Using hospital medical record data to assess the accuracy of the SEER Los Angeles Cancer Surveillance Program for initial treatment of prostate cancer: a small pilot study

Drivers of Differential Time to Diagnosis in Pediatric ALL Tied to Race and Ethnicity

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy, with diagnosis preceded by symptoms that may include fever, weight loss, fatigue, bleeding, and bruising. Timely diagnosis and treatment of ALL may lead to improved outcomes and reduced morbidity from associated complications, including tumor lysis syndrome, hyperviscosity, and stroke. We performed a retrospective cohort analysis of 274 pediatric pre-B cell ALL and acute lymphoblastic lymphoma patients within Montefiore Health System to determine whether there were factors associated with time from symptom onset to diagnosis. The median time to diagnosis for all patients was 11.5 days (interquartile range: 7.8, 14.3). Those with Medicaid insurance (n=189) were diagnosed sooner than those with private/self-pay insurance (n=85) (median of 10 vs. 16 days; P =0.05). English and other language speakers experienced fewer median days from symptom onset to diagnosis date compared with Spanish speakers (11 vs. 7 vs. 14; P =0.05). Insurance status may impact the time to diagnosis to a greater degree in non-Hispanic patients, while the English language and female sex may represent a greater advantage to Hispanic patients. Insurance status and language preference may impact the time to diagnosis of pediatric ALL. There is a further need to confirm our findings and to study possible causes driving these disparities.

Early death from childhood cancer: First medical record-level analysis reveals insights on diagnostic timing and cause of death

BACKGROUND

Approximately 7.5% of pediatric cancer deaths occur in the first 30 days post diagnosis, termed early death (ED). Previous database-level analyses identified increased ED in Black/Hispanic patients, infants, late adolescents, those in poverty, and with specific diagnoses. Socioeconomic and clinical risk factors have never been assessed at the medical record level and are poorly understood.

METHODS

We completed a retrospective case-control study of oncology patients diagnosed from 1995 to 2016 at Children's Hospital Colorado. The ED group (n = 45) was compared to a non-early death (NED) group surviving >31 days, randomly selected from the same cohort (n = 44). Medical records and death certificates were manually reviewed for sociodemographic and clinical information to identify risk factors for ED.

RESULTS

We identified increased ED risk in central nervous system (CNS) tumors and, specifically, high-grade glioma and atypical teratoid/rhabdoid tumor. There was prolonged time from symptom onset to seeking care in the ED group (29.4 vs. 9.8 days) with similar time courses to diagnosis thereafter. Cause of death was most commonly from tumor progression in brain/CNS tumors and infection in hematologic malignancies.

CONCLUSIONS

In this first medical record-level analysis of ED, we identified socioeconomic and clinical risk factors. ED was associated with longer time from first symptoms to presentation, suggesting that delayed presentation may be an addressable risk factor. Many individual patient-level risk factors, including socioeconomic measures and barriers to care, were unable to be assessed through record review, highlighting the need for a prospective study to understand and address childhood cancer ED.

Examining Final-Administered Medication as a Measure of Data Quality: A Comparative Analysis of Death Data with the Central Cancer Registry in Republic of Korea

Death is a crucial outcome in retrospective cohort studies, serving as a criterion for analyzing mortality in a database. This study aimed to assess the quality of extracted death data and investigate the potential of the final-administered medication as a variable to quantify accuracy for the validation dataset. Electronic health records from both an in-hospital and the Korean Central Cancer Registry were used for this study. The gold standard was established by examining the differences between the dates of in-hospital deaths and cancer-registered deaths. Cosine similarity was employed to quantify the final-administered medication similarities between the gold standard and other cohorts. The gold standard was determined as patients who died in the hospital after 2006 and whose final hospital visit/discharge date and death date differed by 0 or 1 day. For all three criteria-(a) cancer stage, (b) cancer type, and (c) type of final visit-there was a positive correlation between mortality rates and the similarities of the final-administered medication. This study introduces a measure that can provide additional accurate information regarding death and differentiates the reliability of the dataset.

Primary site as a novel prognostic factor for cardiovascular mortality post-radiotherapy in limited-stage small cell lung cancer: A large population-based study

Background

The effect of primary site on cardiovascular mortality (CVM) post-radiotherapy (RT) in patients with limited-stage small cell lung cancer (LS-SCLC) remains unclear.

