Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel

BACKGROUND

Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.

OBJECTIVE

To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.

STUDY DESIGN

We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.

RESULTS

We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both).

CONCLUSION

The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

Patterns of seizure prophylaxis after oncologic neurosurgery

BACKGROUND

Evidence supporting routine postoperative antiepileptic drug (AED) prophylaxis following oncologic neurosurgery is limited, and actual practice patterns are largely unknown beyond survey data.

OBJECTIVE

To describe patterns and predictors of postoperative AED prophylaxis following intracranial tumor surgery.

METHODS

The MarketScan Database was used to analyze pharmacy claims data and clinical characteristics in a national sample over a 5-year period.

RESULTS

Among 5895 patients in the cohort, levetiracetam was the most widely used AED for prophylaxis (78.5%) followed by phenytoin (20.5%). Prophylaxis was common but highly variable for patients who underwent open resection of supratentorial intraparenchymal tumors (62.5%, reference) or meningiomas (61.9%). In multivariate analysis, biopsies were less likely to receive prophylaxis (44.8%, OR 0.47, 95% CI 0.33-0.67), and there was near consensus against prophylaxis for infratentorial (9.7%, OR 0.07, CI 0.05-0.09) and transsphenoidal procedures (0.4%, OR 0.003, CI 0.001-0.010). Primary malignancies (52.1%, reference) and secondary metastases (42.2%) were more likely to receive prophylaxis than benign tumors (23.0%, OR 0.63, CI 0.48-0.83), as were patients discharged with home services and patients in the Northeast. There was a large spike in duration of AED use at approximately 30 days.

CONCLUSIONS

Use of seizure prophylaxis following intracranial biopsies and supratentorial resections is highly variable, consistent with a lack of guidelines or consensus. Current practice patterns do not support a clear standard of care and may be driven in part by geographic variation, availability of post-discharge services, and electronic prescribing defaults rather than evidence. Given uncertainty regarding effectiveness, indications, and appropriate duration of AED prophylaxis, well-powered trials are needed.

Trends in Use and Effect on Survival of Simple Hysterectomy for Early-Stage Cervical Cancer

OBJECTIVE

To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer.

METHODS

The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting.

RESULTS

Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy).

CONCLUSION

Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

Illness Understanding and End-of-Life Care Communication and Preferences for Patients With Advanced Cancer in South Africa

Purpose

The understanding of patients with cancer of their condition and their wishes regarding care as they approach end of life (EoL) have been studied more in high-income countries than in low- and middle-income countries (LMICs).

Patients and Methods

Data were analyzed from a cohort study (N = 221) of patients with advanced cancer who were recruited from a palliative care center in Soweto, South Africa (LMIC), between May 2016 and June 2017. Patients were asked about their understanding of their illness, estimated life expectancy, EoL care communication, and EoL care preferences.

Results

Only 13 patients (5.9%) acknowledged that they were terminally ill; nine patients (4.1%) estimated accurately that they had months, not years, left to live. A total of 216 patients (97.7%) reported that they had not had an EoL care discussion with their physician, and 170 patients (76.9%) did not want to know their prognosis even if the doctor knew it. Most patients preferred comfort care (72.9%; n = 161) to life-extending care (14.0%; n = 31), and did not want to be kept alive using extreme measures (80.5%; n = 178) or have their doctors do everything possible to extend their lives (78.3%; n = 173). Finally, 127 patients (57.5%) preferred to die at home, and 51 (23.1%) preferred to die in the hospital. Most patients (81.0%; n = 179) had funeral plans.

Conclusion

South African patients demonstrated less awareness of the fact that they were terminally ill, were less likely to have discussed their prognosis with their doctor, and more strongly preferred comfort care to life-extending EoL care than US and other LMIC patients in prior research. These differences highlight the need for culturally appropriate, patient-centered EoL care for South African patients with advanced cancer as well as to determine individual preferences and needs in all EoL settings.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients

BACKGROUND

Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited.

METHODS

Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs.

RESULTS

In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02).

CONCLUSIONS

RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Use of fertility preservation services in female reproductive-aged cancer patients

OBJECTIVE

The objective of the study was to determine the rates and predictors of fertility preservation services among reproductive-aged women with common cancers in the United States.

STUDY DESIGN

We used the MarketScan database to identify women 18-45 years of age with lung, breast, colorectal, or cervical cancer who underwent surgery and chemotherapy from 2009 through 2016. Services from 3 months before to 3 months after chemotherapy for evaluation for fertility preservation, laboratory testing for fertility evaluation, and fertility-preserving procedures were captured. Multivariable models were used to assess the factors associated with the use of fertility-preservation services.

