Population-based survival of pediatric rhabdomyosarcoma of the head and neck over four decades

OBJECTIVES

Clinical trials have reported increases in the survival of pediatric rhabdomyosarcoma (RMS) from 25% in 1970 to 73% in 2001. The purpose of this study was to examine whether survival of pediatric patients with RMS of the head and neck improved at the US population level.

METHODS

A population-based cohort of patients with rhabdomyosarcoma of the head and neck aged 0-19 years in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013 was queried. The cumulative incidence competing risks (CICR) method was used to estimate risk and survival trends.

RESULTS

718 cases were identified for analysis. Survival rates at 1-, 5-, and 10-years after diagnosis were 91.2%, 73.2%, and 69.4% respectively. Survival rates at 1 year after diagnosis increased from 82.6% to 93.1% during the study period. In the subdistributional hazard analysis, there was a significantly improved disease-specific risk of death in the first year after diagnosis. Overall risk of death did not improve significantly. Favorable prognostic factors included age <10 years at diagnosis, smaller tumor size, absence of distant metastasis, localized tumors, earlier stage at presentation, grossly complete surgical resection, and embryonal or botryoid histology.

CONCLUSIONS

Disease-specific survival in the first year following diagnosis improved, but the change in overall survival at the population level was not statistically significant. These findings should be interpreted in light of the inclusion of patients with distant metastasis at diagnosis, who have poor prognoses, together with the limited statistical power afforded in studies of rare diseases.

Development and validation of a nomogram for prediction of lymph node metastasis in early-stage breast cancer

Background

Lymph node status is an important factor in determining the prognosis of early-stage breast cancer. We endeavored to build and validate a simple nomogram to predict lymph node metastasis (LNM) in patients with early-stage breast cancer.

Methods

Patients with T1-2 and non-metastasis (M0) breast cancer registered in the Surveillance, Epidemiology, and End Results (SEER) database were enrolled. All patients were divided into primary cohort and validation cohort in a 2:1 ratio. In order to assess risk factors for LNM, we performed univariate and multivariate binary logistic regression, and based on results of multivariable analysis, we built the predictive nomogram model. The C-index, receiver operating characteristic (ROC) and calibration plots were applied to assess LNM model performance. Moreover, the nomogram efficiency was further validated through the validation cohort, part of which was from the First Affiliated Hospital of Nanjing Medical University database.

Results

Totally, 184,531 female breast cancer with T1-2 tumor size from SEER database and 1,222 patients from the Chinese institutional data were included. There were 123,019 patients in the primary cohort and 62,734 patients in validation cohort. The LNM nomogram was composed of seven features including age at diagnosis, race, primary site, histologic type, grade, tumor size and subtype. The model showed good discrimination, with a C-index of 0.720 [95% confidence interval (CI): 0.717-0.723] and good calibration. Similar C-index was 0.718 (95% CI: 0.713-0.723) in validation cohort. Consistently, ROC curves presented good discrimination in the primary cohort [area under the curve (AUC) =0.720] and the validation set (AUC =0.718) for the LNM nomogram. Calibration curve of the nomogram demonstrated good agreement.

Conclusions

With the prediction of novel validated nomogram for women with early-stage breast cancer, doctors may distinguish patients with high possibility of LNM and devise individualize treatments.

Segmental resection is associated with decreased survival in patients with stage IA non-small cell lung cancer with a tumor size of 21-30 mm

Background

The feasibility of segmental resection for early-stage non-small cell lung cancer (NSCLC) is still controversial. This study aimed to compare survival outcomes following lobectomy and segmental resection in patients with pathological T1cN0M0 (tumor size 21-30 mm) NSCLC.

Methods

Patients diagnosed between 1998 and 2016 with pathological stage IA NSCLC and with tumors measuring 21-30 mm were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The observational outcomes were cancer-specific survival (CSS) and overall survival (OS) at 5 years. Univariate survival analysis was carried out to identify potential prognostic factors of prolonged survival. Cox proportional hazards model was used to adjust for confounding factors. Additionally, pairwise comparisons were conducted between lobectomy and segmental resection for CSS and OS, and forest plots were drawn.

Results

Of the 9,580 patients analyzed, 400 patients (4.2%) underwent segmental resections. Patients with older age (P<0.001), smaller tumors (P<0.001), and left-sided tumors (P=0.002) were more likely to receive segmental resection. No difference was found in the operative mortality rates between the segmental resection group and the lobectomy group (1.0% vs. 1.2%, P=0.707). The CSS (HR, 1.429; 95% CI, 1.166-1.752; P=0.001) and OS (HR, 1.348; 95% CI, 1.176-1.544; P<0.001) in the segmental resection group were significantly worse than those in the lobectomy group. Subgroup analyses by age, year of diagnosis, sex, tumor size, histology, grade, and the number of dissected lymph nodes also confirmed that lobectomy was associated with improved CSS and OS.

Conclusions

Lobectomy and thorough removal of lymph nodes should continue to be the recommended standard of care for patients with surgically resectable stage IA NSCLC with tumor size of 21-30 mm.

Survival outcomes in prostate cancer patients with a prior cancer

Background

To shed light on the survival outcomes of prostate cancer (PCa) patients diagnosed after a prior cancer and identify prognostic factors for overall survival (OS) and cancer-specific survival (CSS) in PCa patients.

Methods

In the primary group, a total of 1,778 PCa patients with a prior cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) database from 2005 to 2015, retrospectively. Baseline characteristics and causes of death (COD) of these patients were collected and compared. In the second group, a total of 10,296 PCa patients [5,148 patients with PCa as the only malignancy and 5,148 patients with PCa as their second primary malignancy (SPM)] diagnosed between 2010 and 2011 were extracted to investigate the impact of prior cancers on survival outcomes.

Results

In PCa patients with a prior cancer, the most common type of prior cancer was from gastrointestinal system (29.92%), followed by urinary system (21.37%). Patients were more likely to die of the prior caner, and those with prior cancer from respiratory system had the worst survival outcomes. Moreover, the overall ratios in patients with stage (PCa) I–II and III–IV diseases were 0.21 and 1.65, indicating that patients with higher stage diseases were more likely to die of PCa. In the second group, patients with PCa as the SPM had worse OS than those with PCa as the first primary cancer. Lastly, prognostic factors for OS and CSS in PCa patients were explored.

Conclusions

PCa remains to be an important COD for patients with a prior malignancy, especially for those with high-stage diseases. PCa patients with a prior cancer had worse survival outcomes than those without.

Risk factors of regional lymph node (RLN) metastasis among patients with bone sarcoma and survival of patients with RLN-positive bone sarcoma

Background

Regional lymph node metastasis (RLNM) has been reported to be a prognostic factor for poor survival outcomes of bone sarcoma. However, studies about risk factors for RLNM of bone sarcoma are extremely rare, and the outcome of such patients remains to be explored. We aimed to identify risk factors for RLNM of bone sarcoma and conduct survival analysis for patients with bone sarcoma with RLNM.

Methods

A total of 10,641 patients confirmed of malignant bone sarcomas from 1983 to 2014 were identified from the Surveillance, Epidemiology, and End Results (SEER) database, with 311 being regional lymph node positive. Logistic regression analysis was used to identify risk factors for RLNM, while the Cox proportional hazards model and the Fine and Gray’s regression model were used for survival analysis.

Results

The proportion of RLNM was 6.0% in Ewing sarcoma, 2.5% in osteosarcoma and 1.1% in chondrosarcoma. Other bone tumors together had a RLNM rate of 4.2%. Risk factors identified by the logistic regression analysis for RLNM were male patients, primary tumor site, tumor type and size. The multivariate Cox regression analysis suggested age, race, distant metastasis, tumor type and surgical treatment to be prognostic factors for the overall survival of patients with RLNM. Taking non-cancer-specific death as a competing risk, however, we found only age between 30–60 years [sub-distribution hazard ratio (SHR), 1.528, 95% CI, 1.028–2.271; P=0.02], distant metastasis (SHR, 2.418, 95% CI, 1.682–3.474; P<0.001) and surgery treatment (SHR, 0.493, 95% CI, 0.339–0.718; P<0.001) remained significant for the cancer-specific survival in the Fine and Gray’s regression model.

Conclusions

Predictive factors for RLNM of bone sarcoma are sex, tumor site, type and size. In the presence of RKNM, only age, distant metastasis and surgery treatment are prognostic factors for the outcome of patients with bone sarcoma.

Establishment and validation of a novel predictive model to quantify the risk of bone metastasis in patients with prostate cancer

Background

Patients with prostate cancer (PCa) commonly suffer from bone metastasis during disease progression. This study aims to construct and validate a nomogram to quantify bone metastasis risk in patients with PCa.

Methods

Clinicopathological data of patients diagnosed with PCa between 2010 and 2015 were retrospectively retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Predictors for bone metastasis were identified by logistic regression analyses to establish a nomogram. The concordance index (c-index) and calibration plots were generated to assess the nomogram’s discrimination, and the area under the receiver operating characteristic curve (AUC) was used to compare the precision of the nomogram with routine staging systems. The nomogram’s clinical performance was evaluated by decision curve analysis (DCA) and clinical impact curves (CIC). Independent prognostic factors were identified by Cox regression analysis.

Results

A total of 168,414 eligible cases were randomly assigned to the training cohort or validation cohort at a ratio of 1:1. The nomogram, which was established based on independent factors, showed good accuracy, with c-indexes of 0.911 in the training set and 0.910 in the validation set. Calibration plots also approached 45 degrees. After other distant metastatic sites were included in the predictive model, the new nomogram displayed superior prediction performance. The AUCs and net benefit of the nomograms were both higher than those of other routine staging systems. Furthermore, bone metastasis prediction points were shown to be a new risk factor for overall survival.

Conclusions

Novel validated nomograms can effectively predict the risk of bone metastasis in patients with PCa and help clinicians improve cancer management.

Sex-specific survival benefit in early skin melanoma based on 8th AJCC edition: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database

Background

Females have been found to have a survival benefit over males in past studies. However, in early melanoma patients, this benefit occurred in only those aged >60 years. The 8th edition of the American Joint Committee on Cancer (AJCC) readjusted the melanoma staging system, specifically stage I. This study aims to verify whether the sex-specific benefit in females exists in different age groups according to the 8th edition of the staging system.

Methods

We collected the data of individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Based on the 8th edition of the melanoma staging system, patients diagnosed with pathological stage T1a-T3a, N0 and M0 melanoma were enrolled.