Methods

We screened the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2013. We used cumulative incidence function (CIF) curves to compare CVM incidences, and performed Cox proportional hazards and Fine-Gray competing risk analyses to identify independent risk factors of CVM. Propensity score matching (PSM) analysis was conducted.

Results

Among enrolled 4,824 patients (median age 57 years old, 49.2% were male), CVM accounts for 10.0% of all deaths after 5 years since cancer diagnosis. Hazard ratios (HRs) for CVM were 1.97 (95% CI: 1.23–3.16, P = 0.005) for main bronchus (MB) patients, 1.65 (95% CI: 1.04–2.63, P = 0.034) for lower lobe (LL) patients and 1.01 (95% CI: 0.40–2.59, P = 0.977) for middle lobe (ML) patients compared to upper lobe (UL) patients. CIF curves showed that the cumulative CVM incidence was greater in the re-categorized MB/LL group compared to UL/ML group both before PSM (P = 0.005) and after PSM (P = 0.012). Multivariate regression models indicated that MB/LL was independently associated with an increased CVM risk, before PSM (HR_Cox: 1.79, 95% CI: 1.23–2.61, P = 0.002; HR_Fine−Gray: 1.71, 95% CI: 1.18–2.48, P = 0.005) and after PSM (HR_Cox: 1.88, 95% CI: 1.20–2.95, P = 0.006; HR_Fine−Gray: 1.79, 95% CI: 1.15–2.79, P = 0.010).

Conclusions

MB/LL as the primary site is independently associated with an increased CVM risk post-RT in patients with LS-SCLC.

Socioeconomic and Racial Determinants of Brachytherapy Utilization for Cervical Cancer: Concerns for Widening Disparities

PURPOSE

Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database.

MATERIALS AND METHODS

In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared.

RESULTS

Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) + BT, whereas 3,434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P < .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P < .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P < .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P < .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P < .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P = .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P = .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P = .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P < .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P < .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P < .0001) and the 5-year DSS was 55.6% versus 60.5% (P < .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT + BT, with the 5-year OS of 57.3% versus58.5% (P = .24) and the 5-year DSS of 66.3% versus 66.6% (P = .53) for Black and White patients, respectively.

CONCLUSION

This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.

Outcomes of Active Surveillance for Men With Intermediate Risk Prostate Cancer: A Population-Based Analysis

OBJECTIVE

To assesses if active surveillance (AS) is an appropriate treatment modality for patients with intermediate risk (IR) prostate cancer (PCa) utilizing population-level data to compare the survival outcomes of men with low risk (LR) and IR PCa initially treated with AS, watchful waiting (WW) or active treatment (AT).

METHODS

In total, 166,244 patients were initially identified in the surveillance, epidemiology, and end results database using biopsy Gleason grade group (GG) alone-GG1 and GG2. In total, 94,891 patients with GG1 and GG2 disease were further stratified by National Comprehensive Cancer Network risk categories-LR, favorable IR (fIR), and unfavorable IR (uIR). Predictors of cancer-specific (CSS) and overall survival (OS) were analyzed, stratified by risk classification and initial treatment-AT (first-line curative surgery or radiotherapy), AS or WW, utilizing the new "Watchful waiting recode (2010+)" variable.

RESULTS

We found GG2 patients on AS had worse CSS and OS than GG2 patients who received AT and GG1 patients treated with AS or AT; these trends persist within the National Comprehensive Cancer Network fIR and uIR cohorts. WW patients (GG1, GG2, LR, fIR, and uIR) had the worst survival outcomes of any cohort (log-rank tests P < .05).

CONCLUSIONS

We demonstrate a significantly worse 5-year CSS and OS for men with GG2, fIR, and uIR PCa treated with AS compared to AT. Our analysis suggests that AS should not be the preferred treatment modality for IR PCa.

Dual Primary Cancer Patients With Lung Cancer as a Second Primary Malignancy: A Population-Based Study

BACKGROUND

Research on patients with lung cancer as a second primary malignancy (LCSPM) remains limited. This study aims to determine the clinical characteristics, prognosis, and temporal relationship of other cancers to lung cancer in these patients.

