Impact of National Cancer Institute Comprehensive Cancer Centers on ovarian cancer treatment and survival

Associations between race and ethnicity and treatment setting among gynecologic cancer patients

INTRODUCTION

Racial and ethnic disparities in gynecologic cancer care have been documented. Treatment at academic facilities is associated with improved survival, yet no study has examined independent associations between race and ethnicity with facility type among gynecologic cancer patients.

MATERIALS & METHODS

We used the National Cancer Database and identified 484,455 gynecologic cancer (cervix, ovarian, uterine) patients diagnosed between 2004 and 2020. Facility type was dichotomized as academic vs. non-academic, and we used logistic regression to estimate multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between race and ethnicity and facility type. Secondarily, we examined joint effects of race and ethnicity and facility type on overall survival using Cox proportional hazards regression.

RESULTS

We observed higher odds of treatment at academic (vs. non-academic) facilities among American Indian/Alaska Native (OR = 1.42, 95% CI = 1.28-1.57), Asian (OR = 1.64, 95% CI = 1.59-1.70), Black (OR = 1.69, 95% CI = 1.65-1.72), Hispanic (OR = 1.70, 95% CI = 1.66-1.75), Native Hawaiian/Pacific Islander (OR = 1.74, 95% CI = 1.57-1.93), and other race (OR = 1.29, 95% CI = 1.20-1.40) patients compared with White patients. In the joint effects survival analysis with White, academic facility-treated patients as the reference group, Asian, Hispanic, and other race patients treated at academic or non-academic facilities had improved overall survival. Conversely, Black patients treated at academic facilities [Hazard Ratio (HR) = 1.10, 95% CI = 1.07-1.12] or non-academic facilities (HR = 1.19, 95% CI = 1.16-1.21) had worse survival.

DISCUSSION

Minoritized gynecologic cancer patients were more likely than White patients to receive treatment at academic facilities. Importantly, survival outcomes among patients receiving care at academic institutions differed by race, requiring research to investigate intra-facility survival disparities.

Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study

PURPOSE

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients.

METHODS

We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care.

RESULTS

Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death.

CONCLUSION

Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center

Importance

The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas.

Objective

To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses.

Design, Setting, and Participants

This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023.

Exposures

Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison.

Main Outcomes and Measures

The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis.

Results

This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis.

Conclusions and Relevance

In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study

OBJECTIVES

To study the association between hospital volume and outcomes in patients with invasive epithelial ovarian cancer (EOC).

METHODS

This study included 3988 patients diagnosed with invasive EOC between 2014 and 2018, selected from the population-based database of the Belgian Cancer Registry (BCR), and coupled with health insurance and vital status data. The associations between hospital volume and observed survival since diagnosis were assessed with Cox proportional hazard models, while volume associations with 30-day post-operative mortality and complicated recovery were evaluated using logistic regression models.

RESULTS

Treatment for EOC was very dispersed with half of the 100 centres treating fewer than six patients per year. The median survival of patients treated in centres with the highest-volume quartile was 2.5 years longer than in those with the lowest-volume quartile (4.2 years versus 1.7 years). When taking the case-mix of hospitals into account, patients treated in the lowest volume centres had a 47% higher hazard to die than patients treated in the highest volume centres (HR: 1.47, 95% CI: 1.11-1.93, p = 0.006) over the first five years after incidence. A similar association was found when focussing on the surgical volume of the hospitals and considering only operated patients with invasive EOC. Lastly, the 30-day post-operative mortality decreased significantly with increasing surgical volume.

CONCLUSIONS

The large dispersion of care and expertise within Belgium and the volume-outcome associations observed in this study support the implementation of the concentration of care for patients with invasive EOC in reference centres.

Organization of Cancer Specialists in US Physician Practices and Health Systems

PURPOSE

To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers.

METHODS

Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center.

RESULTS

More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas.

CONCLUSION

Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.

Demographic disparities in receipt of care at a comprehensive cancer center

BACKGROUND

National Cancer Institute cancer centers (NCICCs) provide specialized cancer care including precision oncology and clinical treatment trials. While these centers can offer novel therapeutic options, less is known about when patients access these centers or at what timepoint in their disease course they receive specialized care. This is especially important since precision diagnostics and receipt of the optimal therapy upfront can impact patient outcomes and previous research suggests that access to these centers may vary by demographic characteristics. Here, we examine the timing of patients' presentation at Moffitt Cancer Center (MCC) relative to their initial diagnosis across several demographic characteristics.

METHODS

A retrospective cohort study was conducted among patients who presented to MCC with breast, colon, lung, melanoma, and prostate cancers between December 2008 and April 2020. Patient demographic and clinical characteristics were obtained from the Moffitt Cancer Registry. The association between patient characteristics and the timing of patient presentation to MCC relative to the patient's cancer diagnosis was examined using logistic regression.

RESULTS

Black patients (median days = 510) had a longer time between diagnosis and presentation to MCC compared to Whites (median days = 368). Black patients were also more likely to have received their initial cancer care outside of MCC compared to White patients (odds ratio [OR] and 95% confidence interval [CI] = 1.45 [1.32-1.60]). Furthermore, Hispanics were more likely to present to MCC at an advanced stage compared to non-Hispanic patients (OR [95% CI] = 1.28 [1.05-1.55]).

CONCLUSIONS

We observed racial and ethnic differences in timing of receipt of care at MCC. Future studies should aim to identify contributing factors for the development of novel mitigation strategies and assess whether timing differences in referral to an NCICC correlate with long-term patient outcomes.

Multi-Models of Analyzing Dermoscopy Images for Early Detection of Multi-Class Skin Lesions Based on Fused Features

Melanoma is a cancer that threatens life and leads to death. Effective detection of skin lesion types by images is a challenging task. Dermoscopy is an effective technique for detecting skin lesions. Early diagnosis of skin cancer is essential for proper treatment. Skin lesions are similar in their early stages, so manual diagnosis is difficult. Thus, artificial intelligence techniques can analyze images of skin lesions and discover hidden features not seen by the naked eye. This study developed hybrid techniques based on hybrid features to effectively analyse dermoscopic images to classify two datasets, HAM10000 and PH2, of skin lesions. The images have been optimized for all techniques, and the problem of imbalance between the two datasets has been resolved. The HAM10000 and PH2 datasets were classified by pre-trained MobileNet and ResNet101 models. For effective detection of the early stages skin lesions, hybrid techniques SVM-MobileNet, SVM-ResNet101 and SVM-MobileNet-ResNet101 were applied, which showed better performance than pre-trained CNN models due to the effectiveness of the handcrafted features that extract the features of color, texture and shape. Then, handcrafted features were combined with the features of the MobileNet and ResNet101 models to form a high accuracy feature. Finally, features of MobileNet-handcrafted and ResNet101-handcrafted were sent to ANN for classification with high accuracy. For the HAM10000 dataset, the ANN with MobileNet and handcrafted features achieved an AUC of 97.53%, accuracy of 98.4%, sensitivity of 94.46%, precision of 93.44% and specificity of 99.43%. Using the same technique, the PH2 data set achieved 100% for all metrics.

Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California

PURPOSE

We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival.

METHODS

This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model.

RESULTS

4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS.

CONCLUSIONS

Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.

Factor Analysis of Health Care Access With Ovarian Cancer Surgery and Gynecologic Oncologist Consultation

IMPORTANCE

Poor health care access (HCA) is associated with racial and ethnic disparities in ovarian cancer (OC) survival.

OBJECTIVE

To generate composite scores representing health care affordability, availability, and accessibility via factor analysis and to evaluate the association between each score and key indicators of guideline-adherent care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from patients with OC diagnosed between 2008 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Medicare database. The SEER Medicare database uses cancer registry data and linked Medicare claims from 12 US states. Included patients were Hispanic, non-Hispanic Black, and non-Hispanic White individuals aged 65 years or older diagnosed from 2008 to 2015 with first or second primary OC of any histologic type (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3] code C569). Data were analyzed from June 2020 to June 2022.

EXPOSURES

The SEER-Medicare data set was linked with publicly available data sets to obtain 35 variables representing health care affordability, availability, and accessibility. A composite score was created for each dimension using confirmatory factor analysis followed by a promax (oblique) rotation on multiple component variables.

MAIN OUTCOMES AND MEASURES

The main outcomes were consultation with a gynecologic oncologist for OC and receipt of OC-related surgery in the 2 months prior to or 6 months after diagnosis.

RESULTS

The cohort included 8987 patients, with a mean (SD) age of 76.8 (7.3) years and 612 Black patients (6.8%), 553 Hispanic patients (6.2%), and 7822 White patients (87.0%). Black patients (adjusted odds ratio [aOR], 0.75; 95% CI, 0.62-0.91) and Hispanic patients (aOR, 0.81; 95% CI, 0.67-0.99) were less likely to consult a gynecologic oncologist compared with White patients, and Black patients were less likely to receive surgery after adjusting for demographic and clinical characteristics (aOR, 0.76; 95% CI, 0.62-0.94). HCA availability and affordability were each associated with gynecologic oncologist consultation (availability: aOR, 1.16; 95% CI, 1.09-1.24; affordability: aOR, 1.13; 95% CI, 1.07-1.20), while affordability was associated with receipt of OC surgery (aOR, 1.08; 95% CI, 1.01-1.15). In models mutually adjusted for availability, affordability, and accessibility, Black patients remained less likely to consult a gynecologic oncologist (aOR, 0.80; 95% CI, 0.66-0.97) and receive surgery (aOR, 0.80; 95% CI, 0.65-0.99).

CONCLUSIONS AND RELEVANCE

In this cohort study of Hispanic, non-Hispanic Black, and non-Hispanic White patients with OC, HCA affordability and availability were significantly associated with receiving surgery and consulting a gynecologic oncologist. However, these dimensions did not fully explain racial and ethnic disparities.

Healthcare Access Domains Mediate Racial Disparities in Ovarian Cancer Treatment Quality in a US Patient Cohort: A Structural Equation Modelling Analysis

BACKGROUND

Ovarian cancer survival disparities have persisted for decades, driven by lack of access to quality treatment. We conducted structural equation modeling (SEM) to define latent variables representing three healthcare access (HCA) domains: affordability, availability, and accessibility, and evaluated the direct and indirect associations between race and ovarian cancer treatment mediated through the HCA domains.

METHODS

Patients with ovarian cancer ages 65 years or older diagnosed between 2008 and 2015 were identified from the SEER-Medicare dataset. Generalized SEM was used to estimate latent variables representing HCA domains by race in relation to two measures of ovarian cancer-treatment quality: gynecologic oncology consultation and receipt of any ovarian cancer surgery.

RESULTS

A total of 8,987 patients with ovarian cancer were included in the analysis; 7% were Black. The affordability [Ω: 0.876; average variance extracted (AVE) = 0.689], availability (Ω: 0.848; AVE = 0.636), and accessibility (Ω: 0.798; AVE = 0.634) latent variables showed high composite reliability in SEM analysis. Black patients had lower affordability and availability, but higher accessibility compared with non-Black patients. In fully adjusted models, there was no direct effect observed between Black race to receipt of surgery [β: -0.044; 95% confidence interval (CI), -0.264 to 0.149]; however, there was an inverse total effect (β: -0.243; 95% CI, -0.079 to -0.011) that was driven by HCA affordability (β: -0.025; 95% CI, -0.036 to -0.013), as well as pathways that included availability and consultation with a gynecologist oncologist.

CONCLUSIONS

Racial differences in ovarian cancer treatment appear to be driven by latent variables representing healthcare affordability, availability, and accessibility.

IMPACT

Strategies to mitigate disparities in multiple HCA domains will be transformative in advancing equity in cancer treatment.

Prognostic Value of En-Block Radical Bowel Resection in Advanced Ovarian Cancer Surgery With HIPEC

PURPOSE

To identify prognostic factors of survival and recurrence in advanced ovarian cancer patients undergoing radical surgery and HIPEC.

METHODS

In a single Department of Surgical Oncology, Peritoneal Surface Malignancy Program, and over a 16-year period, from a total of 274 epithelial ovarian cancer patients, retrospectively, we identified 152 patients undergoing complete (CC-0) or near-complete (CC-1) cytoreduction, including at least one colonic resection, and HIPEC.

RESULTS

Mean age of patients was 58.8 years and CC-0 was possible in 72.4%. Rates of in-hospital mortality and major morbidity were 2.6% and 15.7%. Only 122 (80.3%) patients completed Adjuvant Systemic Chemotherapy (ASCH). Rates of metastatic Total Lymph Nodes (TLN), Para-Aortic and Pelvic Lymph Nodes (PAPLN) and Large Bowel Lymph Nodes (LBLN) were 58.7%, 58.5%, and 51.3%, respectively. Median, 5- and 10-year survival rates were 39 months, 43%, and 36.2%, respectively. The recurrence rate was 35.5%. On univariate analysis, CC-1, high Peritoneal Cancer Index (PCI), in-hospital morbidity, and no adjuvant chemotherapy were adverse factors for survival and recurrence. On multivariate analysis, negative survival indicators were the advanced age of patients, extensive peritoneal dissemination, low total number of TLN and no systemic PAPLN. Metastatic LBLN and segmental resection of the small bowel (SIR) were associated with a high risk for recurrence.

CONCLUSION

CC-O is feasible in most advanced ovarian cancer patients and HIPEC may confer a survival benefit. Radical bowel resection, with its entire mesocolon, may be necessary, as its lymph nodes often harbor metastases influencing disease recurrence and survival. The role of metastatic bowel lymph nodes has to be taken into account when assessing the impact of systemic lymphadenectomy in this group of patients.

Health insurance literacy among head and neck cancer patients and their caregivers: A cross-sectional pilot study

Objective

Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers.

Methods

We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings.

Results

The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly.

Conclusion

Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial.

Level of Evidence

IV.

Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery

Objective

Given the importance of understanding neighborhood context and geographic access to care on individual health outcomes, we sought to investigate the association of community primary care (PC) access on postoperative outcomes and survival in ovarian cancer patients.