Results

A total of 115,576 patients, including 62,938 male patients and 52,638 female patients, were enrolled in this study. The survival rates of males and females in each stage from IA–IIA were significantly different (P<0.001). In further analyses of each age group, it was found that the proportions of patients with stages IA, IB and IIA were significantly different in each age group. Cox analysis showed that females with stage IA in all age groups benefited significantly, but those in stage IB benefited only when they were aged >60 years. In stage IIA patients, there were significant differences between the <50 and 61–70 years age groups.

Conclusions

Based on data from the SEER database, we found that according to the 8th edition of the AJCC melanoma staging system, females had a higher survival rate than males, and this difference was significant in all age groups in the stage IA group but fluctuated with age in the stage IB and IIA groups.

Patients with hepatocellular carcinoma from more rural and lower-income households have more advanced tumor stage at diagnosis and significantly higher mortality

BACKGROUND

Patients from rural and low-income households may have suboptimal access to liver disease care, which may translate into worse HCC outcomes. The authors provide a comprehensive update of HCC incidence and outcomes among US adults, focusing on the effect of rural geography and household income on tumor stage and mortality.

METHODS

The authors retrospectively evaluated adults with HCC using Surveillance, Epidemiology, and End Results data from 2004 to 2017. HCC incidence was reported per 100,000 persons and was compared using z-statistics. Tumor stage at diagnosis used the Surveillance, Epidemiology, and End Results staging system and was evaluated with multivariate logistic regression. HCC mortality was evaluated using Kaplan-Meier and multivariate Cox proportional hazards methods.

RESULTS

HCC incidence plateaued for most groups, with the exception of American Indians/Alaska Natives (2004-2017: APC, 4.17%; P < .05) and patients in the lowest household income category (<$40,000; 2006-2017: APC, 2.80%; P < .05). Compared with patients who had HCC in large metropolitan areas with a population >1 million, patients in more rural regions had higher odds of advanced-stage HCC at diagnosis (odds ratio, 1.10; 95% CI, 1.00-1.20; P = .04) and higher mortality (hazard ratio, 1.05; 95% CI, 1.01-1.08; P = .02). Compared with the highest income group (≥$70,000), patients with HCC who earned <$40,000 annually had higher odds of advanced-stage HCC (odds ratio, 1.15; 95% CI, 1.01-1.32; P = .03) and higher mortality (hazard ratio, 1.23; 95% CI, 1.16-1.31; P < .001).

CONCLUSIONS

Patients from rural regions and lower-income households had more advanced tumor stage at diagnosis and significantly higher HCC mortality. These disparities likely reflect suboptimal access to consistent high-quality liver disease care, including HCC surveillance.

Clinicopathological characteristics and prognostic factors of pulmonary sarcomatoid carcinoma: a large population analysis

Background

This study was conducted to identify the clinicopathological characteristics and survival outcomes of pulmonary sarcomatoid carcinoma (PSC), and to compare prognostic factors between elderly (≥65 years) and non-elderly (<65 years) patients.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with PSC between 2004 and 2016. The Kaplan-Meier method was used for overall survival (OS) and cancer-specific survival (CSS) analysis. The Cox proportional hazards model was used to detect independent prognostic factors. A propensity score matched (PSM) analysis was conducted to compare OS and CSS in elderly versus non-elderly PSC patients.

Results

A total of 1,039 eligible cases were identified, with a median follow-up of 6 months. The 5-year OS and CSS rates were 12.3% and 18.7%, respectively, and the median survival was 6 months. Multivariate analysis revealed that female (HR =0.750, P<0.004), surgery (HR =0.484, P<0.001), chemotherapy (HR =0.504, P<0.001), and radiation (HR =0.801, P=0.041) were independent favorable prognostic factors. There was a significant difference in the OS and CSS rates between elderly and non-elderly patients after PSM (P=0.007 and P=0.017, respectively). In multivariate analysis, the predictors for OS in the elderly patients were gender, tumor stage, and chemotherapy, whereas in the non-elderly patients, the predictors were tumor stage, chemotherapy, and surgery.

Conclusions

The PSC patients in our study had poor survival outcomes. Comprehensive treatment, including surgery, chemotherapy, and radiotherapy, could improve patient prognosis. Elderly patients had different clinicopathological characteristics, compared to non-elderly patients.

Novel analysis of prognosis of young patients with stage II differentiated thyroid cancer based on AJCC 8.0 and 6.0 criteria to implement the staging system

Background

The incidence of thyroid cancer among young adults is increasing; however, the clinical challenges specific to this population, such as diagnosis, reduced healthcare access, and inconsistent care, have received limited attention. Here, we conducted a subgroup analysis on a series of relatively young patients with differentiated thyroid carcinomas (DTCs), focusing on those with distant metastases at stage II, to obtain a deeper understanding of the factors influencing survival.

Methods

Information on <45- or <55-year-old patients at any T/N stage with distant metastasis (M1) was extracted from the SEER database according to the staging system in the 6^th and 8^th American Joint Committee on Cancer (AJCC) editions, respectively. Patient mortality was evaluated using Cox proportional hazards regression analyses and Kaplan-Meier analyses with log-rank tests.

Results

Both cancer-specific and all-cause mortality rates per 1,000 person-years for patients ≥35 years old significantly differed from those of patients <35 years old. DTC-specific survival curves also significantly differed between these age groups, according to both the AJCC 6.0 and 8.0-based analyses (P=0.0017 and P<0.001, respectively), as did patient survival curves (P=0.0003, P<0.001, respectively). The multivariate Cox regression model also revealed that poor OS was strongly predicted by race (P<0.001) in the analysis based on the criteria of 8^th AJCC staging system.

Conclusions

Age is a risk factor for disease-specific and overall survival (OS) in young patients with stage II DTC, and young male patients exhibited poorer survival than females. Race also emerged as a potential risk factor for young patients in stage II. These findings offer guidance for improving the older and newer versions of the AJCC staging system.

Limited Lymph Node Resection Does Not Decrease Postoperative Mortality After Esophagectomy in Octogenarians With Thoracic Esophageal Cancer

BACKGROUND

Octogenarians with esophageal cancer typically have a poor physical condition, reduced physiological reserves, and high postoperative mortality (POM). Extensive lymph node dissection increases surgical trauma and postoperative complications. The purpose of this study was to examine the associations between the number of dissected lymph nodes and short-term and long-term postoperative outcomes in octogenarians with thoracic esophageal cancer.

METHODS

We examined the data of patients from the Surveillance, Epidemiology, and End Results database. We divided the patients into two groups in accordance with the number of lymph nodes dissected: patients with <15 examined lymph nodes (eLNs) and patients with ≥15 eLNs. Mortality was quantified at 30, 60, and 90 d after surgery. Univariable and multivariable logistic regression analyses were performed to identify predictors of 90-day mortality. Kaplan-Meier analysis and the log-rank test were used to analyze the overall survival and cause-specific survival of the patients.

RESULTS

A total of 208 octogenarians with thoracic esophageal cancer were included in the analysis. The 30-day POM rates were 10.3% and 6.9%, the 60-day POM rates were 16.9% and 13.9%, and the 90-day POM rates were 21.3% and 19.4% for patients with <15 eLNs and ≥15 eLNs, respectively. However, the differences in POM between the two groups were statistically nonsignificant (all P > 0.05). In accordance with the multivariable logistic regression analysis, age and marital status were significantly associated with 90-day POM. Furthermore, no significant difference was found between the groups in terms of long-term survival. The 5-year overall survival rates were 29% and 26.8% (P = 0.719) and the 5-year cause-specific survival rates were 43.2% and 34.1% (P = 0.446) in patients with <15 eLNs and ≥15 eLNs, respectively.

CONCLUSIONS

We have demonstrated that octogenarians undergoing esophagectomy are associated with an unacceptably high POM, and less extensive lymph node resection does not decrease POM. Octogenarians may not benefit from esophagectomy with lymphadenectomy. Additional studies need to be conducted to further guide clinicians performing highly selective esophagectomy.

Skin melanoma survival is not superior in females in the new stage IIID of the 8th edition of the staging system: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database

Background

In the 8th edition of the melanoma staging system, stage III was divided into stages IIIA-IIID. Previous studies have found that the long-term survival rate of females is much higher than that of males. This study was designed to explore whether this sex-specific advantage still exists in the new staging subgroups.

Methods

We obtained data from individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8,726 patients with stage III disease were enrolled in the study (5,370 males and 3,356 females). Among these patients, 505 had stage IIID disease (370 males and 135 females).

Results

In the 7th edition of the staging system, there were significant sex-specific differences in overall survival (OS) and melanoma-specific survival (MSS) in each subgroup of stage III. In stages IIIA-IIIC in the 8th edition, there were also significant differences between males and females (P<0.001), but in stage IIID patients, there were no significant differences in either OS (P=0.312) or MSS (P=0.288). Cox analysis confirmed that stage IIID does not affect prognosis in males. Further research found no difference between males and females with stage IIID disease in any age subgroup.

Conclusions

We compared sex-specific survival differences in patients with stage III disease according to the 8th edition of the staging system. Females with stage IIIA-IIIC disease have better survival rates than males. However, among patients with stage IIID disease, there is no significant difference in survival between males and females.

A population-based competing risk survival analysis of patients with salivary duct carcinoma

Background

Salivary duct carcinoma (SDC) is a rare malignancy with high risk of local recurrence and distant metastases of the salivary gland. This study was designed to summarize the clinical and pathological features and to further evaluate them as potential prognostic factors for SDC in the salivary gland.

Methods

Clinical data of 266 patients diagnosed with SDC between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic factors affecting overall survival (OS) and cancer-specific survival (CSS) were determined by Kaplan-Meier analyses and Cox proportional hazards model. The nomogram was established to predict OS and CSS for SDC. The predictive accuracy of the nomograms was measured by concordance index (C-index).

Results

The 3- and 5-year OS of SDC patients were 67.41% and 47.86%, while the 3- and 5-year CSS were 84.6% and 60.7%, respectively. The primary site, T stage and M stage were identified as independent prognostic factors for OS by the multivariate analysis, whereas N stage, M stage, the presence of multiple primary carcinomas and the treatment modalities were identified as independent prognostic factors for CSS. The C-index values of the prognostic nomogram based the risk factors affecting SDC OS and CSS were 0.703 (0.646–0.760) and 0.771 (0.691–0.851), respectively.

Conclusions

SDC is an aggressive malignancy with a high proportion of advanced stage and lymph node metastases. Patients with increasing age, submandibular gland malignancy, advanced T stage, advanced N stage, advanced M stage, high lymph node ratio (LNR) and the presence of multiple primary carcinomas tend to have unfavorable outcomes. Radiotherapy or chemotherapy improve CSS remarkably. These factors will aid in effective therapeutic treatment modalities for SDC.