METHODS

This study retrospectively analyzed 3465 patients with dual primary cancers from the 5253 patients with LCSPM retrieved from the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2015.

RESULTS

2285 eligible patients were further analyzed in this study cohort with 59.3% of 1-year OS, 34.7% of 3-year OS, and 25.2% of 5-year OS. The most common first primary cancer (FPC) in dual primary cancer patients with LCSPM was prostate cancer, followed by female breast cancer and urinary bladder cancer. In the entire study population, the median interval between the two primary malignancies was 21 months (range: 3.5-52 months). Age, sex, FPC location, surgery, stage, and histology of lung cancer were regarded as independent prognostic factors for these patients. The prognosis of patients with urinary bladder cancer as FPC was the worst in the univariate (p = 0.024) and multivariate (p < 0.001) Cox analyses. Lung cancer-directed surgery could significantly improve long-term survival (HR = 0.22, p < 0.001). Additionally, the C-index of the established nomogram with acceptable calibration curves was 0.760 (95% CI: 0.744-0.776) in the training cohort and was 0.759 (95% CI: 0.737-0.781) in the validation cohort, showing an ideal model discrimination ability. The corresponding decision curve analysis (DCA) indicated the nomogram had relatively ideal clinical utility.

CONCLUSIONS

Cancer patients still have the risk of developing a new primary lung cancer. Close, lifelong follow-up is recommended for all these patients. Early detection for surgical treatment will significantly improve the prognosis of dual primary cancer patients with LCSPM. The nomogram developed to predict 1-, 3-, and 5-year OS rates has relatively good performance.

Long-Term Outcomes in 10-Year Survivors of Early-Stage Hodgkin Lymphoma

PURPOSE

Although radiation therapy improves progression-free survival in early-stage Hodgkin lymphoma (HL), substantial concerns remain regarding the impact of delayed normal tissue effects on quality of life and survival. We hypothesized that treatment with combined-modality therapy (CMT; chemotherapy and radiation therapy) improves overall survival among 10-year survivors compared with treatment with radiation therapy or chemotherapy alone.

METHODS AND MATERIALS

We compared patients in the Surveillance, Epidemiology, and End Results database who received a diagnosis of stage I/II HL between 1983 and 2006 who received chemotherapy and/or external beam radiation and survived at least 10 years. Our primary study outcome was overall survival; we also analyzed cause-specific and other-cause-specific survival.

RESULTS

Of 10,443 ten-year survivors of stage I/II classical HL, 33.6% received chemotherapy alone, 23.8% radiation therapy alone, and 42.6% CMT. Median follow-up was 16.1 years. On multivariate analysis including race, stage, sex, age, and "modern" treatment in 1995 and later, 10-year survivors who received CMT had improved overall survival relative to survivors who received RT alone (hazard ratio, 1.41; 95% confidence interval, 1.21-1.64; P < .01) or chemotherapy alone (hazard ratio, 1.35; 95% confidence interval, 1.16-1.57; P < .01).

CONCLUSIONS

This survival difference was driven by an increase in death from both HL and non-HL causes in those treated with chemotherapy alone. Our analysis suggests that CMT offers optimal survivorship for patients with stage I/II HL.

Association of Sociodemographic and Health-Related Factors With Receipt of Nondefinitive Therapy Among Younger Men With High-Risk Prostate Cancer

IMPORTANCE

Multiple randomized clinical trials have shown that definitive therapy improves overall survival among patients with high-risk prostate cancer. However, many patients do not receive definitive therapy because of sociodemographic and health-related factors.

OBJECTIVE

To identify factors associated with receipt of nondefinitive therapy (NDT) among patients aged 70 years and younger with high-risk prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study identified 72 036 patients aged 70 years and younger with high-risk prostate cancer and Charlson Comorbidity Index scores of 2 or less who were entered in the National Cancer Database between January 2004 and December 2014. Data analysis was conducted from November 2018 to December 2019.

EXPOSURE

Receipt of NDT as an initial treatment approach.

MAIN OUTCOMES AND MEASURES

Survival rates were compared based on receipt of definitive therapy or NDT, and sociodemographic and health-related factors were associated with the type of therapy received. Residual life expectancy was estimated from the National Center for Health Statistics to calculate person-years of life lost.

