Exploratory Subset Analysis of African Americans From the PointBreak Study: Pemetrexed-Carboplatin-Bevacizumab Followed by Maintenance Pemetrexed-Bevacizumab Versus Paclitaxel-Carboplatin-Bevacizumab Followed by Maintenance Bevacizumab in Patients With Stage IIIB/IV Nonsquamous Non-Small-Cell Lung Cancer

Temporal Association Rule Mining: Race-Based Patterns of Treatment-Adverse Events in Breast Cancer Patients Using SEER-Medicare Dataset

PURPOSE

Disparities in the screening, treatment, and survival of African American (AA) patients with breast cancer extend to adverse events experienced with systemic therapy. However, data are limited and difficult to obtain. We addressed this challenge by applying temporal association rule (TAR) mining using the SEER-Medicare dataset for differences in the association of specific adverse events (AEs) and treatments (TRs) for breast cancer between AA and White women. We considered two categories of cancer care providers and settings: practitioners providing care in the outpatient units of hospitals and institutions and private practitioners providing care in their offices.

PATIENTS AN METHODS

We considered women enrolled in the Medicare fee-for-service option at age 65 who qualified by age and not disability, who were diagnosed with breast cancer with attributed patient factors of age and race, marital status, comorbidities, prior malignancies, prior therapy, disease factors of stage, grade, and ER/PR and Her2 status and laterality. We included 141 HCPCS drug J codes for chemotherapy, biotherapy, and hormone therapy drugs, which we consolidated into 46 mechanistic categories and generated AE data. We consolidated AEs from ICD9 codes into 18 categories associated with breast cancer therapy. We applied TAR mining to determine associations between the 46 TR and 18 AE categories in the context of the patient categories outlined. We applied the spark.mllib implementation of the FPGrowth algorithm, a parallel version called PFP. We considered differences of at least one unit of lift as significant between groups. The model's results demonstrated a high overlap between the model's identified TR-AEs associated set and the actual set.

RESULTS

Our results demonstrate that specific TR/AE associations are highly dependent on race, stage, and venue of care administration.

CONCLUSIONS

Our data demonstrate the usefulness of this approach in identifying differences in the associations between TRs and AEs in different populations and serve as a reference for predicting the likelihood of AEs in different patient populations treated for breast cancer. Our novel approach using unsupervised learning enables the discovery of association rules while paying special attention to temporal information, resulting in greater predictive and descriptive power as a patient's health and life status change over time.

Racial Disparities in Breast Cancer Treatments and Adverse Events in the SEER-Medicare Data

Despite lower incidence rates, African American (AA) patients have shorter survival from breast cancer (BC) than white (W) patients. Multiple factors contribute to decreased survival, including screening disparities, later presentation, and access to care. Disparities in adverse events (AEs) may contribute to delayed or incomplete treatment, earlier recurrence, and shortened survival. Here, we analyzed the SEER-Medicare dataset, which captures claims from a variety of venues, in order to determine whether the cancer care venues affect treatment and associated adverse events. We investigated a study population whose claims are included in the Outpatient files, consisting of hospital and healthcare facility venues, and a study population from the National Claims History (NCH) files, consisting of claims from physicians, office practices, and other non-institutional providers. We demonstrated statistically and substantively significant venue-specific differences in treatment rates, drugs administered, and AEs from treatments between AA and W patients. We showed that AA patients in the NCH dataset received lower rates of treatment, but patients in the Outpatient dataset received higher rates of treatment than W patients. The rates of recorded AEs per treatment were higher in the NCH setting than in the Outpatient setting in all patients. AEs were consistently higher in AA patients than in W patients. AA patients had higher comorbidity indices and were younger than W patients, but these variables did not appear to play roles in the AE differences. The frequency of specific anticancer drugs administered in cancer- and venue-specific circumstances and their associated AEs varied between AA and W patients. The higher AE rates were due to slightly higher frequencies in the administration of drugs with higher associated AE rates in AA patients than in W patients. Our investigations demonstrate significant differences in treatment rates and associated AEs between AA and W patients with BC, depending on the venues of care, likely contributing to differences in outcomes.