Survival and prognostic factors in primary vaginal cancer: an analysis of 2004-2014 SEER data

Background

Primary vaginal cancer (PVC) is a rare gynecological malignant tumor and we know little about its survival and prognostic factors. The purpose of this study is to evaluate the potential survival and prognostic factors in women with PVC.

Methods

We used data from the Surveillance, Epidemiology, and End Results (SEER) program to identify 1,781 women who had been diagnosed with PVC between 2004 and 2014. Univariate and multivariable analyses were used to evaluate cases survival and prognostic factors. A stratified analysis was further performed to analyze the prognostic factors in each stage.

Results

There were 20.0% of patients aged ≥80 years and most women were married, 42.1%, and then widowed, 25.2%. The histology types include squamous (74.5%), adenocarcinoma (16.7%), melanoma (3.3%) and sarcoma (1.5%). Five-year cause-specific survival (CSS) rates were overall: 57.8%, Stage I: 76.4%, Stage II: 61.9%, Stage III: 53.3% and Stage IV: 22.5%. Univariate analysis showed that age, marital status, race, pathological grading, histology, TNM stage, tumor size, surgery and radiation were related to prognosis. The 5-year CSS of married women is 64.4%, while those of divorced/separated and widowed are 56.6% and 44.1%, respectively. Multivariate analysis indicated that age, histology, TNM stage, tumor size, surgery and radiation were independent prognostic factors. The elderly (≥80) cases and those with melanoma were correlated to worse prognosis at any stage of PVC. As tumor stage progressed, both of the ≥80 years old patients and the melanoma cases showed a decline tendency of mortality risk.

Conclusions

PVC is a rare gynecological malignant tumor and more likely to occur among older women. Squamous cell carcinoma is the most frequently observed histological type, while melanoma is extremely rare. Age, histology, TNM stage, tumor size, surgery and radiation are independent prognostic factors. Although marital status does not affect survival rates, married women are likely to live longer than widowed and divorced/separated cases. Age ≥80 years seems to be an important cut point in the survival of vaginal cancer. Older age (≥80 years) and melanoma have greater influences on mortality risk in early-stage disease.

Change in Age at Diagnosis of Oropharyngeal Cancer in the United States, 1975-2016

Simple Summary

While previous studies have suggested that HPV-associated head and neck cancer (HNC) is mostly in the younger population, we found that in the last 40 years, the mean age at diagnosis of oropharyngeal cancer has been 60.3 years. We found that after an initially decrease leading up to the early 2000s, there has been a steady increase in age at diagnosis of oropharyngeal cancer since 2002. For non-oropharyngeal HNC, mean age at diagnosis has steadily increased throughout the last four decades. Finally, we found that age at diagnosis of HNC is higher among females in general, and lowest among blacks.

Abstract

The emergence of the human papillomavirus (HPV) as the primary etiology of oropharyngeal cancer has changed head and neck cancer (HNC) epidemiology. This study described change in the age at diagnosis of oropharyngeal and non-oropharyngeal HNC in the United States in the last four decades. Using a retrospective cohort analysis, the Surveillance, Epidemiology, and End Results dataset from 1975 to 2016 was queried for eligible adult cases of HNC, grouped as oropharyngeal (n = 31,702) versus non-oropharyngeal (n = 87,108). Age at diagnosis was compared by gender (female, male) using independent t-test, and by race/ethnicity (Hispanic, non-Hispanic black, non-Hispanic white, non-Hispanic other) using analysis of variance. Joinpoint regression estimated yearly increases/decreases in age of diagnosis by sex and race/ethnicity through annual percent changes (APC), which were summarized with average annual percent changes (AAPC). Mean age at diagnosis for oropharyngeal cancer was 60.3 years. While there was initially a decrease in age at diagnosis, a 0.37% annual increase occurred from 2002 to 2016 (APC = 0.37, 95% confidence interval (CI) 0.28, 0.45). For non-oropharyngeal cancer, mean age at diagnosis was 63.2 years, with a continuous increase in age at diagnosis throughout the study period (1975–2016 AAPC = 0.08, 95% CI 0.04, 0.12). Females had higher average age at diagnosis than males for both sites, while blacks (57.4 years for oropharyngeal cancer; 59.0 years for non-oropharyngeal) had the lowest age at diagnosis of all races/ethnicity. Age at diagnosis of oropharyngeal cancer has increased significantly since 2002, while non-oropharyngeal HNC has increased significantly in the last four decades.

The incidence, risk factors and predictive nomograms for early death among patients with stage IV gastric cancer: a population-based study

Background

Although advances in the treatment of stage IV gastric cancer (GC) patients, some patients were observed to die within 3 months of initial diagnosis. The present study aimed to explore the early mortality and risk factors for stage IV GC and further develop nomograms.

Methods

A total of 2,174 eligible stage IV GC patients were selected from the Surveillance, Epidemiology, and End Results database. Logistic regression analyses were used to determine the risk factors and develop the nomograms to predict all-cause early death and cancer-specific early death. The predictive performance of the nomograms was assessed by receiver operating characteristic curves (ROC), calibration plots and decision curve analyses (DCA) in both training and validation cohorts.

Results

Of 2,174 patients enrolled, 708 died within 3 months of initial diagnosis (n=668 for cancer-specific early death). Early mortality remained stable from 2010-2015. Non-Asian or Pacific Islander (API) race, poorer differentiation, middle sites of the stomach, no surgery, no radiotherapy, no chemotherapy, lung metastases and liver metastases were associated with high risk of both all-causes early death and cancer-specific early death. The nomograms constructed based on these factors showed favorable sensitivity, with the area under the ROC range of 0.816-0.847. The calibration curves and DCAs also exhibited adequate fit and ideal net benefit in prediction and clinical application.

Conclusions

Approximately one-third of stage IV GC patients experienced early death. These associated risk factors and predictive nomograms may help clinicians identify the patients at high risk of early death and be the reference for treatment choices.

Synergic effects of histology subtype, lymph node metastasis, and distant metastasis on prognosis in differentiated thyroid carcinoma using the SEER database

Background

Differentiated thyroid carcinoma (DTC) is the most common clinical type of thyroid carcinoma. There are rare reports on the synergic effects of the different clinicopathological risk factors on the prognosis of it.

Methods

We retrospectively reviewed data on 86,032 DTC patients from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analyses were conducted to evaluate the correlation between clinicopathological factors and the prognosis of DTC. Relative excess risk (RERI) of synergic effect, attributable proportion (AP) of synergic effect, and synergy index (SI) were calculated to assess synergic effects. Kaplan-Meier analyses with log-rank tests was used to plot the survival curve affected by different risk factors.

Results

Histology subtype, lymph node metastasis (LNM) status, and distant metastasis (DM) were independent risk factors for cancer-specific survival (CSS) and all-cause survival (ACS) in the multivariate analysis (all, P<0.001). Patients' age at diagnosis, sex, extrathyroidal extension, and radiation also influenced prognosis (all, P<0.001). The cancer-specific mortality (CSM) and all-cause mortality (ACM) rates per 1,000 person-years were higher in patients with follicular thyroid carcinoma (FTC) and in those with N1 stage and M1 stage disease. Furthermore, we observed a significant synergic effect between histology subtype and N stage, as well as histology subtype and M stage for the CSM of DTC (RERI =48.806, AP =0.853, SI =7.565; RERI =37.889, AP =0.430, SI =1.771, respectively). However, no synergic effect was observed in the case of the N stage and M stage for the CSM of DTC (RERI =7.928, AP =0.084, SI =1.093).

Conclusions

Patients with histology subtype of FTC and N1 stage, histology subtype of FTC and M1 stage had significant additive synergic effects on DTC prognosis for CSM.

Recent trends in use of adjuvant chemotherapy in elderly stage II-III non-small cell lung cancer

Background

Although randomized trials demonstrated survival benefit of adjuvant chemotherapy, previous reports have suggested that its use in elderly populations for early stage non-small cell lung cancer (NSCLC) was infrequent. The current status of adjuvant chemotherapy in this population is unknown.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, we examined the incidence of chemotherapy in resected stage II–III NSCLC between 2004 and 2015. Staging was determined according to the American Joint Committee on Cancer (AJCC) 6th version. Cases were grouped by age (20–69, 70–79, and 80+). Trends in use of chemotherapy by age group were assessed by univariate and multivariate analyses.

Results

A total of 35,009 cases were selected as surgically resected stage II–III NSCLC. Use of chemotherapy was 66.9%, 48.2%, 25.0% in age 20–69, 70–79, 80+, respectively. Multivariate analysis demonstrated that younger age [20–69] and recent year [2010–2015] of diagnosis were associated with increased use of chemotherapy. Chemotherapy use increased from 2004 to 2015 by 11.0%, 18.3%, and 11.3% in age 20–69, 70–79, 80+, respectively. In the age 70–79 group, increased use of chemotherapy was greater in stage II (24.3%) than stage III (14.1%). Five-year overall survival in age 70–79 group mildly increased by 7.6% from 2004 to 2011.

Conclusions

This study suggests that use of adjuvant chemotherapy in the elderly population increased primarily in age 70–79. Few patients in the 80+ age group received adjuvant chemotherapy even in recent years.

Impact of homogeneous and heterogeneous risk factors on the incidence and prognosis of brain metastases in patients with hepatocellular carcinoma

BACKGROUND

This study aimed to identify the incidence, risk factors, and survival outcome associated with brain metastases (BM) in hepatocellular carcinoma (HCC) patients using a large-scale population-based cancer registry database.

METHODS

Between 2010 and 2016, patients with BM from HCC were included using the Surveillance, Epidemiology, and End Results (SEER) program. The risk and prognostic factors for BM were recognized by multivariate logistic and Cox regression model analysis. The overall survival (OS) and cancer-specific survival (CSS) of HCC patients with BM were assessed using Kaplan-Meier curves with log-rank tests.

RESULTS

A total of 141 (0.33%) HCC patients detected with BM were included for analysis. Younger age, tumor pathological undifferentiation, no surgery, radiation therapy, no chemotherapy, synchronous bone, or lung metastases were positively associated with BM in the HCC cohort. The median OS and CSS of the BM patients were 3 months, while the corresponding survival time in HCC patients without BM was 13 and 23 months. Black race, tumor pathological undifferentiation, absence of chemotherapy, and concomitant lung metastases were independently associated with the worse survival.