RESULTS

A total of 72 036 men with a median (range) age of 63 (30-70) years, Charlson Comorbidity Index scores of 2 or less, and high-risk prostate cancer without regional lymph node or distant metastatic disease were analyzed. Among eligible patients, 5252 (7.3%) received NDT as an initial therapeutic strategy. On univariate and multivariate analyses, NDT was associated with worse overall survival (univariate analysis hazard ratio, 2.54; 95% CI, 2.40-2.69; P < .001; multivariate analysis hazard ratio, 2.40; 95% CI, 2.26-2.56; P < .001). Compared with patients with private insurance or managed care, those with no insurance, Medicaid, or Medicare were more likely to receive systemic therapy only (no insurance: odds ratio [OR], 3.34; 95% CI, 2.81-3.98; P < .001; Medicaid: OR, 2.92; 95% CI, 2.48-3.43; P < .001; Medicare: OR, 1.36; 95% CI, 1.20-1.53; P < .001) or no treatment (no insurance: OR, 2.63; 95% CI, 2.24-3.08; P < .001; Medicaid: OR, 1.71; 95% CI, 1.45-2.01; P < .001; Medicare: OR, 1.14; 95% CI, 1.04-1.24; P = .004). Compared with white patients, black patients were more likely to receive systemic therapy only (OR, 1.93; 95% CI, 1.74-2.14; P < .001) or no treatment (OR, 1.46; 95% CI, 1.32-1.61; P < .001), and Hispanic patients were more likely to receive systemic therapy only (OR, 1.36; 95% CI, 1.13-1.64; P = .001) or no treatment (OR, 1.36; 95% CI, 1.14-1.60; P < .001). Between 2004 and 2014, patients without insurance or enrolled in Medicaid had 1.83-fold greater person-years of life lost compared with patients with private insurance (area under the curve, 77 600 vs 42 300 person-years of life lost).

CONCLUSIONS AND RELEVANCE

In this study, receipt of NDT was associated with insurance status and race/ethnicity. While treatment decisions should be individualized for every patient, younger men with high-risk prostate cancer and minimal comorbidities should be encouraged to receive definitive local therapy regardless of other factors. These data suggest that significant barriers to life-extending treatment options for patients with prostate cancer remain.

Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends

BACKGROUND

The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends.

METHODS

In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics.

RESULTS

Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true.

CONCLUSIONS

Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Lung Cancer in Nonelderly Patients: Facility and Patient Characteristics Associated With Not Receiving Treatment

Background: In elderly patients with lung cancer, race/ethnicity is associated with not receiving treatment; however, little attention has been given to nonelderly patients (aged ≤65 years) with a range of disease stages and histologies. Nonelderly patients with lung cancer have superior survival at NCI-designated Comprehensive Cancer Centers (CCCs), although the reasons remain unknown. Patients and Methods: A retrospective cohort study was conducted in 9,877 patients newly diagnosed with small cell or non–small cell lung cancer (all stages) between ages 22 and 65 years and reported to the Los Angeles County Cancer Surveillance Program registry between 1998 and 2008. Multivariable logistic regression examined factors associated with nontreatment. Results: In multivariable analysis, race/ethnicity was associated with not receiving cancer treatment (black: odds ratio [OR], 1.22; P=.004; Hispanic: OR, 1.17; P=.04), adjusting for patient age, sex, disease stage, histology, diagnosis year, distance to treatment facility, type of facility (CCC vs non-CCC), and insurance status. With inclusion of socioeconomic status (SES) in the model, the effect of race/ethnicity was no longer significant (black: OR, 1.02; P=.80; Hispanic: OR, 1.00; P=1.00). Factors independently associated with nontreatment included low SES (OR range, 1.37–2.15; P<.001), lack of private insurance (public: OR, 1.71; P<.001; uninsured: OR, 1.30; P<.001), and treatment facility (non-CCC: OR, 3.22; P<.001). Conclusions: In nonelderly patients with lung cancer, SES was associated with nontreatment, mitigating the effect of race/ethnicity. Patients were also at higher odds of nontreatment if they did not have private insurance or received cancer care at a non-CCC facility. These findings highlight the importance of understanding how both patient-level factors (eg, SES, insurance status) and facility-level factors (eg, treatment facility) serve as barriers to treatment of nonelderly patients with lung cancer.