Methods

This was a retrospective cohort study of Stage III-IV ovarian cancer patients who underwent surgery at a single academic, tertiary care hospital between 2012 and 2015. PC access was determined using a Health Resources and Services Administration designation. Outcomes included 30-day surgical and medical complications, extended hospital stay, ICU admission, hospital readmission, progression-free and overall survival. Descriptive statistics and chi-squared analyses were used to analyze differences between patients from PC-shortage vs not PC-shortage areas.

Results

Among 217 ovarian cancer patients, 54.4 % lived in PC-shortage areas. They were more likely to have Medicaid or no insurance and live in rural areas with higher poverty rates, significantly further from the treating cancer center and its affiliated hospital. Nevertheless, 49.2 % of patients from PC-shortage areas lived in urban communities. Residing in a PC-shortage area was not associated with increased surgical or medical complications, ICU admission, or hospital readmission, but was linked to more frequent prolonged hospitalization (26.3 % vs 14.1 %, p = 0.04). PC-shortage did not impact progression-free or overall survival.

Conclusions

Patients from PC-shortage areas may require longer inpatient perioperative care in order to achieve the same 30-day postoperative outcomes as patients who live in non-PC shortage areas. Community access to PC is a critical factor to better understanding and reducing disparities among ovarian cancer patients.

The essential requirements for an HPB centre to deliver high-quality outcomes

The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.

Improved survival in cervical cancer patients receiving care at National Cancer Institute-designated cancer centers

Background

Locally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.

Methods

Data for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.

Results

Median age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.

Conclusions

This study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

This study demonstrates survival benefit for patients receiving care for cervical cancer at National Cancer Institute–designated cancer centers that is not explained by receipt of guideline‐concordant treatment. Further understanding of these factors will promote equality across oncology care facilities resulting in survival equity for patients with cervical cancer.

Making National Cancer Institute-Designated Comprehensive Cancer Center Knowledge Accessible to Community Oncologists via an Online Tumor Board: Longitudinal Observational Study

BACKGROUND

Expert knowledge is often shared among multidisciplinary academic teams at tumor boards (TBs) across the country, but these conversations exist in silos and do not reach the wider oncology community.

OBJECTIVE

Using an oncologist-only question and answer (Q&A) website, we sought to document expert insights from TBs at National Cancer Institute-designated Comprehensive Cancer Centers (NCI-CCCs) to provide educational benefits to the oncology community.

METHODS

We designed a process with the NCI-CCCs to document and share discussions from the TBs focused on areas of practice variation on theMednet, an interactive Q&A website of over 13,000 US oncologists. The faculty translated the TB discussions into concise, non-case-based Q&As on theMednet. Answers were peer reviewed and disseminated in email newsletters to registered oncologists. Reach and engagement were measured. Following each Q&A, a survey question asked how the TB Q&As impacted the readers' practice.

RESULTS

A total of 23 breast, thoracic, gastrointestinal, and genitourinary programs from 16 NCI-CCC sites participated. Between December 2016 and July 2021, the faculty highlighted 368 questions from their TBs. Q&As were viewed 147,661 times by 7381 oncologists at 3515 institutions from all 50 states. A total of 277 (75%) Q&As were viewed every month. Of the 1063 responses to a survey question on how the Q&A affected clinicians' practices, 646 (61%) reported that it confirmed their current practice, 163 (20%) indicated that a Q&A would change their future practice, and 214 (15%) reported learning something new.

CONCLUSIONS

Through an online Q&A platform, academics at the NCI-CCCs share knowledge outside the walls of academia with oncologists across the United States. Access to up-to-date expert knowledge can reassure clinicians' practices, significantly impact patient care in community practices, and be a source of new knowledge and education.

Prise en charge chirurgicale du cancer épithélial de l'ovaire - première ligne et première rechute: Surgical management of epithelial ovarian cancer - first line and first relapse

Based on recently published data, these recommendations present some evolutions in the surgical management of high grade epithelial ovarian cancers. In apparently early stages (FIGO I and II), surgical staging must be undertaken to confirm the absence of both peritoneal lesions and lymph node involvement (that might change stage and management). Neoadjuvant chemotherapy is not indicated, surgical exploration should be performed upfront, by laparotomy, to reduce the risk of rupture of the primary tumor. In advanced stages, the first step is to evaluate the feasibility of primary surgery with complete tumor cytoreduction. If it appears unfeasible, 3 or 4 cycles of neoadjuvant chemotherapy are administered before interval surgey. Whether it is implemented in the primary or interval setting, surgery must be performed by experimented teams, in an approved facility, having developed a rehabilitation program. Lymph node dissection is not mandatory if no adenopathies have been identified by imaging and by peroperative palpation. At first relapse, the surgical decision must be made by a multidisciplinary team, using scores predictive of complete cytoreduction (AGO or iMODEL criteria). Similarly as in first line, the objective is to achieve resection without any residual disease. Surveillance after first-line treatment must be adapted, according to the probability of another complete cytoreduction in case of late relapse, especially in patients who benefited from primary complete surgery and maintained good performance status.

Tracing the potential of networks to improve community cancer care: an in-depth single case study

Background

Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings.

Methods

An embedded in–depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness.

Results

The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems.

Conclusions

Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.

Racial-Ethnic Comparison of Guideline-Adherent Gynecologic Cancer Care in an Equal-Access System

OBJECTIVE

To compare receipt of National Comprehensive Cancer Network Guideline-adherent treatment for gynecologic cancers, inclusive of uterine, cervical, and ovarian cancer, between non-Hispanic White women and racial-ethnic minority women in the equal-access Military Health System.

METHODS

We accessed MilCanEpi, which links data from the Department of Defense Central Cancer Registry and Military Health System Data Repository administrative claims data, to identify a cohort of women aged 18-79 years who were diagnosed with uterine, cervical, or ovarian cancer between January 1, 1998, and December 31, 2014. Information on tumor stage, grade, and histology was used to determine which treatment(s) (surgery, chemotherapy, radiotherapy) was indicated for each patient according to the National Comprehensive Cancer Network Guidelines during the period of the data (1998-2014). We compared non-Hispanic Black, Asian, and Hispanic women with non-Hispanic White women in their likelihood to receive guideline-adherent treatment using multivariable logistic regression models given as adjusted odds ratios (aORs) and 95% CIs.

RESULTS

The study included 3,354 women diagnosed with a gynecologic cancer of whom 68.7% were non-Hispanic White, 15.6% Asian, 9.0% non-Hispanic Black, and 6.7% Hispanic. Overall, 77.8% of patients received guideline-adherent treatment (79.1% non-Hispanic White, 75.9% Asian, 69.3% non-Hispanic Black, and 80.5% Hispanic). Guideline-adherent treatment was similar in Asian compared with non-Hispanic White patients (aOR 1.18, 95% CI 0.84-1.48) or Hispanic compared with non-Hispanic White women (aOR 1.30, 95% CI 0.86-1.96). Non-Hispanic Black patients were marginally less likely to receive guideline-adherent treatment compared with non-Hispanic White women (aOR 0.73, 95% CI 0.53-1.00, P=.011) and significantly less likely to receive guideline-adherent treatment than either Asian (aOR 0.65, 95% CI 0.44-0.97) or Hispanic patients (aOR 0.56, 95% CI 0.34-0.92).

