Impact of Adjuvant Radiotherapy Setting on Quality-of-Life in Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC).

METHODS

This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits.

RESULTS

A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant.

CONCLUSION

This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3645-3655, 2024.

Impact of facility type and volume in locally advanced esophageal cancer

BACKGROUND

We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer.

METHODS

We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume.

RESULTS

Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p = 0.87).

CONCLUSIONS

Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival.

The Thoracic Research Evaluation and Treatment 2.0 Model: A Lung Cancer Prediction Model for Indeterminate Nodules Referred for Specialist Evaluation

BACKGROUND

Appropriate risk stratification of indeterminate pulmonary nodules (IPNs) is necessary to direct diagnostic evaluation. Currently available models were developed in populations with lower cancer prevalence than that seen in thoracic surgery and pulmonology clinics and usually do not allow for missing data. We updated and expanded the Thoracic Research Evaluation and Treatment (TREAT) model into a more generalized, robust approach for lung cancer prediction in patients referred for specialty evaluation.

RESEARCH QUESTION

Can clinic-level differences in nodule evaluation be incorporated to improve lung cancer prediction accuracy in patients seeking immediate specialty evaluation compared with currently available models?

STUDY DESIGN AND METHODS

Clinical and radiographic data on patients with IPNs from six sites (N = 1,401) were collected retrospectively and divided into groups by clinical setting: pulmonary nodule clinic (n = 374; cancer prevalence, 42%), outpatient thoracic surgery clinic (n = 553; cancer prevalence, 73%), or inpatient surgical resection (n = 474; cancer prevalence, 90%). A new prediction model was developed using a missing data-driven pattern submodel approach. Discrimination and calibration were estimated with cross-validation and were compared with the original TREAT, Mayo Clinic, Herder, and Brock models. Reclassification was assessed with bias-corrected clinical net reclassification index and reclassification plots.

RESULTS

Two-thirds of patients had missing data; nodule growth and fluorodeoxyglucose-PET scan avidity were missing most frequently. The TREAT version 2.0 mean area under the receiver operating characteristic curve across missingness patterns was 0.85 compared with that of the original TREAT (0.80), Herder (0.73), Mayo Clinic (0.72), and Brock (0.68) models with improved calibration. The bias-corrected clinical net reclassification index was 0.23.

INTERPRETATION

The TREAT 2.0 model is more accurate and better calibrated for predicting lung cancer in high-risk IPNs than the Mayo, Herder, or Brock models. Nodule calculators such as TREAT 2.0 that account for varied lung cancer prevalence and that consider missing data may provide more accurate risk stratification for patients seeking evaluation at specialty nodule evaluation clinics.

Underutilization of Systemic Therapy in Patients With NSCLC Undergoing Pneumonectomy: A Missed Opportunity for Survival

Introduction

Recent trials have reported promising results with the addition of immunotherapy to chemotherapy for patients with locally advanced NSCLC, but in practice, the proportion of patients who receive systemic therapy (ST) has historically been low. Underutilization of ST may be particularly apparent in patients undergoing pneumonectomy, in whom the physiologic insult and surgical complications may preclude adjuvant therapy (ADJ). We, therefore, evaluated the use of ST for patients with NSCLC undergoing pneumonectomy.

Methods

We queried the National Cancer Database, including all patients with NSCLC who underwent pneumonectomy between 2006 and 2018. Logistic regression was used to identify associations with ST and neo-ADJ (NEO). Overall survival was compared after propensity score matching (1:1) patients undergoing ST to those undergoing surgery alone using Kaplan-Meier and Cox regression methods.