RESULTS

A total of 18,781 women, including 386 cervical, 1372 colorectal, 246 lung, and 16,777 with breast cancer, were identified. In women 18-35 years old, 11.7% underwent evaluation for fertility preservation, 13.7% underwent laboratory testing, and 6.3% pursued fertility-preserving procedures. The rates of office evaluation, laboratory testing, and performance of procedure were 3.3%, 7.5%, and 1.9 % in women aged 36-40 years and 0.5%, 7.2%, and 0.3% in those aged 41-45 years, respectively. The rate of fertility preservation evaluation rose from 1.0% in 2009 to 5.5% in 2016 (risk ratio, 4.66, 95% confidence interval, 2.38-9.11) while use of fertility-preserving procedures increased from 1.0% to 4.6% (risk ratio, 3.84, 95% confidence interval, 1.94-7.59) during the same time period. In a multivariable model, use of any fertility-preserving interventions were more common in patients with breast cancer (adjusted risk ratio, 2.30, 95% confidence interval, 1.30-4.06), those in the Northeast (adjusted risk ratio, 1.24, 95% confidence interval, 1.10-1.40), and in younger women (18-35 years) (adjusted risk ratio, 2.59, 95% confidence interval, 2.32-2.89).

CONCLUSION

Although limited by lack of information regarding cancer stage and desire for future fertility, only a small fraction of reproductive-aged female cancer patients receiving chemotherapy are evaluated in a nationwide sample for fertility preservation or undergo fertility-preserving procedures.

Use of nonclinical staff to coordinate oral anticancer drug prescriptions

72

Background: In September 2018, Herbert Irving Comprehensive Cancer Center (HICCC) began using non-clinical pharmacy liaisons to oversee coordination of oral anticancer drug (OACD) prescriptions (RXs), a task previously performed by clinical staff. Liaisons interact with payers, specialty pharmacies and financial assistance (FA) groups. We assessed the impact of this strategy on time to receipt of OACDs. Methods: We collected prospective data on all new OACD RXs from HICCC’s medical oncology practice from 1/1/2018 to 9/17/2018 (pre-liaisons) and 9/17/2018 to 5/1/2019 (post-liaisons). We collected patient demographic and insurance data; date of prescription; date of drug delivery; and interactions with payers and FA groups. Federal Drug Association labels were reviewed for drug approval dates and indications. Daily drug cost was defined according to average wholesale price. We define time to receipt (TTR) as days from RX to OACD delivery and used multivariable linear regression to determine factors associated with TTR (log transformed). Results: Over the study period, we evaluated 707 RXs; 93 (13%) were never filled. Of 614 filled RXs, 350 (57%) were placed in the pre-liaison period and 264 (43%) in the post-liaison period. After introduction of liaisons, FA was pursued for more RXs (17% vs 25%, p = 0.007); there was no difference pre- and post-liaisons in patient demographics, distribution of payers, RXs needing prior authorization (PA) (76% vs 77%), off-label RXs (14% vs 16%), RXs for drugs approved < 2 years earlier (5% vs 3%) or mean daily cost ($471 vs $470). Mean TTR before and after liaisons were 11.9 and 11.6 days, respectively. Linear regression showed longer TTR was associated with commercial payers (p = 0.02), need for PA (p = 0.03), FA pursuit (p ≤ 0.0001) and daily OACD cost (p = 0.03); no association was seen with use of liaisons, patient age, off-label use or OACDs approved < 2 years earlier. Conclusions: Implementation of pharmacy liaisons to coordinate OACD prescriptions did not impact the time to OACD receipt, though liaisons were able to pursue financial assistance for more patients. Insurance and cost factors had the greatest impact on time to drug receipt. Task shifting may reduce the clerical workload for providers.

Reproductive characteristics are associated with gene-specific promoter methylation status in breast cancer

BACKGROUND

Reproductive characteristics are well-established risk factors for breast cancer, but the underlying mechanisms are not fully resolved. We hypothesized that altered DNA methylation, measured in tumor tissue, could act in concert with reproductive factors to impact breast carcinogenesis.

METHODS

Among a population-based sample of women newly diagnosed with first primary breast cancer, reproductive history was assessed using a life-course calendar approach in an interviewer-administered questionnaire. Methylation-specific polymerase chain reaction and Methyl Light assays were used to assess gene promotor methylation status (methylated vs. unmethylated) for 13 breast cancer-related genes in archived breast tumor tissue. We used case-case unconditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations with age at menarche and parity (among 855 women), and age at first birth and lactation (among a subset of 736 parous women) in association with methylation status.

RESULTS

Age at first birth > 27 years, compared with < 23 years, was associated with lower odds of methylation of CDH1 (OR = 0.44, 95% CI = 0.20-0.99) and TWIST1 (OR = 0.48, 95% CI = 0.28-0.82), and higher odds of methylation of BRCA1 (OR = 1.63, 95% CI = 1.14-2.35). Any vs. no lactation was associated with higher odds of methylation of the PGR gene promoter (OR = 1.59, 95% CI = 1.01-2.49). No associations were noted for parity and methylation in any of the genes assayed.

CONCLUSIONS

Our findings indicate that age at first birth, lactation and, perhaps age at menarche, are associated with gene promoter methylation in breast cancer, and should be confirmed in larger studies with robust gene coverage.

