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Bush A, Liu CM, Rula EY, Luh J, Yu NY, Laack N, Attia A, Waddle M. Caught Between a Radiation Oncology Case Rate (ROCR) and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02585-9. [PMID: 38986915 DOI: 10.1016/j.ijrobp.2024.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from 3 large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement. METHODS AND MATERIALS Using Mayo Clinic electronic medical record data from 2017 to 2020 and part B claims from the Medicare 5% research identifiable files, episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. Mayo Clinic reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates. RESULTS From Mayo Clinic, 3498 patient episodes were included and 480,526 from the research identifiable files. From both data sets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for Mayo Clinic and the research identifiable files respectively compared with historical reimbursement. On multivariate analysis of Mayo Clinic data, treatment intent (curative vs palliative) was associated with higher historical reimbursement (+$477 to +$7417; P ≤.05) for 12 out of 12 applicable cancer types. Stage (III-IV vs I-II) was associated with higher historical reimbursement (+$1169 to +$3917; P ≤ .05) for 8 out of 12 applicable cancer types. CONCLUSIONS Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared with historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced-stage patients such as freestanding centers in rural settings.
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Affiliation(s)
| | - Chi-Mei Liu
- Neiman Health Policy Institute, Reston, Virginia
| | | | - Join Luh
- St. Joseph Hospital, Eureka, California
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Akimoto T, Aoyama H, Chua ML, Jayamanne D, Mizowaki T, Morris L, Onishi H, Song SY, Zeidan YH, Sharma RA. Challenges and Opportunities With the Use of Hypofractionated Radiation Therapy in Cancer Care: Regional Perspectives From South Korea, Japan, Singapore, and Australia. Adv Radiat Oncol 2023; 8:101291. [PMID: 37457823 PMCID: PMC10344660 DOI: 10.1016/j.adro.2023.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023] Open
Abstract
Hypofractionated radiotherapy schedules provide higher per-fraction radiation doses delivered in fewer fractions than conventional schedules. This novel delivery method is supported by a large body of clinical trial evidence across various cancer sites in both curative and palliative settings. Hypofractionation is associated with benefits such as lower costs, improved patient access and increased treatment precision, which has led to its inclusion in various treatment guidelines. Despite this, utilization is not uniform across cancer sites and geographic regions due to reasons such as reimbursement models, nuances in healthcare systems, and professional culture. Key factors to ensure patients benefit from access to high quality radiotherapy include publishing clinical evidence, cross-country collaboration to fill knowledge gaps, reviewing reimbursement models, and improving patient advocacy in treatment decision-making.
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Affiliation(s)
- Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Chiba, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Melvin L.K. Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore
- Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Dasantha Jayamanne
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Lucinda Morris
- Department of Radiation Oncology, St George Hospital, Sydney, New South Wales, Australia
| | | | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youssef H. Zeidan
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
- Baptist Health, Lynn Cancer Institute, Boca Raton, Florida
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Arakawa Y, Mineharu Y, Uto M, Mizowaki T. Optimal managements of elderly patients with glioblastoma. Jpn J Clin Oncol 2022; 52:833-842. [PMID: 35552425 PMCID: PMC9841411 DOI: 10.1093/jjco/hyac075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/19/2022] [Indexed: 01/21/2023] Open
Abstract
Optimizing the management of elderly patients with glioblastoma is an ongoing task in neuro-oncology. The number of patients with this tumor type is gradually increasing with the aging of the population. Although available data and practice recommendations remain limited, the current strategy is maximal safe surgical resection followed by radiotherapy in combination with temozolomide. However, survival is significantly worse than that in the younger population. Surgical resection provides survival benefit in patients with good performance status. Hypofractionated radiotherapy decreases toxicities while maintaining therapeutic efficacy, thus improving treatment adherence and subsequently leading to better quality of life. The intensity of these treatments should be balanced with patient-specific factors and consideration of quality of life. This review discusses the current optimal management in terms of efficacy and safety, as well as future perspectives.