CONCLUSIONS

Although the overall prognosis of patients with BM from HCC was extremely poor, a list of homogeneous and heterogeneous risk factors were found to be significantly associated with the occurrence and prognosis of BM in HCC patients. These relevant factors may provide more valuable references for individualized treatment in clinical practice.

A novel nomogram based on SEER database for the prediction of liver metastasis in patients with small-cell lung cancer

BACKGROUND

To establish and validate a nomogram to predict liver metastasis in patients with small-cell lung cancer (SCLC).

METHODS

Information on patients diagnosed with SCLC between 2010 and 2015 was retrospectively retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Risk factors for liver metastasis were identified by logistic regression analyses to construct a nomogram. The predictive accuracy was evaluated by concordance indexes (c-index) and calibration plots, and the comparison of discrimination between the nomogram and other routine staging systems was achieved with the area under receiver operating characteristic curve (AUC) analysis. Decision curve analysis (DCA) was performed to measure the clinical performance of the nomogram.

RESULTS

A total of 12,957 patients met our inclusion criteria and were randomly assigned to training (n=6,479) and validation (n=6,478) sets. The nomogram which was established based on independent clinicopathological factors had poor accuracy, and after other distant metastatic sites were added into the predictive model, the new nomogram displayed better discrimination power, with c-indexes of 0.703 in the training set and 0.712 in the validation set. Both internal and external calibration plots approached 45 degrees. The AUCs and net benefit of the predictive model were both higher than those of routine staging systems.

CONCLUSIONS

The validated nomogram might be a practical tool for clinicians to quantify the risk of liver metastasis in patients with SCLC and improve cancer management.

Prognostic value of log odds of positive lymph nodes in node-positive lung squamous cell carcinoma patients after surgery: a SEER population-based study

Background

Log odds of positive lymph nodes (LODDS) is a novel and promising ratio-based lymph node (LN) staging system in many malignancies. This study aimed to evaluate the prognostic value of LODDS, and comprehensively compare the prognostic predictive performance of LODDS with the American Joint Committee on Cancer (AJCC) N classification, number of positive lymph node (NPLN), and lymph node ratio (LNR) among node-positive lung squamous cell carcinoma (SCC) patients after surgery.

Methods

We identified 2,561 patients with N1/N2 stage SCC diagnosed between 2004 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. X-tile analysis was used to calculate the optimal cut-off value for each staging system. Univariable and Multivariable Cox regression analyses were used to assess the association of cancer-specific survival (CSS), and overall survival (OS) with N, NPLN, LNR, and LODDS, separately, and integrally. Moreover, linear trend χ² score, likelihood ratio (LR) test, Akaike information criterion (AIC), and Harrell concordance index (C-index) were adopted as criteria for assessing the predictive ability of each model.

Results

The optimal cut-off values for NPLN, LNR, and LODDS were 3, 0.28, and −0.37, respectively. N, NPLN, LNR, and LODDS were identified as independent prognostic predictors for CSS and OS in patients with SCC when each of them was incorporated into multivariable Cox model separately. Additionally, LODDS had the higher linear trend χ² score, higher LR χ² test score, lower AIC, and higher C-index compared to the other three systems. Moreover, a combination of N, NPLN, and LODDS was superior to any staging system alone for predicting prognosis.

Conclusions

LODDS showed better predictive performance than N, NPLN, and LNR among patients with node-positive SCC after surgery. A combination of LODDS and the current AJCC TNM classification has the potential for becoming a better staging method to more precisely predicting prognosis.

Marital status impacts survival in patients with upper tract urothelial carcinoma: a population-based, propensity-matched study

Background

Marital status has been considered as an independent prognostic factor for various types of cancer survival. The objectives of our study were to investigate the function of marital status on the survival of upper tract urothelial carcinoma (UTUC) patients.

Methods

The patients diagnosed with UTUC between 1988 and 2015 were captured within the Surveillance, Epidemiology, and End Results (SEER) database. Patients were classified into married, divorced/separated, widowed and single cohorts. Kaplan-Meier and Cox regression analysis was conducted to assess the effects of marital status on overall survival (OS) and cancer-specific survival (CSS). A 1:1 matched‐pair analysis was performed to optimize the final statistical results by propensity score matching (PSM).

Results

Among the 10,852 eligible patients, the percentage of married, divorced/separated, widowed and single patients accounted for 58.2% (6,321), 9.0% (980), 23.3% (2,526) and 9.4% (1,025) respectively. The widowed patients had the worst OS and CSS. Marital status was a predictive factor for OS and CSS of UTUC patients. The results of multivariate Cox regression showed that the worst OS [hazard ratio (HR): 1.41; 95% confidence interval (CI): 1.33–1.49, P<0.001] and the poorer CSS (HR: 1.32; 95% CI: 1.22–1.43, P<0.001) were existed in the widowed patients, compared with married patients. The results of the stratified analysis by primary site also indicated the same conclusion. Furthermore, the results were confirmed in the 1:1 matched group.

Conclusions

Marital status acted as an independent prognostic and protective factor for survival in UTUC patients. Additionally, being widowed was related with a high risk of death in UTUC compared with married, divorced, or single patients.

Treatment method and prognostic factors of chondrosarcoma: based on Surveillance, Epidemiology, and End Results (SEER) database

BACKGROUND

Chondrosarcoma is a malignant tumor originating from cartilage tissue. It is the second most malignant bone tumor, accounting for about 10% to 15% of all primary bone tumors. So far, there have been no reports of large-scale clinical statistics on the relationship between non-surgical treatment and prognosis in patients with chondrosarcoma.

METHODS

Through the search of the Surveillance, Epidemiology, and End Results (SEER) database, chondrosarcoma patients registered between January 1, 2004 and December 31, 2016 were selected as research goals. Univariate analysis of overall survival (OS) and chondrosarcoma-specific survival (CSSS) by Kaplan-Meier survival analysis and log-rank test. Mapping Kaplan-Meier curves for prognostic factors that are significant for OS and CSSS in patients with chondrosarcoma. After univariate analysis, the prognostic factors that have a significant effect on the prognosis were included in the multivariate Cox regression analysis, and the independent factors that affected the prognosis were screened.

RESULTS

A total of 1,128 patients with chondrosarcoma were included in the study. Univariate analysis showed that prognostic factors such as age, gender, primary site, histological type, grade, tumor size, metastasis, surgery, radiotherapy, chemotherapy and treatment method had significant effects on all-cause mortality (ACM) and chondrosarcoma-specific mortality (CSSM). These factors were included in the multivariate Cox regression analysis. The results showed age, primary site, histological type, grade, tumor size, metastasis, and treatment method were independent factors affecting ACM and CSSM.

CONCLUSIONS

This study found that although non-surgical treatment of chondrosarcoma has made great progress, at present, it is still not considered that non-surgical treatment can significantly improve the prognosis. There are many factors affecting the prognosis of chondrosarcoma, including age, primary site, histological type, grade, tumor size, distant metastasis and treatment method. In the future, more samples and more detailed data will be needed to study the treatment of chondrosarcoma and to analyze the important factors affecting prognosis through big data analysis.

Development of a nomogram for preoperative prediction of lymph node metastasis in non-small cell lung cancer: a SEER-based study

Background

Lymph node dissection is an important part of lung cancer surgery. Preoperational evaluation of lymph node metastases decides which dissection pattern should be chosen. The present study aimed to develop a nomogram to predict lymph node metastases on the basis of clinicopathological features of non-small cell lung cancer (NSCLC) patients.

Methods

A total of 35,138 patients diagnosed with NSCLC from 2010–2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly divided into training cohort and validation cohort. Possible risk factors were included and analyzed by logistic regression models. A nomogram was then constructed and validated.

Results

21.83% of all patients were confirmed with positive lymph node metastasis. Age at diagnosis, sex, stage, T status, tumor size, grade and laterality were identified as predicting factors for lymph node involvement. These variables were included to build the nomogram. The AUC of the model was 0.696 (95% CI, 0.617 to 0.775). The model was further validated in the validation set with AUC 0.693 (95% CI, 0.628 to 0.758). The model presented with good prediction accuracy in both training cohort and validation cohort.

Conclusions

We developed a convenient clinical prediction model for regional lymph node metastases in NSCLC patients. The nomogram will help physicians to determine which patients will receive the most benefit from lymph node dissection.

Is a simplified TNM staging system more clinically relevant than the American Joint Committee on Cancer system for the follicular variant of papillary thyroid cancer?

Background

Despite the recent release of the 8th edition of the American Joint Committee on Cancer (AJCC) staging manual, risk stratification for the follicular variant of papillary thyroid cancer (FVPTC), which is the second common variant of papillary thyroid carcinoma (PTC) after classical PTC, remains controversial. This study aimed to develop a more accurate and relevant staging system specifically for FVPTC.

Methods

Patients with FVPTC who were included in the Surveillance, Epidemiology, and End Results (SEER) open database between 2010 and 2015 were divided into 47 groups according to their TNM classifications and age. Subsequently, these 47 groups were categorized into appropriate stages based on Kaplan-Meier survival curves, mortality analyses, a Cox proportional hazards model, and clinical considerations.

Results

Our retrospective analysis of 17,628 cases yielded the following new staging classification: stage I, defined as age <55 years and any T/N/M or age ≥55 years and T1-3/any N/M0 (n=17,427, 98.85%); stage II, age ≥55 and T4/any N/M0 or age ≥55 and any T/N0/M1 (n=173, 0.99%); and stage III, age ≥55 and any T/N1/M1 (n=28, 0.16%). The overall mortality rates per 1,000-person-years were 4.135 [95% confidence interval (CI): 3.653–4.681], 71.193 (95% CI: 51.354–98.697), and 199.744 (95% CI: 115.983–343.997) for our new stages I, II, and III, respectively. The hazard ratios for the new stages II and III (reference: stage I) were 5.081 (95% CI: 3.110–8.301) and 21.690 (95% CI: 11.402–41.258), respectively.

Conclusions

Compared to the 8th edition of the AJCC staging system, our newly proposed system provided more accurate risk stratification for patients with FVPTC, as demonstrated by actual survival and mortality outcomes. This new model may thus help guide more personalized treatment for these patients.

Development and validation of nomograms for predicting overall and cancer-specific survival in young patients with non-small cell lung cancer

Background

Young patients with non-small cell lung cancer (NSCLC) represent a distinct subgroup of patients with this disease. This study aimed to construct nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of young patients with NSCLC.