CONCLUSION

Racial-ethnic differences in guideline-adherent care among patients in the equal-access Military Health System suggest factors other than access to care contributed to the observed disparities.

Looking at cancer health disparities in gynecologic oncology in 2020

PURPOSE OF REVIEW

To summarize the most recent evidence on gynecologic cancer disparities and to describe studies investigating the social determinants of health and receipt of evidence-based care and potential interventions to address inequities in care.

RECENT FINDINGS

Significant disparities in disease-specific survival by race/ethnicity, socioeconomic status, and payer status have persisted in women with gynecologic cancers. Compared with white women, black women have an increased likelihood of disease-specific mortality for endometrial cancer and are less likely to receive guideline-adherent care for ovarian cancer. The Covid-19 pandemic has brought significant attention to the structural barriers that contribute to persistent health disparities and how community-based partnerships with a focus on policy interventions are needed for equitable gynecologic cancer outcomes.

SUMMARY

In this review, we discuss structural barriers contributing to racial inequities, the role of Medicaid payer status and receipt of quality cancer care, gender, and racial workforce diversity, and community-based partnerships to create evidence-based interventions to address disparities.

Factors associated with response to neoadjuvant chemotherapy in advanced stage ovarian cancer

OBJECTIVES

To evaluate the factors associated with response to neoadjuvant chemotherapy (NACT) and the ability to undergo interval tumor reductive surgery (iTRS) in patients with advanced ovarian cancer.

METHODS

We performed a retrospective review from April 2013 to March 2019 of patients with advanced stage ovarian cancer triaged to NACT based on our standard triage algorithm. Clinicopathologic and treatment data were analyzed for factors associated with response to NACT, outcomes at iTRS, and their impact on progression-free survival (PFS).

RESULTS

562 patients met inclusion criteria and triaged to NACT following laparoscopy (n = 132) or without laparoscopy (n = 430). 413 patients underwent iTRS (74%). Factors that correlated with a patient reaching iTRS included increasing age (p < 0.001), higher Charlson comorbidity index (p < 0.001), ECOG status 2 or 3 (<0.001), and laparoscopic assessment (<0.001). Patients with CA-125 ≤ 35 U/mL at iTRS had higher rates of complete gross resection (88% vs. 65%, p < 0.001) and improved PFS (16.8 vs. 12.7 months, p < 0.001). Patients receiving dose-dense paclitaxel (76% vs. 60%, p = 0.004) and CA-125 ≤ 35 U/mL at iTRS (85% vs. 66%, p < 0.001) had higher rates of complete radiographic response. On multivariate analysis, germline BRCA 1/2 mutation (p = 0.001), iTRS vs. no surgery (R0, p < 0.001; ≤1 cm, p < 0.001; >1 cm, p < 0.001), dose-dense chemotherapy (p = 0.01), and CA-125 ≤ 35 U/mL at iTRS (p = 0.001) were independent significant factors affecting PFS.

CONCLUSIONS

Normalization of CA-125 at the time of iTRS following NACT may serve as a surrogate marker for prognosis in this high-risk population. Our NACT cohort experienced improved response rates and PFS with dose-dense therapy compared to conventional dosing.

Racial-Ethnic and Socioeconomic Disparities in Guideline-Adherent Treatment for Endometrial Cancer

OBJECTIVE

To evaluate the association of race-ethnicity and neighborhood socioeconomic status with adherence to National Comprehensive Cancer Network guidelines for endometrial carcinoma.

METHODS

Data are from the SEER (Surveillance, Epidemiology, and End Results) cancer registry of women diagnosed with endometrial carcinoma for the years 2006-2015. The sample included 83,883 women after inclusion and exclusion criteria were applied. Descriptive statistics, bivariate analyses, univariate, and multivariate logistic regression models were performed to evaluate the association between race-ethnicity and neighborhood socioeconomic status with adherence to treatment guidelines.

RESULTS

After controlling for demographic and clinical covariates, Black (odds ratio [OR] 0.89, P<.001), Latina (OR .92, P<.001), and American Indian or Alaska Native (OR 0.82, P=.034) women had lower odds of receiving adherent treatment and Asian (OR 1.14, P<.001) and Native Hawaiian or Pacific Islander (OR 1.19 P=.012) women had higher odds of receiving adherent treatment compared with White women. After controlling for covariates, there was a gradient by neighborhood socioeconomic status: women in the high-middle (OR 0.89, P<.001), middle (OR 0.84, P<.001), low-middle (OR 0.80, P<.001), and lowest (OR 0.73, P<.001) neighborhood socioeconomic status categories had lower odds of receiving adherent treatment than the those in the highest neighborhood socioeconomic status group.

CONCLUSIONS

Findings from this study suggest there are racial-ethnic and neighborhood socioeconomic disparities in National Comprehensive Cancer Network treatment adherence for endometrial cancer. Standard treatment therapies should not differ based on sociodemographics. Interventions are needed to ensure that equitable cancer treatment practices are available for all individuals, regardless of racial-ethnic or socioeconomic background.

Role of surgery and hyperthermic intraperitoneal chemotherapy in ovarian cancer

Ovarian cancer is one of the deadliest gynaecological malignancies and tends to be diagnosed at an advanced stage. Similar to many malignancies, surgery plays a critical role in many aspects of ovarian cancer management. Hyperthermic intraperitoneal chemotherapy (HIPEC) involves the induction of hyperthermia and delivery of intraperitoneal chemotherapy directly into the peritoneal cavity. Combined with cytoreductive surgery, HIPEC is an emerging treatment modality for ovarian cancer. Ovarian cancer survival outcomes can be improved by treatment with surgery and HIPEC in selected patients. Thus, this study aimed to review the current role of surgery and HIPEC in epithelial ovarian cancer. Evidence from the monumental and recent literature will be introduced.

•

Surgery plays a critical role in many aspects of ovarian cancer management.

•

Combined with cytoreductive surgery, HIPEC is an emerging modality for ovarian cancer.

•

Improvement of survival outcomes is expected by applying individualised surgery and HIPEC for each ovarian cancer patient.

Analysing the attributes of Comprehensive Cancer Centres and Cancer Centres across Europe to identify key hallmarks

There is a persistent variation in cancer outcomes among and within European countries suggesting (among other causes) inequalities in access to or delivery of high‐quality cancer care. European policy (EU Cancer Mission and Europe’s Beating Cancer Plan) is currently moving towards a mission‐oriented approach addressing these inequalities. In this study, we used the quantitative and qualitative data of the Organisation of European Cancer Institutes’ Accreditation and Designation Programme, relating to 40 large European cancer centres, to describe their current compliance with quality standards, to identify the hallmarks common to all centres and to show the distinctive features of Comprehensive Cancer Centres. All Comprehensive Cancer Centres and Cancer Centres accredited by the Organisation of European Cancer Institutes show good compliance with quality standards related to care, multidisciplinarity and patient centredness. However, Comprehensive Cancer Centres on average showed significantly better scores on indicators related to the volume, quality and integration of translational research, such as high‐impact publications, clinical trial activity (especially in phase I and phase IIa trials) and filing more patents as early indicators of innovation. However, irrespective of their size, centres show significant variability regarding effective governance when functioning as entities within larger hospitals.