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Affiliation(s)
- Yoshiki Arakawa
- For reprints and all correspondence: Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail: ; Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumi Uto
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Mizowaki
- For reprints and all correspondence: Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail: ; Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:
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de Melo SM, Marta GN, Latorraca CDOC, Martins CB, Efthimiou O, Riera R. Hypofractionated radiotherapy for newly diagnosed elderly glioblastoma patients: A systematic review and network meta-analysis. PLoS One 2021; 16:e0257384. [PMID: 34735442 PMCID: PMC8568110 DOI: 10.1371/journal.pone.0257384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate different hypofractionated radiotherapy (HRT) regimens for newly diagnosed elderly glioblastoma (GBM) patients. METHODS We performed a systematic review with network meta-analysis (NMA), including searches on CENTRAL, Medline, EMBASE, CINAHL, clinical trial databases and manual search. Only randomized clinical trials (RCTs) were included. Primary outcomes: overall survival (OS) and adverse events (AE). Secondary outcomes: progression-free-survival (PFS) and quality of life (QoL). We used the Cochrane Risk of Bias (RoB) table for assessing individual studies and CINeMA for evaluating the certainty of the final body of evidence. RESULTS Four RCTs (499 patients) were included. For OS, the estimates from NMA did not provide strong evidence of a difference between the HRTs: 40 Gray (Gy) versus 45 Gy (HR: 0.89; CI 95%: 0.42, 1.91); 34 Gy versus 45 Gy (HR: 0.85; CI 95% 0.43, 1.70); 25 Gy versus 45 Gy (HR: 0.81; CI 95% 0.32, 2.02); 34 Gy versus 40 Gy (HR: 0.95; CI 95% 0.57, 1.61); and 25 Gy versus 34 Gy (HR: 0.95; CI 95% 0.46, 1.97). We performed qualitative synthesis for AE and QoL due to data scarcity and clinical heterogeneity among studies. The four studies reported a similar QoL (assessed by different methods) between arms. One RCT reported grade ≥ 3 AE, with no evidence of a difference between arms. PFS was reported in one study (25 Gy versus 40 Gy), with no evidence of a difference between arms. CONCLUSION This review found no evidence of a difference between the evaluated HRTs for efficacy and safety.
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Affiliation(s)
- Suely Maymone de Melo
- Neuro-Oncology–Hospital do Coração de Sao Paulo, Sao Paulo, Brazil
- Evidence-Based Medicine Post-graduation Program, Universidade Federal de São Paulo (Unifesp), Sao Paulo, Brazil
- Department of Neurosurgery Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), Sao Paulo, Brazil
- * E-mail: (SMM)
| | | | | | - Camila Bertini Martins
- Department of Preventive Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), Sao Paulo, Brazil
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicin—Universität Bern, Bern, Switzerland
| | - Rachel Riera
- Discpline of Evidence-based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), Sao Paulo, Brazil
- Center of Health Technology Assessment—Hospital Sírio-Libanês, Sao Paulo, Brazil
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Lee JW, Kirkpatrick JP, McSherry F, Herndon JE, Lipp ES, Desjardins A, Randazzo DM, Friedman HS, Ashley DM, Peters KB, Johnson MO. Adjuvant Radiation in Older Patients With Glioblastoma: A Retrospective Single Institution Analysis. Front Oncol 2021; 11:631618. [PMID: 33732649 PMCID: PMC7959812 DOI: 10.3389/fonc.2021.631618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/14/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Standard 6-week and hypofractionated 3-week courses of adjuvant radiation therapy (RT) are both options for older patients with glioblastoma (GBM), but deciding the optimal regimen can be challenging. This analysis explores clinical factors associated with selection of RT course, completion of RT, and outcomes following RT. MATERIALS AND METHODS This IRB-approved retrospective analysis identified patients ≥70 years old with GBM who initiated adjuvant RT at our institution between 2004 and 2016. We identified factors associated with standard or hypofractionated RT using the Cochran-Armitage trend test, estimated time-to-event endpoints using the Kaplan-Meier method, and found predictors of overall survival (OS) using Cox proportional hazards models. RESULTS Sixty-two patients with a median age of 74 (range 70-90) initiated adjuvant RT, with 43 (69%) receiving standard RT and 19 (31%) receiving hypofractionated RT. Selection of short-course RT was associated with older age (p = 0.04) and poor KPS (p = 0.03). Eight (13%) patients did not complete RT, primarily for hospice care due to worsening symptoms. After a median follow-up of 37 months, median OS was 12.3 months (95% CI 9.0-15.1). Increased age (p < 0.05), poor KPS (p < 0.0001), lack of MGMT methylation (p < 0.05), and lack of RT completion (p < 0.0001) were associated with worse OS on multivariate analysis. In this small cohort, GTV size and receipt of standard or hypofractionated RT were not associated with OS. CONCLUSIONS In this cohort of older patients with GBM, age and KPS was associated with selection of short-course or standard RT. These regimens had similar OS, though a subset of patients experienced worsening symptoms during RT and discontinued treatment. Further investigation into predictors of RT completion and survival may help guide adjuvant therapies and supportive care for older patients.