Methods

NSCLC patients under 50 years old diagnosed between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database and randomly divided into training (n=1,357) and validation (n=678) cohorts at a ratio of 2:1. Independent prognostic factors for OS or CSS were identified through the log-rank test, Cox proportional hazards models or competing risk model and further integrated to construct nomograms. The predictive capability of the nomogram was assessed by Harrell's concordance index (C-index), the calibration curve and risk group stratification.

Results

A total of 2,035 patients were enrolled. In the training cohort, insurance, marital status, histological type, grade, T stage, N stage and surgery were identified as independent prognostic for OS and CSS. The C-index value were 0.759 [95% confidence interval (CI): 0.731-0.787] for OS and 0.810 (95% CI: 0.803-0.818) for BCSS in the training cohort and 0.751 (95% CI: 0.711-0.790) for OS and 0.807 (95% CI: 0.795-0.819) for CSS in the validation cohort. The calibration curves showed optimal agreement between the predicted and actual survival both in internal and external validation. In addition, patients in the validation cohort within different risk groups exhibited significantly different survival even in each TNM stage.

Conclusions

Nomograms were developed and validated to predict OS and CSS of young patients with NSCLC in our study. A prospective study with more potential prognostic factors and the latest TNM classification is required to ameliorate this model.

Incidence of patients with bone metastases at diagnosis of solid tumors in adults: a large population-based study

Background

Bones are one of the most common metastatic sites for solid malignancies. Bone metastases can significantly increase mortality and decrease the quality of life of cancer patients. In the United States, around 350,000 people die each year from bone metastases. This study aimed to analyze and update the incidence and prognosis of bone metastases with solid tumors at the time of cancer diagnosis and its incidence rate for each solid cancer.

Methods

We used the Surveillance, Epidemiology, and End Results (SEER) database to find patients diagnosed with solid cancers originating from outside the bones and joints between 2010 and 2016. Data were stratified by age, sex, and race. Patients with a tumor in situ or with an unknown bone metastases stage were excluded. We then selected most of the sites where cancer often occurred, leaving 2,207,796 patients for the final incidence analysis. For the survival analysis, patients were excluded if they were diagnosed at their autopsy or on their death certificate, or had unknown follow-ups. The incidence of bone metastases and overall survival was compared between patients with different primary tumor sites.

Results

We identified 2,470,634 patients, including 426,594 patients with metastatic disease and 113,317 patients with bone metastases, for incidence analysis. The incidence of bone metastases among the metastatic subset was 88.74% in prostate cancer, 53.71% in breast cancer, and 38.65% in renal cancer. In descending order of incidence, there were patients with other cancers in the genitourinary system (except for renal, bladder, prostate, and testicular cancer) (37.91%), adenocarcinoma of the lung (ADC) (36.86%), other gynecologic cancers (36.02%), small-cell lung cancer (SCLC) (34.56%), non-small cell lung cancer not otherwise specified and others [NSCLC (NOS/others)] (33.55%), and bladder (31.08%) cancers. The rate of bone metastases is 23.19% in SCLC, 22.50% in NSCLC (NOS/others), 20.28% in ADC, 8.44% in squamous cell carcinoma of the lung (SCC), and 4.11% in bronchioloalveolar carcinoma [NSCLC (BAC)]. As for the digestive system, the overall bone metastases rate was 7.99% in the esophagus, 4.47% in the gastric cancer, 4.42% in the hepatobiliary cancer, 3.80% in the pancreas, 3.26% in other digestive organs, 1.24% in the colorectum, and 1.00% in the anus. Overall, the incidence rate of bone metastases among the entire cohort in breast and prostate cancer was 3.73% and 5.69%, respectively.

Conclusions

The results of this study provide population-based estimates for the incidence rates of patients with bone metastases at initial diagnosis of their solid tumor. The findings can help clinicians to early detect bone metastases by bone screening to anticipate the occurrence of symptoms and favorably improve the prognosis.

Nomograms predicting survival for all four subtypes of breast cancer: a SEER-based population study

Background

The prognosis of female breast cancer (BC) patients is determined by many clinicopathological factors. In this study, we aimed to identify prognostic factors for BC and develop reliable nomograms to predict the 1-, 3-, and 5-year overall survival (OS) and breast cancer-specific survival (BCSS).

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to screen 227,989 eligible patients as the study cohort. The whole cohort was randomly divided into a training cohort (n=113,996) and a testing cohort (n=113,993). The log-rank test and Cox proportional hazards analysis were applied to select variables and build nomogram models based on the training cohort. Internal and external validation were performed to evaluate the performance of the models by calculating the C-index and generating calibration plots in the training cohort and testing cohort.

Results

The following factors were included in both the OS and BCSS nomograms: subtypes of BC, metastasis (bone, liver, lung, and brain), age at diagnosis, race, tumor size, grade, number of positive lymph nodes, and marital status. The calibration plots presented excellent consistency between the actual and nomogram-predicted survival probabilities in both the training cohort and testing cohort. The C-index values of the nomograms were 0.796 and 0.793 for OS and 0.856 and 0.853 for BCSS in the training and testing cohorts, respectively.

Conclusions

The established nomograms provide a visualization of the risk of each prognostic factor and can assist clinicians in predicting the 1-, 3-, and 5-year OS and BCSS for all 4 subtypes of BC.

Comparison of treatment strategies for patients with limited-stage small cell lung cancer who received chemotherapy

Background

The standard care for limited-stage small cell lung cancer (SCLC) is unclear. The purpose of this study is to compare the outcome for patients receiving chemotherapy alone, chemotherapy plus surgery (CS), chemotherapy plus radiation (CR), or chemotherapy plus surgery and radiation (CSR) for limited-stage SCLC.

Methods

Patients with T1-4N0-2M0 SCLC who received chemotherapy from 2004 to 2014 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) of these patients, stratified by different stage, was compared in accordance to the method of receiving different treatments using Kaplan-Meier method and Cox regression analysis.

Results

A total of 7,204 patients were included, where 1,347 (18.7%) patients received chemotherapy alone, 296 (4.1%) undergone CS, 5,296 (73.5%) patients were subjected to CR and 267 (3.7%) patients were managed by the three combination of CSR. Chemotherapy alone was associated with the worst survival in comparison to the other two method of combination i.e., chemotherapy with radiation or surgery. When compared with CR, CS had no survival benefit in patients with stage in excess of T1-2N0 disease, but was associated with improved 5-year OS in patients with T1-2N0 disease, which ranged from 29.1% to 54.3% (P<0.001). For patients with T1-2N2 disease who received CSR demonstrated superior OS over those who received CR (P=0.004) or CS (P=0.036). Cox regression analysis showed CS was associated with improved OS when compared with CR in patients with N0 disease (HR, 0.54; 95% CI, 0.43–0.68; P=0.000) and CSR was associated with better OS in comparison with CR in patients with N2 disease (HR, 0.71; 95% CI, 0.55–0.93; P=0.013).

Conclusions

Patients with limited-stage SCLC can benefit from local treatment such as surgery, radiation, and surgery plus radiation. For patients with N0 disease, CS was associated with improved survival in comparison to CR. If N2 was identified after surgery, radiation may be added to improve OS.

Suicide among cancer patients: adolescents and young adult (AYA) versus all-age patients

Background

Many researchers have studied suicide risk factors of patients with one specific cancer. But there is no comprehensive study to compare suicide issues between adolescents and young adult (AYA) group and all-age groups in a pan-cancer view.

Methods

Patients diagnosed with 20 solid malignancies were identified from SEER database. Multivariable logistic regression was operated to find out risk factors of suicide.

Results

Male sex has less impact on AYA than all-age patients (OR 2.72, 95% CI: 2.23-3.31, P<0.001 vs. OR 4.64, 95% CI: 4.37-4.94, P<0.001), while white race (OR 3.28, 95% CI: 2.02-5.77, P<0.001 vs. OR 3.40, 95% CI: 3.02-3.84, P<0.001) and unmarried status (OR 1.51, 95% CI: 1.24-1.83, P<0.001 vs. OR 1.39, 95% CI: 1.33-1.46, P<0.001) have similar impact on AYA and all-age groups. Localized cancer stage may have stronger impact on AYA than all-age (OR 2.90, 95% CI: 1.83-4.84; P<0.001 vs. OR 1.76, 95% CI: 1.61-1.92; P<0.001), while surgery only influence all-age (OR 1.14, P=0.451 vs. 1.24, P<0.001). Within 5 years from cancer diagnosis, longer survival time is associated with higher suicide risk of both all-age and AYA patients.

Conclusions

Male sex, white race and unmarried status, earlier cancer stage and longer survival time within 5 years are similar prevalent risk factors for both AYA group patients and all-age patients. It is not necessary to pick AYA cancer patients out when considering suicide risk of cancer patients.

Synergic effects of histology subtype, tumor size, and lymph node metastasis on distant metastasis in differentiated thyroid cancer

Background

Detection of distant metastasis (DM) is important in differentiated thyroid cancer (DTC). This study aimed to investigate the synergic effects of histology subtype, tumor size, and lymph node metastasis (LNM) status on the occurrence of DM in DTC.

Methods

We collected data of 96,788 patients with DTC. Univariate and multivariate analyses were conducted to identify the risk factors of DM. Relative excess risk of synergic effect, attributable proportion of synergic effect, and synergy index were then calculated to assess synergic effects. Further, Kaplan-Meier method using the log-rank test and receiver operating characteristic (ROC) curves were utilized.

Results

Age at diagnosis (P<0.001), sex (P<0.001), race (P<0.01), tumor size (P<0.001), N stage (P < 0.001), histology subtype (P<0.001), and extrathyroidal extension (P<0.001) were risk factors for DM in both univariate and multivariate analyses. We also found a significant additive synergic effect between histology subtype and LNM, and between tumor size and LNM on DM in the DTC patients. In addition, patients with follicular thyroid cancer and N1 stage had the sharpest decline in cancer-specific survival curves (P<0.001) and all-cause survival curves (P<0.001) compared to patients with other combinations of histology subtype and N stage. Similar results were obtained in patients with larger tumors (≥10 mm) and N1 stage. The areas under the curve of histology subtype, tumor size, and LNM status were 0.569, 0.744, and 0.681, respectively.

Conclusions

Age at diagnosis, sex, race, tumor size, N stage, histology subtype, and extrathyroidal extension are risk factors for DM in DTC patients. LNM has a synergic effect with either follicular thyroid histology or larger tumor size for higher risk of DM which is important for diagnosing DM.