Guideline Concordance With Durvalumab in Unresectable Stage III Non-Small Cell Lung Cancer: A Single Center Veterans Hospital Experience

Background

Durvalumab is recommended by national guidelines for patients with unresectable stage III non-small cell lung cancer (NSCLC) following concurrent chemoradiation therapy (CRT). Nonadherence to guidelines is associated with adverse outcomes. We studied the adherence and identified barriers to durvalumab usage at the Birmingham Veterans Affairs Medical Center (VAMC) Oncology Clinic in Alabama.

Methods

Using retrospective analysis, we assessed the use of consolidative durvalumab among veterans at Birmingham VAMC. The health records of all veterans with stage III unresectable NSCLC from October 2017 to August 2019 were reviewed. Data collected included demographics, barriers to CRT initiation and completion, durvalumab usage, and reasons for not prescribing durvalumab.

Results

In our data review, 34 patients were found to have stage III unresectable NSCLC. Twenty (58.8%) of those 34 initiated CRT, but only 16 (47.1%) completed CRT treatment and 7 (20.6%) underwent further treatment with durvalumab. Of the 14 patients who did not initiate CRT, the most common reasons were poor performance status and/or the presence of comorbidities. Of the evaluable cohort of 34, 11 (32.4%) patients with stage III NSCLC received durvalumab. Of the 9 eligible patients who did not receive durvalumab, the most common reasons cited were toxicities experienced during or following CRT (11.8%).

Conclusions

Just one-third of patients were eligible to receive durvalumab at Birmingham VAMC. This was likely due to the difference between clinical trial and real-world patient populations. Interventions to address socioeconomic and system level barriers to improve our center's delivery of lung cancer treatment are planned.

Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery

OBJECTIVE

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.

METHODS

This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.

RESULTS

Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.

CONCLUSIONS

Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.

Adherence to treatment guidelines as a major determinant of survival disparities between black and white patients with ovarian cancer

OBJECTIVE

To evaluate whether non-adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and other factors related to treatment access contribute to racial disparities in ovarian cancer survival.

METHODS

This large cohort study included patients from the National Cancer Database who were diagnosed with ovarian cancer between 2004 and 2014, with follow-up data up to 2017. The multivariable Cox regression was used to assess the effect of study variables on five-year overall survival. The proportion contributions of prognostic factors to the survival disparities were estimated using individual and sequential adjustment of these factors based on the Cox proportional hazards models.

RESULTS

Of the 120,712 patients eligible for this study, 110,032 (91.1%) were whites and 10,680 (8.9%) were blacks. Black patients, compared with their white counterparts, had a lower adherence to NCCN guidelines (60.8% vs. 70.4%, respectively, P < 0.001), and a higher five-year mortality after cancer diagnosis (age- and tumor characteristics- adjusted hazard ratio: 1.22, 95% confidence interval: 1.19-1.25). Non-adherence to NCCN treatment guidelines was the most significant contributor to racial disparity in ovarian cancer survival, followed by access to care and comorbidity, each explaining 36.4%, 22.7%, and 18.2% of the racial differences in five-year overall survival, respectively. These factors combined explain 59.1% of racial survival disparities. Risk factors identified for non-adherence to treatment guidelines among blacks include insurance status, treatment facility type, educational attainment, age, and comorbidity.

CONCLUSIONS

Adherence status to NCCN treatment guidelines is the most important contributor to the survival disparities between black and white patients with ovarian cancer. Our findings call for measures to promote equitable access to guideline-adherence care to improve the survival of black women with ovarian cancer.

Relationship status and other demographic influences on survival in patients with ovarian cancer

OBJECTIVE

To evaluate the influence of marital status and other demographic factors on survival of patients with ovarian cancer.

STUDY DESIGN

Data were obtained from the Surveillance, Epidemiology, and End Results database from 2010 to 2015. Analyses were performed using Kaplan-Meier and multivariate Cox proportional hazard methods.

RESULTS

Of 19 643 patients with ovarian cancer (median age 60 years, range 18-99), 16 278 (83%), 1381 (7%), 1856 (9%), and 128 (1%) were White, Black, Asian, and Native American, respectively. The majority of patients (10 769, 55%) were married while 4155 (21%) were single, 2278 (12%) were divorced, and 2441 (12%) were widowed. Patients were more likely to be married if they were Asian (65%) or White (56%) than if they were Black (31%) or Native American (39%) (p<0.001). Most married patients were insured (n=9760 (91%), non-Medicaid) compared with 3002 (72%) of single, 1777 (78%) divorced, and 2102 (86%) of widowed patients (p<0.001). Married patients were more likely to receive chemotherapy than single, divorced, and widowed patients (8515 (79%) vs 3000 (72%), 1747 (77%), and 1650 (68%), respectively; p<0.001). The 5-year disease-specific survival of the overall group was 58%. Married patients had improved survival of 60% compared with divorced (52%) and widowed (44%) patients (p<0.001). On multivariate analysis, older age (HR 1.02, 95% CI 1.016 to 1.021, p<0.001), Black race (HR 1.24, 95% CI 1.11 to 1.38, p<0.001), and Medicaid (HR 1.19, 95% CI 1.09 to 1.30, p<0.001) or uninsured status (HR 1.23, 95% CI 1.05 to 1.44, p<0.01) carried a worse prognosis. Single (HR 1.17, 95% CI 1.08 to 1.26, p<0.001), divorced (HR 1.14, 95% CI 1.04 to 1.25, p<0.01), and widowed (HR 1.16, 95% CI 1.06 to 1.26, p<0.001) patients had decreased survival.

CONCLUSION

Married patients with ovarian cancer were more likely to undergo chemotherapy with better survival rates. Black, uninsured, or patients with Medicaid insurance had poorer outcomes.

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

BACKGROUND

Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.

METHODS

Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.

RESULTS

Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.

DISCUSSION

Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Parity as a Prognostic Factor in Patients with Advanced-Stage Epithelial Ovarian Cancer

Aim

This study aimed to determine the prognostic factors influencing the overall survival (OS) of Iranian women with epithelial ovarian cancer (EOC).

Methods

Information about newly diagnosed patients with confirmed EOC at Motahari Clinic, Shiraz, Iran, from January 1, 2001, to December 31, 2016, was retrospectively reviewed and analyzed. Cox-adjusted proportional hazards (PH) and stratified Cox (SC) models were used to determine the potential prognostic factors.

Results

The mean (±SD) age at the diagnosis of 385 patients with EOC was 49.0 (±13.2) years old. Early-stage EOC (ESEOC) and advanced-stage EOC (ASEOC) were diagnosed in 34.3% and 65.7% of the total patients, respectively. The median (95% CI) OS was 35 (28-41) months. For ESEOC patients, a stage II-tumor led to a lower OS in the multivariable analysis compared to a lower stage tumor (P= 0.025). For ASEOC patients, age≥65 years at diagnosis (P=0.008) led to a lower OS. ASEOC patients with 2-5 parities (P=0.014) and >5 parity (P=0.001) demonstrated better OS than nulliparous women.