Outcomes of Hysterectomy Performed by Very Low-Volume Surgeons

OBJECTIVE

To perform a population-based analysis to first examine the changes in surgeon and hospital procedural volume for hysterectomy over time and then to explore the association between very low surgeon procedural volume and outcomes.

METHODS

All women who underwent hysterectomy in New York State from 2000 to 2014 were examined. Surgeons were classified based on the average annual procedural volume as very low-volume surgeons if they performed one procedure per year. We used multivariable models to examine the association between very low-volume surgeon status and morbidity, mortality, transfusion, length of stay, and cost.

RESULTS

Among 434,125 women who underwent hysterectomy, very low-volume surgeons accounted for 3,197 (41.0%) of the surgeons performing the procedures and operated on 4,488 (1.0%) of the patients. The overall complication rates were 32.0% for patients treated by very low-volume surgeons compared with 9.9% for those treated by other surgeons (P<.001) (adjusted relative risk 1.97, 95% CI 1.86-2.09). Specifically, the rates of intraoperative (11.3% vs 3.1%), surgical site (15.1% vs 4.1%) and medical complications (19.5% vs 4.8%), and transfusion (38.5% vs 11.8%) were higher for very low-volume compared with higher volume surgeons (P<.001 for all). Patients treated by very low-volume surgeons were also more likely to have a prolonged length of stay (62.0% vs 22.0%) and excessive hospital charges (59.8% vs 24.6%) compared with higher volume surgeons (P<.001 for both). Mortality rate was 2.5% for very low-volume surgeons compared with 0.2% for higher volume surgeons (P<.001) (adjusted relative risk 2.89, 95% CI 2.32-3.61).

CONCLUSION

A substantial number of surgeons performing hysterectomy are very low-volume surgeons. Performance of hysterectomy by very low-volume surgeons is associated with increased morbidity, mortality, and resource utilization.

Failure to Rescue and Mortality Following Resection of Intracranial Neoplasms

BACKGROUND

There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications.

OBJECTIVE

To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms.

METHODS

We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication).

RESULTS

A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]).

CONCLUSION

While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.

Safety of same-day discharge for minimally invasive hysterectomy for endometrial cancer

BACKGROUND

Same-day discharge is becoming increasingly common for women who undergo minimally invasive hysterectomy. For women with endometrial cancer, there are limited data to describe the safety of same-day discharge.

OBJECTIVE

To examine trends and outcomes of same-day discharge for women with endometrial cancer who underwent minimally invasive hysterectomy.

STUDY DESIGN

The National Surgical Quality Improvement Program database was used to identify patients who underwent minimally invasive hysterectomy based for endometrial cancer from 2011 to 2016. The cohort was limited to women discharged on the day of surgery/postoperative day 0 or postoperative day 1. Multivariable models were used to examine clinical, demographic, and procedural characteristics associated with discharge on postoperative day 0. Multivariable models also were developed to examine the association between same-day discharge and readmission.

RESULTS

A total of 17,935 patients who underwent minimally invasive hysterectomy were identified. Of those discharged within 1 day, 1828 (12.4%) were discharged on postoperative day 0 and 12,892 (87.6%) were discharged on postoperative day 1 or after. The rate of same-day discharge rose from 5.6% in 2011 to 16.3% in 2016 (P<.001). In a multivariable model, more recent year of surgery was associated with same-day discharge whereas older age (≥70 years old), chronic obstructive pulmonary disease, and hypertension were associated with a decreased likelihood of same-day discharge. Similarly, obese women were 15% less likely to have a same-day discharge than normal-weight women (risk ratio, 0.85; 95% confidence interval, 0.75-0.97). Hispanic women (risk ratio, 1.61; 95% confidence interval, 1.35-1.92 compared with white women) and those who underwent lymphadenectomy (risk ratio, 1.17; 95% confidence interval, 1.07-1.29) were more likely to have a same-day discharge. The readmission rate was 2.3% in those women discharged on the day of surgery compared with 3.1% in women discharged on postoperative day 1 (P=.051). In a multivariable model, there was no association between same-day discharge and readmission (risk ratio, 0.99; 95% confidence interval, 0.71-1.38). Among women discharged on the day of surgery, a longer operative time and the occurrence of a perioperative complication were associated with readmission.

CONCLUSION

Same-day discharge for minimally invasive hysterectomy for endometrial cancer is increasing. In selected patients, there is no increased risk of readmission with same day discharge.

Urinary concentrations of environmental phenols and their associations with breast cancer incidence and mortality following breast cancer

BACKGROUND

Environmental phenols, compounds used widely in personal care and consumer products, are known endocrine disruptors. Few epidemiologic studies have examined the association of phenol biomarkers with breast cancer incidence and, to our knowledge, none have considered associations with mortality following breast cancer. We examined seven urinary phenol biomarkers in association with breast cancer incidence and subsequent mortality, and examined effect measure modification by body mass index (BMI).