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Affiliation(s)
- Jessica W. Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, United States
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, United States
| | - Frances McSherry
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - James E. Herndon
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Eric S. Lipp
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - Annick Desjardins
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - Dina M. Randazzo
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - Henry S. Friedman
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - David M. Ashley
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - Katherine B. Peters
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
| | - Margaret O. Johnson
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, United States
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Uysal B, Gamsiz H, Sager O, Dincoglan F, Demiral S, Ozcan F, Colak O, Beyzadeoglu M. Comparative outcomes of short-term and long-term fractionation with temozolomide in older glioblastoma patients: Single-center experience. J Cancer Res Ther 2021; 18:1610-1615. [DOI: 10.4103/jcrt.jcrt_984_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ridwan SM, El-Tayyeb F, Hainfeld JF, Smilowitz HM. Distributions of intravenous injected iodine nanoparticles in orthotopic u87 human glioma xenografts over time and tumor therapy. Nanomedicine (Lond) 2020; 15:2369-2383. [PMID: 32975163 PMCID: PMC7610150 DOI: 10.2217/nnm-2020-0178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/13/2020] [Indexed: 01/15/2023] Open
Abstract
Aim: To analyze the localization, distribution and effect of iodine nanoparticles (INPs) on radiation therapy (RT) in advanced intracerebral gliomas over time after intravenous injection. Materials & methods: Luciferase/td-tomato expressing U87 human glioma cells were implanted into mice which were injected intravenously with INPs. Mice with gliomas were followed for tumor progression and survival. Immune-stained mouse brain sections were examined and quantified by confocal fluorescence microscopy. Results: INPs injected intravenously 3 days prior to RT, compared with 1 day, showed greater association with CD31-staining structures, accumulated inside tumor cells more, covered more of the tumor cell surface and trended toward increased median survival. Conclusion: INP persistence and redistribution in tumors over time may enable greater RT enhancement and clinically relevant hypo-fractionated-RT and may enhance INP efficacy.
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Affiliation(s)
- Sharif M Ridwan
- Department of Cell Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - Ferris El-Tayyeb
- Department of Cell Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - James F Hainfeld
- Nanoprobes, Inc., 95 Horseblock Road, Unit 1, Yaphank, NY 11980, USA
| | - Henry M Smilowitz
- Department of Cell Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA
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8
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Youssef M, Ludmir EB, Mandel JJ, Patel AJ, Jalali A, Treiber J, Wu J, McAleer MF, de Groot JF. Treatment strategies for glioblastoma in older patients: age is just a number. J Neurooncol 2019; 145:357-364. [DOI: 10.1007/s11060-019-03304-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/27/2019] [Indexed: 01/05/2023]
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9
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Immortal Time Bias in National Cancer Database Studies. Int J Radiat Oncol Biol Phys 2019; 106:5-12. [PMID: 31404580 DOI: 10.1016/j.ijrobp.2019.07.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/17/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE In studies evaluating the benefit of adjuvant therapies, immortal time bias (ITB) can affect the results by incorrectly reporting a survival advantage. It does so by including all deceased patients who may have been planned to receive adjuvant therapy within the observation cohort. Given the increase in National Cancer Database (NCDB) analyses evaluating postoperative radiation therapy (PORT) as an adjuvant therapy, we sought to examine how often such studies accounted and adjusted for ITB. METHODS AND MATERIALS A systematic review was undertaken to search MEDLINE and EMBASE from January 2014 until May 2019 for NCDB studies evaluating PORT. After appropriate exclusion criteria were applied, 60 peer-reviewed manuscripts in which PORT was compared with postoperative observation or maintenance therapy were reviewed. The manuscripts were reviewed to evaluate whether ITB was accounted for, the method with which it was adjusted for, impact factor, year of publication, and whether PORT was beneficial. RESULTS Of the 60 publications reviewed, 23 studies (38.3%) did not include an adjustment for ITB. Most studies that did adjust for ITB employed a single landmark (LM) time (n = 31), 4 used a sequential landmark analyses, and 2 used a time-dependent Cox model. In 23 of 31 studies (74.2%) that did adjust for ITB via a single LM time, the rationale behind why the specified LM time was chosen was not clearly explained. There was no relationship between adjusting for ITB and year of publication (P = .074) or whether the study was published in a high-impact journal (P = .55). CONCLUSIONS Studies assessing adjuvant radiation therapy by analyzing the NCDB are susceptible to ITB, which overestimates the effect size of adjuvant therapies and can provide misleading results. Adjusting for this bias is essential for accurate data representation and to better quantify the impact of adjuvant therapies such as PORT.