Conclusion

Patients with ESEOC, higher tumor stage was associated with a shorter OS. The age at diagnosis harmed the OS of patients with ASEOC. More than one parity improved OS in ASEOC patients.

Risk factors for early death among ovarian cancer patients: a nationwide cohort study

Objective

To characterize ovarian cancer patients who die within 6 months of diagnosis and to identify prognostic factors for these early deaths.

Methods

A nationwide cohort study covering ovarian cancer in Denmark in 2005–2016. Tumor and patient characteristics including comorbidity and socioeconomic factors were obtained from the comprehensive Danish national registers.

Results

A total of 5,570 patients were included in the study. Three months after ovarian cancer diagnosis 456 (8.2%) had died and 664 (11.9%) died within 6 months of diagnosis. Adjusted for age and comorbidity, patients who died early were admitted to hospital significantly more often in a 6-month period before the diagnosis (odds ratio [OR]=1.61 [1.29–2.00], and OR=1.47 [1.21–1.78]), for patients who died within 3 and 6 months respectively). Low educational level (OR=2.11), low income (OR=2.50) and singlehood (OR=1.90) were factors significantly associated with higher risk of early death. The discriminative ability of risk factors in identifying early death was assessed by cross-validated area under the receiver operating characteristic curve (AUC). The AUC was found to be 0.91 (0.88–0.93) and 0.90 (0.87–0.92) for death within 3 and 6 months, respectively.

Conclusions

Despite several admissions to hospital, the ovarian cancer diagnosis is delayed for a subgroup of patients, who end up dying early, probably due to physical deterioration in the ineffective waiting time. Up to 90% of high-risk patients might be identified significantly earlier to improve the prognosis. The admittance of the patients having risk symptoms should include fast track investigation for ovarian cancer.

KNDC1 Is a Predictive Marker of Malignant Transformation in Borderline Ovarian Tumors

BACKGROUND

Few screening markers for malignant transformation in borderline ovarian tumors (BOT) have been clearly established. The kinase noncatalytic C-lobe domain containing 1 (KNDC1), a brain-specific Ras guanine nucleotide exchange factor, negatively regulates dendrite growth. However, the biological role and underlying mechanism of KNDC1 in human cancers, including ovarian cancer (OC), remain unknown.

METHODS

Gene chip screening was used to detect the expression of KNDC1 mRNA in normal ovarian tissues, BOT tissues, and OC tissues. And results were further validated by RT-qPCR, Western blotting and immunohistochemistry. KNDC1 overexpression and knockdown ovarian cancer cells were established to study the possible pathways that KNDC1 was involved. The effects of KNDC1 on the malignant behaviors of ovarian tumors were also investigated both in vitro and in vivo.

RESULTS

We observed that the expression of KNDC1 mRNA and KNDC1 protein in OC was significantly downregulated compared with BOT. Subsequent investigation revealed that knockdown of KNDC1 enhanced the proliferation of ovarian cancer cells in vitro via induction of ERK1/2 phosphorylation, whereas reinforcing the expression of KNDC1 attenuated the ERK1/2 activity. Similarly, knockdown of KNDC1 also promoted cell proliferation in vivo. Survival analysis showed that lower KNDC1 predicted a poor progression-free survival (PFS) for patients.

CONCLUSION

Collectively, we conclude that KNDC1 might function as a tumor suppressor in ovarian tumors, inhibiting the proliferation of ovarian cells by suppressing ERK1/2 activity and hindering the malignant transformation of BOT.

Overexpression of YES1 is associated with favorable prognosis and increased platinum-sensitivity in patients with epithelial ovarian cancer

AIMS

The prognostic application of YES1 in epithelial ovarian cancer (EOC) is currently unclear. We aimed to investigate the expression of YES1 and its correlation with survival outcome in patients with EOC.

METHODS

A retrospective study of patients diagnosed with EOC at the Cancer Center, Sun Yat-Sen University, Guangzhou, China between 2002 and 2013 was conducted. The immunohistochemical expression of YES1 was assessed using tissue microarray. Survival rates were analyzed by the Kaplan-Meier method and were compared between groups using the log-rank test. Multivariate analyses were performed using the Cox proportional hazards model.

RESULTS

A total of 132 patients with EOC were enrolled. Patients in the YES1-high group exhibited significantly better OS and PFS, compared with those in the YES1-low group (P=0.02 and P=0.03, respectively). Further univariate and multivariate regression analyses indicated YES1 as an independent prognostic factor for the OS of patients with EOC. Notably, within the high YES1 expression group, 40 cases (74.1%) were of the platinum-sensitive group while 14 (25.9%) overlapped were of the platinum-resistant group. Conversely, in the low YES1 expression group, 11 cases (47.8%) were platinum-sensitive, and 12 (52.2%) platinum-resistant. Overall, patients within the high YES1 expression group were deemed significantly more sensitive to platinum-based chemotherapy than the low YES1 expression group (P=0.03), and YES1 levels were consistently and significantly higher in the platinum-sensitive group.

CONCLUSIONS

High YES1 cytoplasmic expression in EOC patient tissue is significantly correlated with favorable prognosis. Patients with high YES1 expression tend to be sensitive to platinum-based chemotherapy.

Potential cytotoxic and anti-metastatic effects of berberine on gynaecological cancers with drug-associated resistance

Gynaecological disorders, such as cervical, ovarian, and endometrial cancers are the second most prevalent cancer types in women worldwide. Therapeutic approaches for gynaecological cancers involve chemotherapy, radiation, and surgery. However, lifespan is not improved, and novel medications are required. Among various phytochemicals, berberine, a well-known natural product, has been shown to be a promising cancer chemopreventive agent. Pharmacokinetics, safety, and efficacy of berberine have been investigated in the several experiments against numerous diseases. Here, we aimed to provide a literature review from available published investigations showing the anticancer effects of berberine and its various synthetic analogues against gynaecological disorders, including cervical, ovarian, and endometrial cancers. In conclusion, berberine has been found to efficiently inhibit viability, proliferation, and migration of cancer cells, mainly, via induction of apoptosis by both mitochondrial dependent and -independent pathways. Additionally, structural modification of berberine showed that berberine analogues can improve its antitumor effects against gynaecological cancers.

Simulated Costs of the ASCO Patient-Centered Oncology Payment Model in Medicare Beneficiaries With Newly Diagnosed Advanced Ovarian Cancer

PURPOSE

Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO's Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings.

MATERIALS AND METHODS

SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging.

RESULTS

Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%.

CONCLUSION

APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.

Efficacy and safety of neoadjuvant chemotherapy versus primary debulking surgery in patients with ovarian cancer: a meta-analysis

OBJECTIVE

Neoadjuvant chemotherapy (NACT) for the treatment of epithelial ovarian cancer (EOC) has remained controversial. This meta-analysis was performed to systematically assess the efficacy and safety of NACT versus primary debulking surgery (PDS) in patients with EOC.