Receipt of brachytherapy is an independent predictor of survival in glioblastoma in the Surveillance, Epidemiology, and End Results database

INTRODUCTION

There has been a resurgence of interest in brachytherapy as a treatment for glioblastoma, with several currently ongoing clinical trials. To provide a foundation for the analysis of these trials, we analyze the Surveillance, Epidemiology, and End Results (SEER) database to determine whether receipt of brachytherapy conveys a survival benefit independent of traditional prognostic factors.

MATERIALS AND METHODS

We identified 60,456 glioblastoma patients, of whom 362 underwent brachytherapy. We grouped patients based on receipt of brachytherapy and compared clinical and demographic variables between groups using Student's t-test and Pearson's chi-squared test. We assessed survival using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

Median overall survival was 16 months in patients who received brachytherapy compared to 9 months in those who did not (log-rank p < 0.001). Patients who underwent brachytherapy tended to be younger (p < 0.001), suffered from smaller tumors (< 4 cm, p < 0.001), and were more likely to have undergone gross total resection (GTR, p < 0.001). In univariable Cox models, these variables were independently associated with improved overall survival. Additionally, improved survival was associated with known receipt of chemotherapy (HR 0.459, p < 0.001), external beam radiation (HR 0.447, p < 0.001), and brachytherapy (HR 0.637, p < 0.001). The association between brachytherapy and improved survival remained robust (HR 0.859, p = 0.031) in a multivariable model that adjusted for patient age, tumor size, tumor location, GTR, receipt of chemotherapy, and receipt of external beam radiation.

CONCLUSION

Our SEER analysis indicates that brachytherapy is associated with improved survival in glioblastoma after controlling for age, tumor size/location, extent of resection, chemotherapy, and external beam radiation.

Impact of prior cancer on outcomes in nasopharyngeal carcinoma

Background

Prior cancer is a common exclusion criterion in nasopharyngeal carcinoma (NPC) trials. However, whether a prior cancer diagnosis affects trial outcomes is still unknown. We aimed to determine the impact of prior cancer on survival in NPC patients.

Methods

We identified patients diagnosed with NPC between 2004 and 2009 in the Surveillance, Epidemiology, and End Results (SEER) database. Variables were compared by chi-squared test and t-test as appropriate. Propensity score-adjusted Kaplan-Meier methods and Cox proportional hazard models were used to evaluate the impact of prior cancer on overall survival (OS).

Results

Among 3,131 eligible NPC patients, 349 (11.15%) patients had a history of prior cancer. The Kaplan-Meier curves did not show a statistically significantly different OS (P=0.19). Subgroup analyses stratified by timing of prior cancer and AJCC TNM stage of index cancer displayed the same tendency: prior cancer did not adversely affect OS compared to patients without prior cancer (P>0.05). Furthermore, in propensity score-adjusted COX models analysis, patients with prior cancer had the same/non-inferior OS [hazard ratio (HR) =1.12; 95% confidence interval, 0.88 to 1.42].

Conclusions

Among patients with NPC, prior cancer does not convey an adverse effect on clinical outcomes, regardless of the timing of prior cancer and AJCC TNM stage of index cancer. Broader inclusion trial criteria could be adopted in NPC patients with a history of prior cancer. However, further studies are still needed to confirm this conclusion.

Clear cell adenocarcinoma of the lung: a SEER analysis

Clear cell adenocarcinoma (CCA) in lung has been considered as a rare subtype of lung adenocarcinoma. However, recent classifications of lung adenocarcinoma proposed to discontinue CCA due to lack of available data with clinical significance. Patients with CCA and lung adenocarcinoma not otherwise specified (LANOS) were queried from The Surveillance, Epidemiology, and End Results Program (SEER) database. Cancer-specific survival was studied according to gender (male, female), age (0-69, 70+), SEER specific stage A system (localized, regional and distant), year of diagnosis (1973-2000, 2001-2013), surgery (yes, no), and radiation therapy (yes, no) using Kaplan-Meier curves. Multivariate analysis was used to study independent predictors of cancer-specific survival. A total of 1,227 and 233,154 patients with the diagnosis of CCA and LANOS respectively were found in the SEER database. CCA histology was significantly associated with an early year of diagnosis, younger age, early stage, surgery, and lack of radiation. Kaplan-Meier curves showed that patients with CCA histology had significantly better cancer-specific survival (P<0.0001, Log-Rank). Subset analysis demonstrated the difference in cancer-specific survival between CCA and NOS histology was significant in localized and regional but not distant stage disease (P=0.0453, 0.0009, 0.0664, respectively). Patients with CCA histology have superior survival in the locoregional stage according to our SEER analysis, suggesting its unique role in prognosis despite it being removed from recent pathologic classifications.

Accuracy of the HPV status site-specific factor 10 (SSF-10) variable for patients with oropharyngeal cancers in the Iowa Cancer Registry, 2010-2014

BACKGROUND

Surveillance, Epidemiology, and End Results Cancer Registries (SEER) began collecting human papillomavirus (HPV) status for upper aerodigestive tract cancers in 2010. However, classification of p16-testing was not included in the Collaborative Stage coding guidelines, potentially leading to inconsistent coding.

METHODS

The HPV values for Iowa patients with oropharyngeal cancers (n = 824) were recoded based on modified guidelines that included p16 test results, and compared with the original guidelines.

RESULTS

Forty percent of patients were recoded to a different value, and the HPV testing rate increased from 45% to 55%; 56% received p16-testing only. Of those originally coded as HPV-type 16 (n = 187), 89% were recoded to HPV-not otherwise specified (NOS). When comparing high-level positive/negative/not done categories, original coding captured 81% of patients with HPV-positive cancers.

CONCLUSION

p16 was the most common HPV test but was inconsistently coded as HPV-testing. p16-positivity was also erroneously equated with HPV-type 16. Adding a separate p16 variable would improve consistency and accuracy of HPV coding.

Is the new distribution of early esophageal adenocarcinoma stages improving the prognostic prediction of the 8th edition of the TNM staging system for esophageal cancer?

Background

The 8^th edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging system released in 2017 reclassified the pTNM stage of early esophageal adenocarcinoma from stage IA in the 7^th edition to stage IA and IB and from stage IB in the 7^th edition to stage IC. In this study, we analyzed the reliability of the new staging system through clinical data analysis.

Methods

We selected patient data from the Surveillance, Epidemiology, and End Results (SEER) database. From 2004 to 2014, data for a total of 714 patients were included in the study and were divided into groups representing stage IA (n=84), IB (n=386) and IC (n=244) according to the 8^th edition.

Results

In the 8^th edition, there was no significant difference between groups IA and IB in overall survival (OS) (P=0.331) or esophageal cancer-specific survival (ECSS) (P=0.341). However, the long-term survival rates of groups IA and IB were significantly higher than those of group IC. Cox regression analysis indicated that the use of new staging system does not affect prognosis. We also attempted to stratify the tumors by T stage and histological grade but found no significant difference.

Conclusions

We used the SEER database to compare the staging of early esophageal adenocarcinomas between the 8^th and 7^th editions of the AJCC/UICC TNM staging system. Based on our data, the 8^th edition is not superior to the 7^th edition.

Esophageal cancer in patients under 50: a SEER analysis

Background

Concomitant with rising rates of esophageal adenocarcinoma, there has been a significant increase of diagnoses among relatively younger individuals. However, most studies that focus on esophageal cancer (EC) in younger patients have had small sample sizes of patients treated at a single institute. The aim of this study was to analyze the clinical characteristics, outcomes and independent prognostic factors for EC in patients under 50-year-old using a large, multi-center dataset.

Methods

The national Surveillance, Epidemiology, and End Results (SEER) database was analyzed for EC reported from 2004 to 2013. Patients were divided into two groups, those under 50-year-old and those 50 years or older, and comparisons were made regarding demographics, histology, stage distribution, treatment, overall survival (OS), and esophageal cancer-specific survival (ECSS). Multivariate Cox proportional hazard regression analyses were also used to identify independent prognostic factors.

Results

Among the 16,544 eligible patients, 1,385 (8.37%) were under 50 and 15,159 (91.63%) were over 50. Compared with the older group, patients under 50 were characterized by a higher frequency of males, lower esophagus involvement, adenocarcinoma histology, stage III/IV disease, and receiving esophagectomy or radiation therapy. The stage-wise OS and ECSS were significantly better in the younger group (P<0.001). The multivariate analysis indicated that African-American heritage, grade III or IV, later stage, and not undergoing surgical or radiation therapy were independent negative prognostic factors of ECSS for patients under 50.

Conclusions

EC patients under 50-year-old had distinctive clinicopathological characteristics compared with patients over 50-year-old. Despite more often presenting with stage III and IV disease, survival rates were better in the younger cohort. Prognostic factors for ECSS in patients under 50 differed from those in all age patients.

Adherence to tyrosine kinase inhibitors among Medicare Part D beneficiaries with chronic myeloid leukemia

BACKGROUND

Tyrosine kinase inhibitors (TKIs) improve the survival of patients with chronic myeloid leukemia (CML) dramatically; however, nonadherence to TKI therapy may lead to resistance to the therapy. TKIs are very expensive and are covered under Part D insurance for Medicare patients. To the authors' knowledge, the impact of low-income subsidy status and cost sharing on adherence among this group has not been well studied in the literature.

METHODS

Surveillance, Epidemiology, and End Results (SEER) registry data linked with Medicare Part D data from the years 2007 through 2012 were used in the current study. The authors identified 836 patients with CML with Medicare Part D insurance coverage who were new TKI users. Treatment nonadherence was defined as a binary variable indicating the percentage of days covered was <80% during the 180-day period after the initiation of TKI therapy. Logistic regression was used to examine the relationship between out-of-pocket costs per 30-day drug supply, Medicare Part D plan characteristics, and treatment adherence while controlling for other patient characteristics.

RESULTS

Overall, 244 of the 836 patients with CML (29%) were nonadherent to targeted oral therapy during the 180 days after the initiation of treatment with TKIs. The multivariable logistic regression demonstrated that patients with heavily subsidized (odds ratio, 6.7; 95% confidence interval, 2.8-15.9) and moderately subsidized (odds ratio, 3.0; 95% confidence interval, 1.4-6.5) Medicare Part D plans were much more likely to demonstrate nonadherence compared with patients without a subsidy.

CONCLUSIONS

The current population-based study found a significantly higher rate of nonadherence among heavily subsidized patients with substantially lower out-of-pocket costs, which suggests that future research is needed to help lower the nonadherence rate among these individuals. Cancer 2018;124:364-73. © 2017 American Cancer Society.