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Iorgulescu JB, Torre M, Harary M, Smith TR, Aizer AA, Reardon DA, Barnholtz-Sloan JS, Perry A. The Misclassification of Diffuse Gliomas: Rates and Outcomes. Clin Cancer Res 2019; 25:2656-2663. [PMID: 30635340 DOI: 10.1158/1078-0432.ccr-18-3101] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/29/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE The integrated histopathologic and molecular diagnoses of the 2016 WHO classification of central nervous system tumors have revolutionized patient care by improving diagnostic accuracy and reproducibility; however, the frequency and consequences of misclassification of histologically diagnosed diffuse gliomas are unknown. EXPERIMENTAL DESIGN Patients with newly diagnosed ICD-O-3 (International Classification of Diseases) histologically encoded diffuse gliomas from 2010-2015 were identified from the National Cancer Database, the misclassification rates and overall survival (OS) of which were assessed by WHO grade and 1p/19q status. In addition, misclassification rates by isocitrate dehydrogenase (IDH), ATRX, and p53 statuses were examined in an analogous multi-institutional cohort of registry-encoded diffuse gliomas. RESULTS Of 74,718 patients with diffuse glioma, only 74.4% and 78.8% of molecularly characterized WHO grade II and III oligodendrogliomas were in fact 1p/19q-codeleted. In addition, 28.9% and 36.8% of histologically encoded grade II and III "oligoastrocytomas", and 6.3% and 8.8% of grade II and III astrocytomas had 1p/19q-codeletion, thus molecularly representing oligodendrogliomas if also IDH mutant. OS significantly depended on accurate WHO grading and 1p/19q status. CONCLUSIONS On the basis of 1p/19q, IDH, ATRX, and p53, the misclassification rates of histologically encoded oligodendrogliomas, astrocytomas, and glioblastomas are approximately 21%-35%, 6%-9%, and 9%, respectively; with significant clinical implications. Our findings suggest that when compared with historical histology-only classified data, in national registry, as well as, institutional databases, there is the potential for false-positive results in contemporary trials of molecularly classified diffuse gliomas, which could contribute to a seemingly positive phase II trial (based on historical comparison) failing at the phase III stage. Critically, findings from diffuse glioma clinical trials and historical cohorts using prior histology-only WHO schemes must be cautiously reinterpreted.
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Affiliation(s)
- J Bryan Iorgulescu
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.,Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Matthew Torre
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Maya Harary
- Harvard Medical School, Boston, Massachusetts.,Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Timothy R Smith
- Harvard Medical School, Boston, Massachusetts.,Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ayal A Aizer
- Harvard Medical School, Boston, Massachusetts.,Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Center, Boston, Massachusetts
| | - David A Reardon
- Harvard Medical School, Boston, Massachusetts.,Center for Neuro-Oncology, Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Arie Perry
- Department of Pathology, University of California, San Francisco, San Francisco, California
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11
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Wong ML, McMurry TL, Schumacher JR, Hu CY, Stukenborg GJ, Francescatti AB, Greenberg CC, Chang GJ, McKellar DP, Walter LC, Kozower BD. Comorbidity Assessment in the National Cancer Database for Patients With Surgically Resected Breast, Colorectal, or Lung Cancer (AFT-01, -02, -03). J Oncol Pract 2018; 14:e631-e643. [PMID: 30207852 DOI: 10.1200/jop.18.00175] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accurate comorbidity measurement is critical for cancer research. We evaluated comorbidity assessment in the National Cancer Database (NCDB), which uses a code-based Charlson-Deyo Comorbidity Index (CCI), and compared its prognostic performance with a chart-based CCI and individual comorbidities in a national sample of patients with breast, colorectal, or lung cancer. PATIENTS AND METHODS Through an NCDB Special Study, cancer registrars re-abstracted perioperative comorbidities for 11,243 patients with stage II to III breast cancer, 10,880 with stage I to III colorectal cancer, and 9,640 with stage I to III lung cancer treated with definitive surgical resection in 2006-2007. For each cancer type, we compared the prognostic performance of the NCDB code-based CCI (categorical: 0 or missing data, 1, 2+), Special Study chart-based CCI (continuous), and 18 individual comorbidities in three separate Cox proportional hazards models for postoperative 5-year overall survival. RESULTS Comorbidity was highest among patients with lung cancer (13.2% NCDB CCI 2+) and lowest among patients with breast cancer (2.8% NCDB CCI 2+). Agreement between the NCDB and Special Study CCI was highest for breast cancer (rank correlation, 0.50) and lowest for lung cancer (rank correlation, 0.40). The NCDB CCI underestimated comorbidity for 19.1%, 29.3%, and 36.2% of patients with breast, colorectal, and lung cancer, respectively. Within each cancer type, the prognostic performance of the NCDB CCI, Special Study CCI, and individual comorbidities to predict postoperative 5-year overall survival was similar. CONCLUSION The NCDB underestimated comorbidity in patients with surgically resected breast, colorectal, or lung cancer, partly because the NCDB codes missing data as CCI 0. However, despite underestimation of comorbidity, the NCDB CCI was similar to the more complete measures of comorbidity in the Special Study in predicting overall survival.
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Affiliation(s)
- Melisa L Wong
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Timothy L McMurry
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Jessica R Schumacher
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Chung-Yuan Hu
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Stukenborg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Amanda B Francescatti
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Caprice C Greenberg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Chang
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Daniel P McKellar
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Louise C Walter
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Benjamin D Kozower
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
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