Health Disparities: Interventions for Pulmonary Disease - A Narrative Review

There is expansive literature documenting the presence of health disparities, but there are disproportionately few studies describing interventions to reduce disparity. In this narrative review, we categorize interventions to reduce health disparity in pulmonary disease within the US health care system to support future initiatives to reduce disparity. We identified 211 articles describing interventions to reduce disparity in pulmonary disease related to race, income, or sex. We grouped the studies into the following four categories: biologic, educational, behavioral, and structural. We identified the following five main themes: (1) there were few interventional trials compared with the breadth of studies describing health disparities, and trials involving patients with asthma who were Black, low income, and living in an urban setting were overrepresented; (2) race or socioeconomic status was not an effective marker of individual pharmacologic treatment response; (3) telehealth enabled scaling of care, but more work is needed to understand how to leverage telehealth to improve outcomes in marginalized communities; (4) future interventions must explicitly target societal drivers of disparity, rather than focusing on individual behavior alone; and (5) individual interventions will only be maximally effective when specifically tailored to local needs. Much work has been done to catalog health disparities in pulmonary disease. Notable gaps in the identified literature include few interventional trials, the need for research in diseases outside of asthma, the need for high quality effectiveness trials, and an understanding of how to implement proven interventions balancing fidelity to the original protocol and the need to adapt to local barriers to care.

Disparities in Lung Cancer Treatment

PURPOSE OF REVIEW

Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities.

RECENT FINDINGS

Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.

Patterns of Care and Survival in Stage III NSCLC Among Black and Latino Patients Compared With White Patients

BACKGROUND

Race and socioeconomic status have continued to affect the survival and patterns of care of patients with non-small-cell lung cancer (NSCLC). However, data evaluating these associations in patients with stage III disease remain limited. Therefore, we investigated the patterns of care and overall survival (OS) of black and Latino patients with locally advanced NSCLC compared with white patients, using the National Cancer Database.

MATERIALS AND METHODS

All patients with stage III NSCLC from 2004 to 2013 who had undergone external beam radiotherapy (RT) alone, RT with chemotherapy (bimodality), or RT with chemotherapy followed by surgery (trimodality) were analyzed within the National Cancer Database according to race (n = 113,945). Univariate associations among the demographic, disease, and treatment characteristics within the 3 cohorts were assessed using χ2 tests. The OS between cohorts were analyzed using the log-rank test and multivariate Cox proportional hazards regression.

RESULTS

The black and Latino patients were younger at diagnosis, had lower median household incomes, and were less likely to be insured than were the white patients. The black patients were more likely to receive RT alone (19.3% vs. 18%; P < .001) and less likely to have undergone concurrent chemo-RT (53.6% vs. 56.1%; P < .001) compared with the white patients. Black patients had improved OS (P < .001). In contrast, the Latino patients had survival equivalent to that of the white patients (P = .920).

CONCLUSIONS

Despite epidemiologic differences and a propensity for less aggressive treatment, black patients with locally advanced NSCLC had better OS than white patients and Latino patients had equivalent outcomes. Additional research is needed to elucidate this finding, perhaps focusing on biological differences among the cohorts.

Pembrolizumab plus chemotherapy for first-line treatment of metastatic nonsquamous non-small-cell lung cancer: a network meta-analysis

Aim: A systematic review and network meta-analysis were conducted to evaluate the efficacy of pembrolizumab + pemetrexed + platinum relative to other regimens in metastatic nonsquamous non-small-cell lung cancer (NSq-NSCLC). Patients & methods: Eligible studies evaluated first-line regimens in NSq-NSCLC patients without known targetable mutations. Relative treatment effects were synthesized with random effects proportional hazards Bayesian network meta-analyses. Results: The hazard ratio (HR) for overall survival (OS) for pembrolizumab + pemetrexed + platinum was statistically significant over all platinum-doublet (HR range: 0.42–0.61), platinum-doublet + bevacizumab (HR range: 0.44–0.53) and platinum-doublet + atezolizumab regimens (HR range: 0.56–0.62). Additionally, pembrolizumab + pemetrexed + platinum numerically improved OS over atezolizumab + paclitaxel + carboplatin + bevacizumab (HR: 0.65; 95% credible interval: 0.43, 1.01). Pembrolizumab + pemetrexed + platinum had 95.6% probability of being the best treatment regimen for OS. Conclusion: Pembrolizumab + pemetrexed + platinum is likely the most efficacious first-line regimen for metastatic NSq-NSCLC.