METHODS

Participants included 711 women with breast cancer and 598 women without breast cancer who were interviewed for the population-based Long Island Breast Cancer Study Project. Among women with breast cancer, phenol biomarkers were quantified in spot urine samples collected on average within three months of a first diagnosis of primary in situ or invasive breast cancer in 1996-1997. Women with breast cancer were monitored for vital status using the National Death Index. After a median follow-up of 17.6 years, we identified 271 deaths, including 98 deaths from breast cancer. We examined creatinine-corrected phenol concentrations and the sum of parabens (Σparabens) in association with breast cancer incidence using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs), and with mortality using Cox regression to estimate hazard ratios (HRs) and 95% CIs. We evaluated multiplicative effect measure modification using cross-product terms in nested models.

RESULTS

The highest (vs lowest) quintiles of urinary methylparaben, propylparaben, and Σparabens were associated with risk of breast cancer with ORs ranging from 1.31 to 1.50. Methylparaben, propylparaben, and Σparabens were also associated with all-cause mortality HRs ranging from 0.68 to 0.77. Associations for breast cancer incidence were more pronounced among women with BMI < 25.0 kg/m2 than among women with BMI ≥ 25.0 kg/m2; however, associations for mortality were more pronounced among women with BMI ≥ 25 kg/m2 than among women with BMI < 25 kg/m2.

CONCLUSIONS

Select parabens may have differential associations with risk of developing breast cancer and mortality following breast cancer.

Self-reported residential pesticide use and survival after breast cancer

INTRODUCTION

Previous investigations found elevated mortality after breast cancer in association with biomarkers of persistent organochlorine pesticides in non-occupationally exposed women. We hypothesized that lifetime residential pesticide use, which includes persistent and non-persistent pesticides, would also be associated with increased mortality after breast cancer.

METHODS

A population-based cohort of 1505 women with invasive or in situ breast cancer was interviewed in 1996-1997, shortly after diagnosis, about pre-diagnostic lifetime residential pesticide use. Participants were followed for mortality through 2014 (595 deaths from any cause and 236 from breast cancer, after 17.6 years of follow-up). Pesticides were examined as 15 individual categories; a group of seven used for lawn and garden purposes; a group of eight used for nuisance-pest purposes; and all combined. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and breast cancer-specific mortality. Modification by estrogen receptor (ER) status, body mass index, and long-term residence was examined.

RESULTS

Ever use (HR = 0.77, 95%CI = 0.63-0.95) and higher lifetime applications (4th quartile: HR = 0.62, 95%CI = 0.47-0.81, ptrend = 0.3) of the lawn and garden group of pesticides were inversely associated with all-cause mortality, compared to never use. The inverse association for lawn and garden pesticide use was limited to ER positive (vs. negative) tumors (pinteraction = 0.05). Nuisance-pest pesticides, and all groups combined, were not associated with all-cause or breast cancer-specific mortality.

CONCLUSIONS

Contrary to our hypothesis, lifetime residential use of lawn and garden pesticides, but not all combined or nuisance-pest pesticides, was inversely associated with all-cause mortality after breast cancer.

HIV status does not have an impact on positron emission tomography-computed tomography (PET-CT) findings or radiotherapy treatment recommendations in patients with locally advanced cervical cancer

INTRODUCTION

Positron emission tomography-computed tomography (PET-CT) imaging is commonly used to identify nodal involvement in locally advanced cervical carcinoma, but its appropriateness for that purpose among HIV-positive patients has rarely been studied. We analyzed PET-CT findings and subsequent treatment prescribed in patients with locally advanced cervical carcinoma in Cape Town, South Africa.

METHODS

We identified a cohort of consecutive cervical carcinoma patients International Federation of Gynecology and Obstetrics (FIGO) stage IIB to IIIB at our cancer center who underwent a planning 18-fluorodeoxyglucose (¹⁸FDG) PET-CT scan from January 2015 through December 2018. Demographics, PET-CT findings, and subsequent treatment prescribed were recorded. Patients were selected for PET-CT only if they had no signs of distant disease on staging chest X-ray or abdominal ultrasound; were deemed suitable for radical chemoradiation by the multi-disciplinary team; and had normal renal function. HIV-positive patients ideally had to have been established on continuous antiviral therapy for more than 3 months and to have a CD4 cell count above 150 cells/μL. Small cell and neuroendocrine carcinoma cases were excluded from the study. Differences in demographic and clinical measures between HIV-positive and HIV-negative patients were evaluated by means of t-tests for continuous variables and χ² tests for categorical variables.