METHODS

PubMed, Embase, ClinicalTrials.gov, and Cochrane Library were queried to assess the therapeutic value of NACT versus PDS in EOC. Electronic databases were queried by using the keywords "ovarian cancer/neoplasms", "primary debulking surgery", and "neoadjuvant chemotherapy".

RESULTS

The available trials were pooled, and hazard ratios (HRs), relative risk ratios (RRs) and associated 95% confidence intervals (95% CIs) were determined. Sixteen trials involving 57,450 participants with EOC (NACT, 9,475; PDS, 47,975) were evaluated. We found that NACT resulted in markedly decreased overall survival than PDS in patients with EOC (HR=1.30; 95% CI=1.13-1.49; heterogeneity: p<0.001, I²=82.7%). Furthermore, our results demonstrated that the NACT group displayed increased completeness of debulking removal (RR=1.69, 95% CI=1.32-2.17; heterogeneity: p<0.001, I²=81.9%), and reduced risk of postsurgical death (RR=0.18, 95% CI=0.06-0.51; heterogeneity: p=0.698, I²=0%) and major infection (RR=0.29, 95% CI=0.17-0.51; heterogeneity: p=0.777, I²=0%) compared with patients administered PDS.

CONCLUSIONS

This meta-analysis indicated that NACT results in increased completeness of debulking removal, and reduced risk of postsurgical death and major infection compared with PDS, while PDS is associated with improved survival in comparison with NACT in EOC patients.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42019120625.

Improving adherence to lung cancer guidelines: a quality improvement project that uses chart review, audit and feedback approach

Introduction

The implementation of evidence-based clinical practice guidelines is one of the most effective interventions for improving quality of care. A gap between guidelines and clinical practice often exists, which may result in patients not receiving appropriate care. This project aimed at improving adherence to lung cancer guidelines at our institution.

Method

The records of patients with lung cancer were evaluated for adherence to guidelines by using an auditing tool that was developed to capture pertinent information. The study team collected data about the following variables: compliance with documentation of pathological diagnosis, documentation of disease stage prior to treatment initiation, presentation at thoracic tumour board within 30 days of diagnosis, management course, and management of end of life in terms of early 'no code' initiation, stopping chemotherapy and referral to palliative care prior to 2 weeks of death. Annual audits were performed from 2012 to 2015. Education and discussion with team members to address the deviations were the main interventions to improve adherence.

Results

The baseline measurements were taken in 2012 (49 patients). Histological subtype identification improved from 94% to 100%. Presentation of new cases at the tumour board improved from 35% to 82%. Testing for epidermal growth factor receptor mutation for non-squamous cell lung cancer improved from 77% to 100%. The staging was documented in 100% of the cases.

Conclusion

Running audits to monitor adherence to guidelines and discussions with the team have a positive effect on providing consistent evidence-based care for patients with lung cancer.

Evaluating the benefits of neoadjuvant chemotherapy for advanced epithelial ovarian cancer: a retrospective study

Objective

To compare the chemoresistance and survival in patients with stage IIIC or IV epithelial ovarian cancer who were treated with neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) or primary debulking surgery (PDS). The clinical characteristics of patients who benefited from NACT were further evaluated.

Methods

We retrospectively analyzed 220 patients who underwent NACT followed by IDS or PDS from January 2002 to December 2016. Differences in clinicopathological features, chemoresistance and prognosis were analyzed.

Results

The incidence rate for optimal cytoreduction and chemoresistance in the NACT group was relatively higher than PDS group. No differences were observed in progression free survival or overall survival. Patients without macroscopic RD in NACT group (NACT-R0) had a similar prognosis compared to those in PDS group who had RD<1 cm, and a relatively better prognosis compared to the PDS group that had RD ≥ 1 cm. The survival curve showed that patients in NACT-R0 group that were chemosensitive seemed to have a better prognosis compared to patients in PDS group that had RD.

Conclusion

Patients without RD after PDS had the best prognosis, whereas patients with RD after NACT followed by IDS had the worst. However, even if patients achieved no RD, their prognosis varied depending on chemosensitivity. Survival was better in patients who were chemosensitive compared to thosewho underwent PDS but had RD. Hence evaluating the chemosensitivity and feasibility of complete cytoreduction in advance is crucial.

Estimating Cost-effectiveness of a Multimodal Ovarian Cancer Screening Program in the United States: Secondary Analysis of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

Importance

The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is the largest randomized clinical trial to evaluate screening's impact on ovarian cancer mortality, assigning women to multimodal screening (MMS) with serum cancer antigen 125 (CA-125) interpreted using a risk algorithm. If the MMS screening method is eventually shown to reduce mortality and be cost-effective, then it may be accepted by the medical community as a feasible screening tool.

Objective

To estimate the cost-effectiveness of an MMS screening program in the United States.

Design, Setting, and Participants

A Markov simulation model was constructed using data from UKCTOCS to compare MMS with no screening in the United States. Screening would begin at the age of 50 years for women in the general population. Published estimates of the long-term effect of MMS screening on ovarian cancer mortality and the trial's published hazard ratios were used to simulate mortality estimates up to 40 years from start of screening. Base-case costs included CA-125, ultrasound, and false-positive work-up results, in addition to a risk algorithm cost estimate of $100. The utility and costs of ovarian cancer treatment were incorporated into the model.

Interventions

Screening strategies varied by costs of the algorithm and treatment for advanced ovarian cancer, rates of screening compliance, ovarian cancer incidence, and extrapolation of ovarian cancer mortality.

Main Outcomes and Measures

Costs, quality-adjusted life-years (QALYs), and mortality reduction of ovarian cancer screening.

Results

Multimodal screening is both more expensive and more effective in reducing ovarian cancer mortality over a lifetime than no screening. After accounting for uncertainty in the underlying parameters, screening women starting at age 50 years with MMS is cost-effective 70% of the time, when decision makers are willing to pay $150 000 per QALY. Screening reduced mortality by 15%, with an incremental cost-effectiveness ratio (ICER) ranging from $106 187 (95% CI, $97 496-$127 793) to $155 256 (95% CI, $150 369-$198 567).

Conclusions and Relevance

Ovarian cancer screening is potentially cost-effective in the United States depending on final significance of mortality reduction and cost of the CA-125 risk algorithm. These results are limited by uncertainty around the effect of screening on ovarian cancer mortality beyond the 11 years of UKCTOCS.

First-Line Systemic Treatments for Stage IV Non-Small Cell Lung Cancer in California: Patterns of Care and Outcomes in a Real-World Setting

BACKGROUND

Multiple systemic treatments have been developed for stage IV non-small cell lung cancer (NSCLC), but their use and effect on outcomes at the population level are unknown. This study describes the utilization of first-line systemic treatments among stage IV NSCLC patients in California and compares survival among treatment groups.

METHODS

Data on 17 254 patients diagnosed with stage IV NSCLC from 2012 to 2014 were obtained from the California Cancer Registry. Systemic treatments were classified into six groups. The Kaplan-Meier method and multivariable Cox proportional hazards models were used to compare survival between treatment groups.