The Impact of Multiple Primary Rules on Cancer Statistics in Canada, 1992 to 2012

INTRODUCTION

Several sets of multiple primary rules have been used in Canada to determine whether a cancer is new and little is known of the impact on cancer statistics. We examine the effect of rules on the magnitude and trend of age-standardized incidence rates (ASIRs) of cancer in Canada between 1992 and 2012.

METHODS

Cancer- and sex-specific ASIRs were estimated using Canadian Cancer Registry (CCR) rules and the more conservative International Agency for Research on Cancer (IARC) rules. CCR- and IARC-based ASIRs and trends were compared using rate ratios (CCR:IARC) and joinpoint analysis, respectively. We highlight instances where CCR-based ASIRs exceed the upper 95% confidence limit of corresponding IARC-based ASIRs, as well as instances where the magnitude and/or direction of annual percent change (APC) in ASIRs differ across rules. Additionally, we examine how differences in CCR- and IARC-based estimates vary across regions.

RESULTS

Between 1992 and 2012, ASIR ratios (CCR:IARC) for all cancers combined increased from about 1 to 1.061 and 1.067 for males and females, respectively, and reached as high as 1.141 for male melanoma and 1.109 for female breast cancer. Between 2010 and 2012, ASIR ratios were elevated for stage 0-1 colorectal (males, 1.060; females, 1.072) and lung and bronchus cancer (males, 1.052; females, 1.061) and all stages of female breast cancer (stage 0-1, 1.100; stage 2, 1.061; stage 3, 1.059; stage 4, 1.094). Where differences existed, CCR-based trends tended to demonstrate steeper increases (eg, male and female melanoma) or less steep declines (eg, all male cancers, female breast cancer). Ontario was particularly impacted and substantially influenced national estimates.

CONCLUSION

Multiple primary rules can substantially affect the magnitude and trend of ASIRs. The impact will continue to grow as the number of people surviving cancer, and thus at risk for subsequent cancers, continues to grow. Because of inconsistencies in the multiple primary rules used over time, we recommend using IARC rules for monitoring trends and making comparisons across jurisdictions, and using CCR rules for quantifying the full burden of cancer.

Population-based cancer survival in the United States: Data, quality control, and statistical methods

BACKGROUND

Robust comparisons of population-based cancer survival estimates require tight adherence to the study protocol, standardized quality control, appropriate life tables of background mortality, and centralized analysis. The CONCORD program established worldwide surveillance of population-based cancer survival in 2015, analyzing individual data on 26 million patients (including 10 million US patients) diagnosed between 1995 and 2009 with 1 of 10 common malignancies.

METHODS

In this Cancer supplement, we analyzed data from 37 state cancer registries that participated in the second cycle of the CONCORD program (CONCORD-2), covering approximately 80% of the US population. Data quality checks were performed in 3 consecutive phases: protocol adherence, exclusions, and editorial checks. One-, 3-, and 5-year age-standardized net survival was estimated using the Pohar Perme estimator and state- and race-specific life tables of all-cause mortality for each year. The cohort approach was adopted for patients diagnosed between 2001 and 2003, and the complete approach for patients diagnosed between 2004 and 2009.

RESULTS

Articles in this supplement report population coverage, data quality indicators, and age-standardized 5-year net survival by state, race, and stage at diagnosis. Examples of tables, bar charts, and funnel plots are provided in this article.

CONCLUSIONS

Population-based cancer survival is a key measure of the overall effectiveness of services in providing equitable health care. The high quality of US cancer registry data, 80% population coverage, and use of an unbiased net survival estimator ensure that the survival trends reported in this supplement are robustly comparable by race and state. The results can be used by policymakers to identify and address inequities in cancer survival in each state and for the United States nationally. Cancer 2017;123:4982-93. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Refining the American Joint Committee on Cancer Staging Scheme For Resectable Pancreatic Ductal Adenocarcinoma Using Recursive Partitioning Analysis

Purpose: It remains unclear whether the recently proposed 8^th edition of the American Joint Committee on Cancer (AJCC) staging scheme for pancreatic ductal adenocarcinoma (PDAC) outperforms the 7^th edition. We assessed the prognostic performance of both these schemes and performed recursive partitioning analysis (RPA) to objectively regroup the 7^th and 8^th AJCC stages and derive a refined staging scheme. Methods: We examined 8542 patients with resectable PDAC from the 2004-2012 Surveillance, Epidemiology, and End Results database. The dataset was randomly divided into training and validation sets. The performance of different staging schemes was evaluated in terms of prognostic stratification, discriminatory ability, and prognostic homogeneity. Results: The 7^th and 8^th T classifications showed prominent heterogeneity within each subcategory when assessed against each other in the case of node-negative disease. RPA divided resectable PDAC into RPA-IA (8^th T1N0 limited to the pancreas), RPA-IB (8^th T1N0 extending beyond the pancreas, or 8^th T2-T3N0 limited to the pancreas), RPA-IIA (8^th T2N0 extending beyond the pancreas, or 8^th T1N1-N2), RPA-IIB (8^th T3N0 extending beyond the pancreas, or 8^th T2-T3N1), and RPA-III stages (8^th T2-T3N2) (median survival in the training set: 47, 28, 20, 16, and 14 months, respectively; P < 0.001). The RPA staging scheme outperformed the 7^th and 8^th AJCC classifications in terms of prognostic stratification, discriminatory ability, and prognostic homogeneity for both the training and validation sets. Conclusions: The proposed RPA staging is a superior risk-stratified tool to the 7^th and 8^th AJCC classifications and is not substantially more complex.

Prognostic significance of sites of extrathoracic metastasis in patients with non-small cell lung cancer

BACKGROUND

Metastatic non-small cell lung cancer (NSCLC) continues to have a poor prognosis despite recent advances in both targeted radiotherapy methodologies such as stereotactic body radiotherapy (SBRT) and immunotherapies. The impact of location of metastatic disease in patients with NSCLC has not been investigated; we aimed to investigate this using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

We included 39,910 patients from the SEER database treated for M1b NSCLC from 2010-2013. We identified patients with metastatic disease in the brain, lung, liver, and bone. We used Kaplan-Meier analyses and Cox proportional hazards models to assess the impact of varying sites of metastatic disease on overall survival (OS).

RESULTS

Patients with disease coded as in the brain without other disease in the lung, liver, or bone had improved OS relative to all other comers with M1b disease (HR =0.84, 95% CI, 0.84-0.90, P<0.001). Likewise, patients with disease coded as in the bone without other disease in the lung, liver, or brain had improved OS relative to all other comers with M1b disease (HR =0.89, 95% CI, 0.86-0.92, P<0.001).

CONCLUSIONS

This hypothesis-generating analysis suggests that patients with limited metastatic NSCLC to the bone or brain may particularly benefit from aggressive upfront therapies.

Which patients with inoperable vulvar cancer may benefit from brachytherapy in addition to external beam radiation? A Surveillance, Epidemiology, and End Results analysis

PURPOSE

It is unknown whether brachytherapy after external beam radiation (EBRT + BT) results in improved outcomes compared with EBRT alone for patients with inoperable vulvar cancer. The purpose of this study was to compare survival outcomes for patients who received these treatment modalities.

METHODS AND MATERIALS

Data between 1973 and 2011 from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Patients with Federation of International Gynecologists and Obstetricians stage I-IVA vulvar cancer treated with definitive EBRT + BT or EBRT alone were included. Patients with prior surgical resection were excluded. Disease-specific survival (DSS) and overall survival were compared using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

A total of 649 patients were analyzed, of which 617 received EBRT alone and 32 received EBRT + BT. Median follow-up was 33 months in surviving patients. The use of brachytherapy declined from 16% of cases treated in 1973-1980 to 4% in 2001-2011 (p = 0.04). EBRT + BT vs. EBRT alone was not significantly associated with improved DSS (45% vs. 33% at 5 years) or overall survival (34% vs. 24% at 5 years) on univariate or multivariate analyses. On post hoc subgroup analyses, brachytherapy consolidation was associated with higher 5-year DSS in a composite subgroup that included patients with stage IVA disease, tumor >4 cm, or node-positive disease (52% vs. 27%, p = 0.02).

CONCLUSIONS

Utilization of BT consolidation with EBRT for vulvar cancer is declining in the United States. EBRT + BT is not associated with improved survival compared with EBRT alone in the overall group of patients. Certain subgroups of patients might benefit from brachytherapy, but this hypothesis requires validation in future studies.

Ascertainment of postprostatectomy radiotherapy for prostate cancer in the Surveillance, Epidemiology, and End Results database

BACKGROUND

Surveillance, Epidemiology, and End Results (SEER) data are frequently used to examine receipt of adjuvant radiotherapy (RT), but to the authors' knowledge the accuracy of data regarding second-course treatments is unknown.

METHODS

Using SEER-Medicare-linked data, the authors identified a cohort of men who underwent radical prostatectomy for localized prostate cancer with indications for RT due to adverse pathologic risk factors. Receipt of RT was compared between the SEER database and Medicare claims, with the latter considered to be the "gold standard." Multivariable logistic regression was used to assess factors associated with ascertainment of RT in SEER.

RESULTS

A total of 3842 men were analyzed, 749 of whom were found to have Medicare claims for RT within 1 year of undergoing prostatectomy. SEER ascertainment of postprostatectomy RT was 56% overall: 76% among patients who received RT within 2 months of prostatectomy, 73% among patients who received RT between 2 to 4 months after prostatectomy, 63% among patients who received RT between 4 to 6 months after prostatectomy, 44% among patients who received RT between 6 to 8 months after prostatectomy, and 21% among patients who received RT between 8 to 12 months after prostatectomy. On multivariable analysis, increasing time from prostatectomy to RT was found to be significantly associated with decreased SEER ascertainment (odds ratio, 0.70 per month; P<.001). There also was variation noted by SEER region and urban/rural locale.

CONCLUSIONS

SEER underascertains the receipt of postprostatectomy RT compared with Medicare claims, and the magnitude of the underascertainment increases with longer time between prostatectomy and RT. These findings have direct implications for the use of SEER data alone to assess patterns of care and guideline concordance for second-course treatment. Cancer 2016;122:3069-3074. © 2016 American Cancer Society.

Risk of brain metastases in patients with nonmetastatic lung cancer: Analysis of the Metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER) data

BACKGROUND

Brain metastases (BM) remain an important cause of morbidity and mortality in patients with lung cancer. The current study evaluated population-based incidence and outcomes of BM in patients with nonmetastatic lung cancer.

METHODS

Patients diagnosed with nonmetastatic first primary lung cancer between 1973 and 2011 in the Metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER) registry were used for the current analysis. Age-adjusted odds ratios of developing BM based on various demographic characteristics and histology were calculated with 95% confidence intervals. Adjusted Cox proportional hazard ratios and log-rank tests of Kaplan-Meier survival curves were calculated to evaluate survival differences for non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).