RESULTS

Over a 4 year period, 278 patients-192 HIV-negative (69.1%) and 86 HIV-positive (30.9%)-met the inclusion criteria. HIV-positive patients had a median CD4 count of 475 cells/µL (IQR 307-612 cells/µL). More than 80% of patients had pelvic nodal involvement, and more than 40% had uptake in common iliac and/or para-aortic nodes. Nodal involvement was not associated with HIV status. Fifty-four patients (19.4%) had at least one site of distant metastatic disease. Overall, 235 patients (84.5%) were upstaged following PET-CT staging scan. Upstaging was not associated with HIV status (HIV-negative 83.9% vs HIV-positive 87.2%; p=0.47). Ten patients who did not return for radiotherapy were excluded from the analysis. Following their PET-CT scan, treatment intent changed for 124 patients (46.3%): 53.6% of HIV-positive patients and 42.9% of HIV-negative patients (p=0.11).

CONCLUSION

We found no differences between HIV-positive or HIV-negative patients in nodal involvement or occult metastases, and PET-CT imaging did not lead to, or justify, treatment differences between the two groups. Future studies will evaluate survival and correlation of upstaging with outcome.

Extent of resection and survival for oligodendroglioma: a U.S. population-based study

BACKGROUND

National guidelines recommend maximal safe resection of low-grade and high-grade oligodendrogliomas. However, there is no level 1 evidence to support these guidelines, and recent retrospective studies on the topic have yielded mixed results.

OBJECTIVE

To assess the association between extent of resection (EOR) and survival for oligodendrogliomas in the general U.S.

POPULATION

METHODS

Cases diagnosed between 2004 and 2013 were selected from the Surveillance, Epidemiology, and End-Results (SEER) Program and retrospectively analyzed for treatment, prognostic factors, and survival times. Cases that did not undergo tumor de-bulking surgery (e.g. no surgery or biopsy alone) were compared to subtotal resection (resection) and gross-total resection (GTR). The primary end-points were overall survival (OS) and cause-specific survival (CSS). An external validation cohort with 1p/19q-codeleted tumors was creating using the TCGA and GSE16011 datasets.

RESULTS

3135 Cases were included in the final analysis. The 75% survival time (75ST) and 5-year survival rates were 47 months and 70.8%, respectively. Subtotal resection (STR, 75ST = 50 months) and GTR (75ST = 61 months) were associated with improved survival times compared to cases that did not undergo surgical debulking (75ST = 20 months, P < 0.001 for both), with reduced hazard ratios (HRs) after controlling for other factors (HR 0.81 [0.68-0.97] and HR 0.65 [0.54-0.79], respectively). GTR was associated with improved OS in both low-grade and anaplastic oligodendroglioma subgroups (HR 0.74 [0.58-0.95], HR 0.60 [0.44-0.82], respectively) while STR fell short of significance in the subgroup analysis. All findings were corroborated by multivariable analysis of CSS and externally validated in a cohort of patients with 1p19q-codeleted tumors.

CONCLUSION

Greater EOR is associated with improved survival in oligodendrogliomas. Our findings in this U.S. population-based cohort support national guidelines.

Prediagnosis aspirin use, DNA methylation, and mortality after breast cancer: A population-based study

BACKGROUND

The authors hypothesized that epigenetic changes may help to clarify the underlying biologic mechanism linking aspirin use to breast cancer prognosis. To the authors' knowledge, this is the first epidemiologic study to examine whether global methylation and/or tumor promoter methylation of breast cancer-related genes interact with aspirin use to impact mortality after breast cancer.

METHODS

Prediagnosis aspirin use was assessed through in-person interviews within a population-based cohort of 1508 women diagnosed with a first primary breast cancer in 1996 and 1997. Global methylation in peripheral blood was assessed by long interspersed elements-1 (LINE-1) and the luminometric methylation assay. Promoter methylation of 13 breast cancer-related genes was measured in tumor by methylation-specific polymerase chain reaction and the MethyLight assay. Vital status was determined by the National Death Index through December 31, 2014 (N = 202/476 breast cancer-specific/all-cause deaths identified among 1266 women with any methylation assessment and complete aspirin data). Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs, and the likelihood ratio test was used to evaluate multiplicative interactions.

RESULTS

All-cause mortality was elevated among aspirin users who had methylated promotor of BRCA1 (HR, 1.67; 95% CI, 1.26-2.22), but not among those with unmethylated promoter of BRCA1 (HR, 0.99; 95% CI, 0.67-1.45; P for interaction ≤.05). Decreased breast cancer-specific mortality was observed among aspirin users who had unmethylated promotor of BRCA1 and PR and global hypermethylation of LINE-1 (HR, 0.60, 0.78, and 0.63, respectively; P for interaction ≤.05), although the 95% CIs included the null.

CONCLUSIONS

The current study suggests that the LINE-1 global methylation and promoter methylation of BRCA1 and PR in tumor may interact with aspirin use to influence mortality after breast cancer.

Elevation of Serum CEA in Patients with Squamous Cell Carcinoma of the Anus

The proportion of anal cancer cases that produce elevated carcinoembryonic antigen (CEA) levels is not well described in the medical literature. In this study, we used electronic health record data from a single urban cancer center to identify patients from 2004-2018 with anal cancer who have also had a pre-initial treatment CEA measurement. We identified 40 patients who met our eligibility criteria. Of those, 11 (27.5%) had an elevated pretreatment CEA. Elevated CEA was not associated with any of the clinical or demographic covariates; however, three out of five patients with a recurrence had an elevated CEA.

