breast cancers by race and tumor biologic features

Abstract Background: Black women have higher breast cancer mortality than white women, particularly within the hormone receptor positive, human epidermal growth factor receptor 2 negative (HR+/HER2-) clinical subtype. Interactions between tumor biology and treatment factors are complex and racial disparities in early events (such as 5-year recurrence risk) are not well characterized. Methods: Using data from the Carolina Breast Cancer Study (Phase 3, 2008-2013), a large population-based study enrolling 50% black and 50% white women from 44 counties in North Carolina, we estimated associations between race and recurrence among non-metastatic HR+/HER2- tumors, overall and within subgroups defined by PAM50 Risk of Recurrence score (ROR-PT, calculated from subtype, proliferation level, and tumor size), PAM50 intrinsic subtype, and tumor grade. We also compared treatment patterns by race among HR+/HER2- patients with high-risk disease. Relative frequency differences (RFD), interpretable as the percentage difference between index and referent groups, were estimated using multivariable linear regression. Recurrence risk was estimated using survival curves standardized for age and stage and inverse probability-weighted Cox models. Results: Among 1,775 eligible women, black women had higher recurrence risk relative to white women (crude hazard ratio: 1.8, 95% confidence interval [CI]: 1.3, 2.5), which remained elevated after standardizing for age and clinical covariates (hazard ratio: 1.4, CI: 1.0, 1.9). In stratified analyses, racial disparities persisted among women with high ROR-PT score (5-year standardized recurrence risk 18.9% in black vs. 12.5% in white women) and in high grade patients (5-year standardized recurrence risk 16.6% in black vs. 12.0% in white women). Black women with high grade tumors were significantly less likely to initiate endocrine therapy (RFD: -8.4%, CI: -15.9, -1.0) and experienced treatment delay more often than white women (RFD: +10.4%, CI: 1.8, 19.0). Conclusions: Racial disparities in HR+/HER2- breast cancer recurrence persist within high-risk subgroups. Efforts to identify treatment inequities and other causes of variation in cancer treatment are critical to reducing outcome disparities. Note: This abstract was not presented at the conference. Citation Format: H. Shelton Earp, Andrew F Olshan, Lisa A Carey, Charles M Perou, Melissa A Troester, Halei C. Benefield, Katherine E Reeder-Hayes, Hazel B Nichols, Benjamin C Calhoun, Michael I Love, Xuezheng Sun, Erin L Kirk, Joseph Geradts, Katherine A Hoadley, Stephen R Cole. Outcomes of hormone-receptor positive, HER2-negative breast cancers by race and tumor biologic features [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C045.

Regional differences in recommended cancer treatment for the elderly.

BackgroundLittle is known about regional variation in cancer treatment and its determinants. We compare rates of adherence to treatment guidelines for elderly patients across Texas and whether local specialist supply is an important determinant of treatment variation.MethodsPrevious literature reviewed indicated 7 recommended courses of treatment for colorectal, pancreatic, and prostate cancer. We analyzed Texas Cancer Registry data linked with Medicare claims for the years 2004 to 2007 to study patients with these cancers. We tested for unadjusted and adjusted differences in treatment rates across 22 hospital referral regions (HRR). We tested whether variation in the local supply of specialists treating each cancer was an important determinant of treatment.ResultsWe found significant differences in adjusted treatment rates across regions. For removal and examination of 12+ lymph nodes with colon cancer resection, 13 of 22 HRRs had rates significantly different from the median region. For adjuvant chemotherapy for regional colon cancer, five HRRs significantly differed from the median. For prostate cancer treatment with a favorable diagnosis, nine HRRs differed from the median HRR. Of the 7 treatments, only the local availability of surgeons was an important determinant for excision of lymph nodes for colon cancer patients.ConclusionsThere are significant variations across Texas for seven recommended cancer treatments. No one region has consistently higher or lower treatments than other regions, and local specialist supply is not an important predictor of treatment. Different factors may be determining regional variation in treatment rates across cancer types and treatment options.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1534-z) contains supplementary material, which is available to authorized users.

Payment Reform: Unprecedented and Evolving Impact on Gynecologic Oncology

With the signing of the Medicare Access and CHIP Reauthorization Act in April 2015, the Centers for Medicare and Medicaid Services (CMS) is now positioned to drive the development and implementation of sweeping changes to how physicians and hospitals are paid for the provision of oncology-related services. These changes will have a long-lasting impact on the sub-specialty of gynecologic oncology, regardless of practice structure, physician employment and compensation model, or local insurance market. Recently, commercial payers have piloted various models of payment reform via oncology-specific clinical pathways, oncology medical homes, episode payment arrangements, and accountable care organizations. Despite the positive results of some pilot programs, adoption remains limited. The goals are to eliminate unnecessary variation in cancer treatment, provide coordinated patient-centered care, while controlling costs. Yet, meaningful payment reform in oncology remains elusive. As the largest payer for oncology services in the United States, CMS has the leverage to make cancer services more value based. Thus far, the focus has been around pricing of physician-administered drugs with recent work in the area of the Oncology Medical Home. Gynecologic oncology is a unique sub-specialty that blends surgical and medical oncology, with treatment that often involves radiation therapy. This forward-thinking, multidisciplinary model works to keep the patient at the center of the care continuum and emphasizes care coordination. Because of the breadth and depth of gynecologic oncology, this sub-specialty has both the potential to be disrupted by payment reform as well as potentially benefit from the aspects of reform that can align incentives appropriately to improve coordination. Although the precise future payment models are unknown at this time, focused engagement of gynecologic oncologists and the full care team is imperative to assure that the practice remains patient centered, embodies the highest quality in research and education, yet transforms into a sustainable and agile sub-specialty to pro-actively and effectively manage the immense and relentless financial pressures and regulatory expectations that will be faced over the next decade.