RESULTS

The incidence of BM in patients with nonmetastatic NSCLC and SCLC was 9% and 18%, respectively. There was variation in the incidence of BM according to NCSLC histology. The incidence of BM was higher in patients aged <60 years for both NSCLC and SCLC, but there were no differences noted by race for either histological group. Female patients with NSCLC were more likely to have BM than male patients. There was variation in the proportion of BM in both patients with NSCLC and SCLC over the three 13-year periods of diagnosis. The risk of death (hazard ratio) was found to be significantly higher for patients with NSCLC with BM, but was not significantly higher in patients with SCLC with BM.

CONCLUSIONS

The incidence of BM in patients with nonmetastatic lung cancer varies according to histology, age, and sex. BM are associated with worse survival for patients with NSCLC but not those with SCLC. Cancer 2016;122:1921-7. © 2016 American Cancer Society.

Early impact of the Patient Protection and Affordable Care Act on insurance among young adults with cancer: Analysis of the dependent insurance provision

BACKGROUND

The Patient Protection and Affordable Care Act (ACA) included provisions to extend dependent health care coverage up to the age of 26 years in 2010. The authors examined the early impact of the ACA (before the implementation of insurance exchanges in 2014) on insurance rates in young adults with cancer, a historically underinsured group.

METHODS

Using National Cancer Institute Surveillance, Epidemiology, and End Results data for 18 cancer registries, the authors examined insurance rates before (pre) (January 2007-September 2010) versus after (post) (October 2010-December 2012) dependent insurance provisions among young adults aged 18 to 29 years when diagnosed with cancer during 2007 through 2012. Using multivariate generalized mixed effect models, the authors conducted difference-in-differences analysis to examine changes in overall and Medicaid insurance after the ACA among young adults who were eligible (those aged 18-25 years) and ineligible (those aged 26-29 years) for policy changes.

RESULTS

Among 39,632 young adult cancer survivors, the authors found an increase in overall insurance rates in those aged 18 to 25 years after the dependent provisions (83.5% for pre-ACA vs 85.4% for post-ACA; P<.01), but not among individuals aged 26 to 29 years (83.4% for pre-ACA vs 82.9% for post-ACA; P = .38). After adjusting for patient sociodemographics and cancer characteristics, the authors found that those aged 18 to 25 years had a 3.1% increase in being insured compared with individuals aged 26 to 29 years (P<.01); however, there were no significant changes noted in Medicaid enrollment (P = .17).

CONCLUSIONS

The findings of the current study identify an increase in insurance rates for young adults aged 18 to 25 years compared with those aged 26 to 29 years (1.9% vs -0.5%) that was not due to increases in Medicaid enrollment, thereby demonstrating a positive impact of the ACA dependent care provisions on insurance rates in this population. Cancer 2016;122:1766-73. © 2016 American Cancer Society.

Predictors for regional lymph node metastasis in T1 rectal cancer: a population-based SEER analysis

BACKGROUND

Local resection of early-stage rectal cancer significantly reduces perioperative morbidity compared with radical resection. Identifying patients at risk of regional lymph node metastasis (LNM) is crucial for long-term survival after local resection.

METHODS

Patients after oncological resection of T1 rectal cancer were identified in the Surveillance, Epidemiology, and End Results register 2004-2012. Potential predictors of LNM and its impact on cancer-specific survival were assessed in logistic and Cox regression with and without multivariable adjustment.

RESULTS

In total, 1593 patients with radical resection of T1 rectal cancer and a minimum of 12 retrieved regional lymph nodes were identified. The overall LNM rate was 16.3 % (N = 260). A low risk of LNM was observed for small tumor size (P = 0.002), low tumor grade (P = 0.002) and higher age (P = 0.012) in multivariable analysis. The odds ratio for a tumor size exceeding 1.5 cm was 1.49 [95 % confidence interval (CI) 1.06-2.13], for G2 and G3/G4 carcinomas 1.69 (95 % CI 1.07-2.82) and 2.72 (95 % CI 1.50-5.03), and for 65- to 79-year-old and over 80-year-old patients 0.65 (95 % CI 0.43-0.96) and 0.39 (95 % CI 0.18-0.77), respectively. Five-year cancer-specific survival for patients with LNM was 90.0 % (95 % CI 85.3-95.0 %) and for patients without LNM 97.1 % (95 % CI 95.9-98.2 %, hazard ratio = 3.21, 95 % CI 1.82-5.69, P < 0.001).

CONCLUSIONS

In this population-based analysis, favorable cancer-specific survival rates were observed in nodal-negative and nodal-positive T1 rectal cancer patients after primary radical resection. The predictive value of tumor size, grading and age for LNM should be considered in medical decision making about local resection.

Trends, predictors, and impact of systemic chemotherapy in small cell lung cancer patients between 1985 and 2005

BACKGROUND

The last 3 decades have witnessed limited therapeutic advances in small cell lung cancer (SCLC) management. This study evaluated real-world trends in the use of systemic therapies and the impact on patient outcomes in the United States.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database was used to find patients diagnosed with SCLC between 1985 and 2005. The 1985-1990 period served as the baseline for a temporal analysis conducted at 5-year intervals (1985-1990, 1991-1995, 1996-2000, and 2001-2005). Cox proportional models were used to estimate the effect of chemotherapy on survival. Results were validated with a propensity-matched analysis.

RESULTS

There were 47,351 eligible patients: 52% were male; the median age was 71 years; and 87% were white, 7% were black, and 1.4% were Asian. The proportion of patients treated with chemotherapy was low but increased over time (38%, 55%, 50%, and 53%; P < .001). Race, diagnosis period, age, stage, and location of residence significantly predicted chemotherapy use. Females (51%), Asians (53%), and rural residents (60%) were more likely to receive chemotherapy. The median overall survival with and without chemotherapy was 9.6 and 3.6 months, respectively. Linear trend analyses showed a modest reduction in the impact of chemotherapy on survival for patients treated with chemotherapy versus untreated patients (hazard ratios [HRs], 0.59, 0.61, 0.64, and 0.62; P < .001) but an overall trend of improved survival for treated (HRs, 1.0, 1.03, 1.00, and 0.96; P = .005) and untreated patients (HRs, 1.0, 0.99, 0.94, and 0.92; P < .001). There was no survival difference between patients treated with carboplatin and patients treated with cisplatin (HR, 0.99; confidence interval [CI], 0.81-1.19; P = .875). Additional therapy beyond platinum-based chemotherapy was associated with a survival benefit (HR, 0.78; CI, 0.75-0.81; P < .001).

CONCLUSIONS

Chemotherapy use was associated with a survival benefit in Medicare patients with SCLC treated in a real-world setting.

Increased risk of additional cancers among patients with gastrointestinal stromal tumors: A population-based study

BACKGROUND

Most gastrointestinal stromal tumors (GISTs) are considered nonhereditary or sporadic. However, single-institution studies suggest that GIST patients develop additional malignancies at increased frequencies. It was hypothesized that greater insight could be gained into possible associations between GISTs and other malignancies with a national cancer database inquiry.

METHODS

Patients diagnosed with GISTs (2001-2011) in the Surveillance, Epidemiology, and End Results database were included. Standardized prevalence ratios (SPRs) and standardized incidence ratios (SIRs) were used to quantify cancer risks incurred by GIST patients before and after GIST diagnoses, respectively, in comparison with the general US population.

RESULTS

There were 6112 GIST patients, and 1047 (17.1%) had additional cancers. There were significant increases in overall cancer rates: 44% (SPR, 1.44) before the GIST diagnosis and 66% (SIR, 1.66) after the GIST diagnosis. Malignancies with significantly increased occurrence both before and after diagnoses included other sarcomas (SPR, 5.24; SIR, 4.02), neuroendocrine-carcinoid tumors (SPR, 3.56; SIR, 4.79), non-Hodgkin lymphoma (SPR, 1.69; SIR, 1.76), and colorectal adenocarcinoma (SPR, 1.51; SIR, 2.16). Esophageal adenocarcinoma (SPR, 12.0), bladder adenocarcinoma (SPR, 7.51), melanoma (SPR, 1.46), and prostate adenocarcinoma (SPR, 1.20) were significantly more common only before the GIST diagnosis. Ovarian carcinoma (SIR, 8.72), small intestine adenocarcinoma (SIR, 5.89), papillary thyroid cancer (SIR, 5.16), renal cell carcinoma (SIR, 4.46), hepatobiliary adenocarcinoma (SIR, 3.10), gastric adenocarcinoma (SIR, 2.70), pancreatic adenocarcinoma (SIR, 2.03), uterine adenocarcinoma (SIR, 1.96), non-small cell lung cancer (SIR, 1.74), and transitional cell carcinoma of the bladder (SIR, 1.65) were significantly more common only after the GIST diagnosis.

CONCLUSIONS

This is the first population-based study to characterize the associations and temporal relations between GISTs and other cancers by both site and histological type. These associations may carry important clinical implications for future cancer screening and treatment strategies.

Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer

BACKGROUND

In the United States, an estimated 48 million individuals live without health insurance. The purpose of the current study was to explore the Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer.

METHODS

A total of 688,794 patients aged 18 to 64 years who were diagnosed with one of the top 25 incident cancers (representing 95% of all cancer diagnoses) between 2007 and 2010 in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Patient characteristics included age, race, sex, marital status, and rural or urban residence. County-level demographics included percent poverty level. Insurance status was defined as having non-Medicaid insurance, Medicaid coverage, or no insurance.

RESULTS

On multivariate logistic regression analyses, younger age, male sex, nonwhite race, being unmarried, residence in counties with higher levels of poverty, and rural residence were associated with being uninsured versus having non-Medicaid insurance (all P <.001). The highest rates of non-Medicaid insurance were noted among patients with prostate cancer (92.3%), melanoma of the skin (92.5%), and thyroid cancer (89.5%), whereas the lowest rates of non-Medicaid insurance were observed among patients with cervical cancer (64.2%), liver cancer (67.9%), and stomach cancer (70.9%) (P <.001). Among uninsured individuals, the most prevalent cancers were lung cancer (14.9%), colorectal cancer (12.1%), and breast cancer (10.2%) (P <.001). Lung cancer caused the majority of cancer mortality in all insurance groups.

CONCLUSIONS

Rates of insurance coverage vary greatly by demographics and by cancer type. The expansion of health insurance coverage would be expected to disproportionally benefit certain demographic populations and cancer types.