Factors Associated with Multidisciplinary Consultations in Patients with Early Stage Breast Cancer

Purpose: Multidisciplinary care (MDC) encourages multiple specialists to formulate a unified treatment plan. We sought to determine the frequency and predictors of MDC and assess the association between MDC and nationally-recognized quality metrics in patients with breast cancer. Methods: We used the surveillance, epidemiology, and end results-medicare dataset to evaluate patients diagnosed with stages I-III breast cancer who underwent breast-conserving surgery between 2002 and 2011 with follow-up to 2012. We defined MDC as a visit claim from a surgeon, radiation oncologist and medical oncologist within 12 months of diagnosis. We used multivariable regression analysis to determine the association between demographic and clinical variables and MDC, and to assess the association between MDC and three nationally-recognized quality indicators (adjuvant hormone therapy for hormone receptor-positive tumors, chemotherapy for hormone receptor-negative cancer, and radiation after lumpectomy). Results: Of the 61,039 patients in our initial cohort, 53,849 (88.2%) saw a medical oncologist, 46,521 (76.2%) saw a radiation oncologist, and 43,280 (70.9%) were evaluated by all three providers the first year after diagnosis. MDC use was higher in patients with the highest socioeconomic status compared with the lowest [odds ratio (OR) 1.74, 95% CI 1.63-1.86], in patients diagnosed in later years, and those with stage III disease compared to stage I [OR 1.29, 95% CI 1.19-1.41]. Patients older in age (≥80 vs. 65-69 years, OR 0.33, 95% CI 0.31-0.34), patients with more comorbidities, those who lived in a rural setting compared to urban (OR 0.61, 95% CI 0.57-0.64), and unmarried patients (OR 0.79, 95% CI 0.76-0.82) were less likely to see all three providers. In a multivariable analysis, MDC use was associated with increased likelihood of meeting each quality metric. Conclusion: Early stage breast cancer patients were evaluated by a surgeon, radiation oncologist and medical oncologist less than 75% of the time. Enhanced coordination of care and navigation programs may improve the quality of care delivered.

Latino Ethnicity, Immigrant Status, and Preference for End-of-Life Cancer Care

Background: Little is known about how immigration status influences preference for life-extending care (LEC) at the end of life (EoL). Objective: The purpose was to determine how preference for LEC at the EoL for advanced cancer patients varied by Latino ethnicity and immigrant status, and over time between two large cohorts. Methods: Data were derived from two sequential multi-institutional, longitudinal cohort studies of advanced cancer patients, recruited from 2002 to 2008 (coping with cancer I [CwC-1]) and 2010 to 2015 (coping with cancer II [CwC-2]). Self-reported U.S.-born whites (whites) (N = 253), U.S.-born Latinos (US-L) (N = 34), and Latino immigrants (LI) (N = 65) with a poor-prognosis cancer were included. The primary independent variables were immigrant status, Latino ethnicity, and CwC cohort. The primary dependent variable was preference for LEC. Results: Within CwC-2, LI were 9.4 times more likely to prefer LEC over comfort care versus US-L (adjusted odds ratio [AOR] = 9.4; 95% confidence interval [CI]: 1.2-72.4), and US-L were 0.3 times less likely to prefer LEC versus whites (AOR = 0.3; 95% CI: 0.1-1.0). LI from CwC-2 were 11.4 times more likely to prefer LEC versus LI from CwC-1 (AOR = 11.4; 95% CI: 2.7-48.4). Within CwC-1, there was no difference in LEC preference between LI and US-L, nor between US-L and whites. Conclusions: Immigrant status had a strong effect on preference for LEC at the EoL among the more recent cohort of Latino cancer patients. Preference for LEC appears to have increased significantly over time for LI but remained unchanged for US-L. LI may increasingly want LEC near death.

Abstract 3294: Urinary estrogen metabolites and long-term all-cause and cause-specific mortality following breast cancer diagnosis: A population-based study

Background: Estrogen metabolites play a role in breast cancer development. Previous studies have particularly focused on the two competing metabolism pathways which yield metabolites 2-hydroxyestrone (2-OHE1) and 16-hydroxyestrone (16-OHE1). 2-OHE1 has been shown to have antiestrogenic effects, but 16-OHE1has strong estrogenic and even genotoxic activity. No study has investigated their biologically plausible role in predicting prognosis/mortality among women diagnosed with breast cancer.