RESULTS

Fifty-one percent of patients were known to have received systemic treatment. For patients with nonsquamous histology, pemetrexed regimens were the most common treatment (14.8%) followed by tyrosine kinase inhibitors (11.9%) and platinum doublets (11.5%). Few patients received pemetrexed/bevacizumab combinations (4.5%), bevacizumab combinations (3.6%), or single agents (1.7%). There was statistically significantly better overall survival for those on pemetrexed regimens (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.80 to 0.92), bevacizumab regimens (HR = 0.73, 95% CI = 0.65 to 0.81), pemetrexed/bevacizumab regimens (HR = 0.68, 95% CI = 0.61 to 0.76), or tyrosine kinase inhibitors (HR = 0.62, 95% CI = 0.57 to 0.67) compared with platinum doublets. The odds of receiving most systemic treatments decreased with decreasing socioeconomic status. For patients with squamous histology, platinum doublets were predominant (33.7%) and were not found to have statistically significantly different overall survival from single agents.

CONCLUSIONS

These population-level findings indicate low utilization of systemic treatments, survival differences between treatment groups, and evident treatment disparities by socioeconomic status.

European Society of Gynaecological Oncology (ESGO) Guidelines for Ovarian Cancer Surgery

METHODS

The European Society of Gynaecological Oncology council nominated an international multidisciplinary development group made of practicing clinicians who have demonstrated leadership and interest in the care of ovarian cancer (20 experts across Europe). To ensure that the statements are evidence based, the current literature identified from a systematic search has been reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group (expert agreement). The guidelines are thus based on the best available evidence and expert agreement. Before publication, the guidelines were reviewed by 66 international reviewers independent from the development group including patients representatives.

RESULTS

The guidelines cover preoperative workup, specialized multidisciplinary decision making, and surgical management of diagnosed epithelial ovarian, fallopian tube, and peritoneal cancers. The guidelines are also illustrated by algorithms.

Development and validation of a model that includes two ultrasound parameters and the plasma D-dimer level for predicting malignancy in adnexal masses: an observational study

Background

Pre-operative discrimination of malignant from benign adnexal masses is crucial for planning additional imaging, preparation, surgery and postoperative care. This study aimed to define key ultrasound and clinical variables and develop a predictive model for calculating preoperative ovarian tumor malignancy risk in a gynecologic oncology referral center. We compared our model to a subjective ultrasound assessment (SUA) method and previously described models.

Methods

This prospective, single-center observational study included consecutive patients. We collected systematic ultrasound and clinical data, including cancer antigen 125, D-dimer (DD) levels and platelet count. Histological examinations served as the reference standard. We performed univariate and multivariate regressions, and Bayesian information criterion (BIC) to assess the optimal model. Data were split into 2 subsets: training, for model development (190 observations) and testing, for model validation (n = 100).

Results

Among 290 patients, 52% had malignant disease, including epithelial ovarian cancer (72.8%), metastatic disease (14.5%), borderline tumors (6.6%), and non-epithelial malignancies (4.6%). Significant variables were included into a multivariate analysis. The optimal model, included three independent factors: solid areas, the color score, and the DD level. Malignant and benign lesions had mean DD values of 2.837 and 0.354 μg/ml, respectively. We transformed established formulae into a web-based calculator (http://gin-onc-calculators.com/gynonc.php) for calculating the adnexal mass malignancy risk. The areas under the curve (AUCs) for models compared in the testing set were: our model (0.977), Simple Rules risk calculation (0.976), Assessment of Different NEoplasias in the adneXa (ADNEX) (0.972), Logistic Regression 2 (LR2) (0.969), Risk of Malignancy Index (RMI) 4 (0.932), SUA (0.930), and RMI3 (0.912).

Conclusions

Two simple ultrasound predictors and the DD level (also included in a mathematical model), when used by gynecologist oncologist, discriminated malignant from benign ovarian lesions as well or better than other more complex models and the SUA method. These parameters (and the model) may be clinically useful for planning adequate management in the cancer center. The model needs substantial validation.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5629-x) contains supplementary material, which is available to authorized users.

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.

Radiation Oncology Device Approval in the United States and Canada

Background

Medical devices are a crucial component in the field of radiation oncology. The review and licensing of radiation oncology devices (RODs) is managed on a national basis in Canada by Health Canada and in the United States by the Food and Drug Administration (FDA). The purpose of this study was to examine differences in ROD licensing timelines between Health Canada and the FDA that may impact the ability of Canadians to access the most up-to-date radiation oncology care.

Methods

A list of ROD was compiled by searching keywords, manufacturers, and proprietary device names in the publicly accessible Canadian Medical Devices Active Licence Listing (MDALL) and the American Establishment Registration & Device Listing and the 510(k) Premarket Notification database. ROD licensing dates were then obtained through both databases. ROD were included if they were licensed in both countries.

Results

A total of 51 RODs were included in this study and it was found that 71% (36/51) were issued licenses for sale in the United States before Canada, at a mean of 506 days sooner (median [IQR] = 282 [326.5]). No trends in licensing dates were found by stratifying devices by type. Analyses were limited to the date of licensing only, as Health Canada provided no publicly-available information regarding submission milestones such as first submission date for the RODs studied.

Conclusions

The majority of radiation oncology devices examined were licensed for sale in the USA before Canada. Due to the absence of publicly available information regarding initial ROD application date, we cannot evaluate the impact of the approval process on the overall difference in licensing date. Importantly, this research highlights a lack of publicly-available information from Health Canada regarding the medical device approval process for the radiation oncology devices studied herein.

Disparities in Systemic Treatment Use in Advanced-stage Non-Small Cell Lung Cancer by Source of Health Insurance

BACKGROUND

Management of advanced-stage non-small cell lung cancer (NSCLC) has changed significantly over the past two decades with the development of numerous systemic treatments, including targeted therapies. However, a high proportion of advanced-stage patients are untreated. The role that health insurance plays in receipt of systemic treatments is unclear.

METHODS

Using California Cancer Registry data (2012-2014), we developed multivariable Poisson regression models to assess the independent effect of health insurance type on systemic treatment utilization among patients with stage IV NSCLC. Systemic treatment information was manually abstracted from treatment text fields.

RESULTS

A total of 17,310 patients were evaluated. Patients with Medicaid/other public insurance were significantly less likely to receive any systemic treatments [risk ratio (RR), 0.78; 95% confidence interval (CI), 0.75-0.82], bevacizumab combinations (RR, 0.57; 95% CI, 0.45-0.71), or tyrosine kinase inhibitors (RR, 0.70; 95% CI, 0.60-0.82) compared with the privately insured. Patients with Medicare or dual Medicare-Medicaid insurance were not significantly different from the privately insured in their likelihood of receiving systemic treatments.

CONCLUSIONS

Substantial disparities in the use of systemic treatments for stage IV NSCLC exist by source of health insurance in California. Patients with Medicaid/other public insurance were significantly less likely to receive systemic treatments compared with their privately insured counterparts.

IMPACT

Source of health insurance influences care received. Further research is warranted to better understand barriers to treatment that patients with Medicaid face.