Methods: In the Long Island Breast Study Project, spot urine samples were obtained from 687 women diagnosed with first primary breast cancer (shortly after diagnosis) in 1996-1997. Urinary concentrations of estrogen metabolites 2-OHE1 and 16-OHE1 were measured using enzyme linked immuno-assay. Vital status was determined by the National Death Index through December 31, 2014; 244 deaths (84 breast cancer-specific and 80 cardiovascular diseases-specific) were identified. We used multivariable-adjusted Cox proportional hazards regression model to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for all-cause, breast cancer and cardiovascular diseases mortality as related to the two individual metabolites and their ratio (2-OHE1/16-OHE1). Multiplicative interactions with menopausal hormone therapy, body mass index, menopausal status, and breast cancer treatments were evaluated with likelihood ratio tests.

Results: During a median follow-up of 18 years, urinary concentration of the 2-OHE1/16-OHE1 ratio (&gt; median of 1.8 vs. ≤ median of 1.8) was associated with reduced risk of all-cause mortality (HR=0.74, 95% CI=0.56-0.98) among women with breast cancer. This inverse association with the 2-OHE1/16-OHE1 ratio was also observed for breast cancer mortality (HR=0.73, 95% CI=0.45-1.17) and cardiovascular diseases mortality (HR=0.76, 95% CI=0.47-1.23), although the 95%CIs included the null. The 2-OHE1/16-OHE1 ratio-mortality associations did not significantly differ by menopausal hormone therapy, body mass index, and menopausal status at the time of urine collection (Pinteration &gt;0.05). Consistent patterns of association were not observed between the individual metabolites and mortality outcomes.

Conclusion: To our knowledge, our study represents the first population-based epidemiologic evidence suggesting that the urinary concentration of the 2-OHE1/16-OHE1 ratio measured shortly after breast cancer diagnosis may be associated with improved overall mortality for breast cancer survivors. Future investigation is necessary to confirm our findings and to further understand the underlying biological mechanisms for estrogen metabolism–mortality relationships following breast cancer diagnosis.

Citation Format: Tengteng Wang, Patrick B. Bradshaw, Sarah J. Nyante, Hazel B. Nichols, Patricia G. Moorman, Geoffrey C. Kabat, Susan L. Teitelbaum, Alfred I. Neugut, Marilie D. Gammon. Urinary estrogen metabolites and long-term all-cause and cause-specific mortality following breast cancer diagnosis: A population-based study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3294.

Use of Bevacizumab for Elderly Patients With Stage IV Colon Cancer: Analysis of SEER-Medicare Data

BACKGROUND

Bevacizumab is used for the treatment of metastatic colon cancer in conjunction with first-line chemotherapy. In this study, we examined receipt of first-line bevacizumab and predictors of its use among older patients with stage IV colon cancer.

MATERIALS AND METHODS

We used data from the Surveillance, Epidemiology, and End Results-Medicare dataset to identify patients with stage IV colon cancer diagnosed from 2005 to 2013 who received FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) or FOLFIRI (5-fluorouracil/leucovorin/irinotecan) as first-line therapy. We used multivariable regression analysis to determine demographic and clinical factors associated with use of concomitant bevacizumab.

RESULTS

We identified 3785 patients with stage IV colon cancer who met our eligibility criteria. Of these, 2352 (62.1%) received bevacizumab. Bevacizumab use has decreased over time from 68.2% in 2005 to 57.6% in 2013 (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.91-0.97). Patients were less likely to receive bevacizumab if they were older (compared with 65-69 years, ≥ 80 years: OR, 0.64; 95% CI, 0.52-0.80), or had multiple comorbidities (compared with comorbidity score of 0, score of 1: OR, 0.73; 95% CI, 0.60-0.89).

CONCLUSION

Over one-half of elderly patients received bevacizumab as part of their first-line therapy for stage IV colon cancer. Bevacizumab use has been slowly decreasing since 2005. Newer anti-epidermal growth factor receptor treatments have not been supplanting bevacizumab, as first-line biologic use in general has also decreased during this time period.

Quality of Care and Outcomes of Patients With Gynecologic Malignancies Treated at Safety-Net Hospitals

Background

Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers.

Methods

We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Medicaid beneficiaries were defined as SNH. Quality metrics were derived from evidence-based recommendations. Thirty-day mortality, readmission rates, and 5-year survival were calculated. Multivariable models were developed to determine the association between treatment at SNH and outcomes.

Results

Overall, 594 750 patients diagnosed with gynecologic cancer were treated at 1340 hospitals. Compared with non-SNH, patients at SNH were younger, more frequently racial minorities, low income, and had more aggressive histologies and advanced-stage tumors. SNH had lower rates of minimally invasive surgery for uterine cancer (62.3% vs 75.9%, P < .0001), debulking for ovarian cancer (83.6% vs 86.9%, P < .05), and lymph node assessment for all three cancer types (P < .05). Rates of chemotherapy for uterine and ovarian cancer was greater whereas concurrent chemoradiation for cervical cancer was lower (P < .05 for all). Thirty-day mortality and readmission rates were equivalent. Mortality was moderately worse for patients with stage IV ovarian cancer and stage II-III cervical cancer (P < .05) but were otherwise equivalent.

Conclusions

After adjusting for patient and tumor characteristics, women with gynecologic cancers treated at SNH receive lower-quality surgical care and equivalent medical care and a subset of these patients has modest decreases in survival.

Clair CM, Hou JY, Khoury-Collado FMD, Ananth CV, Neugut AI, Hershman DL. Potential Consequences of Minimum-Volume Standards for Hospitals Treating Women With Ovarian Cancer

OBJECTIVE

To assess the potential effects of implementing minimum hospital volume standards for ovarian cancer on survival and access to care.

METHODS

We used the National Cancer Database to identify hospitals treating women with ovarian cancer from 2005 to 2015. We estimated the number of patients treated by each hospital during the prior year. Multivariable models were used to estimate the ratio of observed/expected 60-day, and 1-, 2- and 5-year mortalities. The mean predicted observed/expected ratio of hospitals was plotted based on prior year volume. The number of hospitals that would be restricted if minimum-volume standards were implemented was modeled.

RESULTS

A total of 136,196 patients treated at 1,321 hospitals were identified. Increasing hospital volume was associated with decreased 60-day (P=.004), 1-year (P<.001), 2-year (P<.001) and 5-year (P=.008) mortality. In 2015, using a minimum-volume cutpoint of one case in the prior year would eliminate 144 (13.6%) hospitals (treated 2.6% of all patients); a cutpoint of three would eliminate 364 (34.5%) hospitals (treated 7.7% of the patients). The mean observed/expected ratios for hospitals with a prior year volume of 1 was 1.14 for 60-day mortality, 1.06 for 1-year mortality, 1.12 for 2-year mortality, and 1.08 for 5-year mortality. Among hospitals with a prior year volume of one, 49.2% had an observed/expected ratio for 2-year mortality of at least 1 (indicating worse than expected performance), and 50.8% had an observed/expected ratio of less than 1 (indicating better than expected performance). The mean observed/expected ratios for hospitals with a prior year volume of two or less were 1.11 for 60-day mortality, 1.09 for 1-year mortality, 1.08 for 2-year mortality, and 1.07 for 5-year mortality. Implementing a minimum-volume standard of one case in the prior year would result in one fewer death for every 198 patients at 60 days, for every 613 patients at 1 year, and for every 62 patients at 5 years.

CONCLUSION

Implementation of minimum hospital volume standards could restrict care at a significant number of hospitals, including many centers with better-than-predicted outcomes.

Clair CM, Hou JY, Tergas AI, Melamed A, Ananth CV, Neugut AI, Hershman DL, Wright JD. Development and validation of a risk-calculator for adverse perioperative outcomes for women with ovarian cancer

BACKGROUND

Primary cytoreduction followed by platinum-based chemotherapy is the primary treatment for advanced ovarian cancer. However, neoadjuvant chemotherapy followed by interval debulking is an alternative option, particularly in those who may be poor surgical candidates.

OBJECTIVE

The objective of this study was to determine factors associated with short-term, significant perioperative morbidity and mortality for women undergoing surgery for ovarian cancer and to create a nomogram to predict the risk of adverse perioperative outcomes.

STUDY DESIGN

We used the National Surgical Quality Improvement Program database to identify women with ovarian, fallopian tube, or primary peritoneal cancer who underwent surgery from 2011 to 2015. Demographic factors, clinical characteristics, comorbidity, functional status, and the extent of surgery were used to predict the risk of severe perioperative complications or death using multivariable models. Multiple imputation methods were employed for missing data. A nomogram was developed based on the final model. The discrimination ability of the model was assessed with a calibration plot and discrimination concordance index.

RESULTS

We identified a total of 7029 patients. Overall, 5.8% of patients experienced a Clavien-Dindo IV complication, 9.8% of patients were readmitted, 3.0% of patients required a reoperation, and 0.9% of patients died within 30 days. Among the baseline variables assessed, increasing age, emergent surgery, ascites, bleeding disorder, low albumin, higher American Society of Anesthesiology classification score, and a higher extended procedure score were associated with serious perioperative morbidity or mortality. Of these factors, performance of ≥3 cytoreductive procedures (adjusted odds ratio 4.53, 95% confidence interval 3.01-6.82), American Society of Anesthesiology classification score ≥ class 4 (adjusted odds ratio 2.89, 95% confidence interval 1.17-7.14), bleeding disorder (adjusted odds ratio 2.73, 95% confidence interval 1.82-4.10), and age ≥80 years (adjusted odds ratio 2.46, 95% confidence interval 1.66-3.63) were most strongly associated with risk of an event. The final nomogram included the above variables and had an internal discrimination concordance index of 0.71, with accurate predictions in an internal validation set, indicating a 71% correct identification of patients across all possible pairs.

CONCLUSION

Women undergoing surgery for ovarian cancer are at significant risk for the occurrence of adverse perioperative outcomes. Using readily identifiable characteristics, this nomogram can predict adverse outcomes.