Results

A total of 2619 patients were identified. Among these, 12% received NEO, 43% received ADJ, and 45% surgery alone. Age younger than 65 years (adjusted odds ratio [aOR] = 1.53, 95% confidence interval; [CI]: 1.10-2.11), Asian ethnicity (aOR = 2.68, 95% CI: 1.37-5.23), treatment at a high-volume center (aOR = 1.39, 95% CI: 1.06-1.81), and private insurance (aOR = 1.42, 95% CI: 1.05-1.94) were associated with NEO, whereas age younger than 65 years (aOR = 1.95, 95% CI: 1.61-2.38), comorbidity index less than or equal to 1 (aOR = 1.66, 95% CI: 1.29-2.16), and private insurance (aOR = 1.47, 95% CI: 1.20-1.80) were associated with any ST. In the matched cohort, ST was associated with better survival than surgery (adjusted hazard ratio = 0.67, 95% CI: 0.58-0.78).

Conclusions

A high proportion of patients who undergo pneumonectomy do not receive ST. Patient and socioeconomic factors are associated with the receipt of ST. Given its survival benefit, emphasis should be placed on multimodal treatment strategies, perhaps with greater consideration given to neoadjuvant approaches.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Current Management of Stage IIIA (N2) Non-Small-Cell Lung Cancer

There have been numerous recent advances in the treatmetn of stage IIIA non-small cell lung cancer. The most significant involve the addition of targeted therapies adn immune checkpoint inhibitors into perioperative care. These exciting advances are improving survival in this challenging patient population, but some-decade old controveries around the definition of resectability, prognositic importance of tumor response to induction therapy, and the role of pneumonectomy persist.

Lymph Node Upstaging for Robotic, Thoracoscopic, and Open Lobectomy for Stage T2-3N0 Lung Cancer

BACKGROUND

There may be equivalent efficacy of the lymph node evaluation for minimally invasive lobectomy compared with open lobectomy for stage I non-small cell lung cancer. We sought to compare the lymph node evaluation for lobectomy by approach for patients with larger tumors who are clinically node negative.

METHODS

This retrospective study analyzed 24 257 patients with clinical stage T2-3N0M0 non-small cell lung cancer from the National Cancer Database. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. The rates of pathologic lymph node upstaging were compared. A Cox multivariable regression model was performed to test the association with overall survival.

RESULTS

After IPTW adjustment 20 834 patients were included in the analysis. Of these, 1996 patients underwent robotic lobectomy, 5122 patients underwent thoracoscopic lobectomy, and 13 725 patients underwent open lobectomy from 2010 to 2017. The IPTW-adjusted N1 upstaging rate was similar for robotic (11.79%), thoracoscopic (11.49%), and open (11.85%) lobectomy (P = .274). The adjusted N2 upstaging rates were 5.03%, 5.66%, and 6.15% for robotic, thoracoscopic, and open lobectomy, respectively (P = .274). On IPTW-adjusted multivariable analysis, robotic and thoracoscopic lobectomy were associated with improved survival compared with open lobectomy (P < .001).

CONCLUSIONS

There was no significant difference in N1 and N2 lymph node upstaging rates between surgical approaches for patients with clinical stage T2-3N0 non-small cell lung cancer, indicating similarly effective lymph node evaluation. Overall survival after robotic and thoracoscopic lobectomy was significantly better compared with open lobectomy in this patient population with a high propensity for occult nodal disease.

Intraoperative challenges after induction therapy for non-small cell lung cancer: Effect of nodal disease on technical complexity

Objectives

Neoadjuvant therapy has been theorized to increase complexity of non-small cell lung cancer resections; however, specific factors that contribute to intraoperative challenges after induction therapy have not been well described. We aimed to characterize the effect of nodal involvement and nodal treatment response on surgical complexity after neoadjuvant therapy.

Methods

We identified patients treated with neoadjuvant therapy followed by anatomic lung resection for cN + non-small cell lung cancer between 2010 and 2020. Patients were categorized according to clinical N1 versus N2 disease. To evaluate the effect of nodal response to therapy, thoracic radiologists measured clinically suspected and pathologically involved lymph nodes before and after induction therapy. Operative reports were reviewed to identify technical challenges specifically related to nodal disease. Categorical outcomes were compared using Fisher exact test.

Results

One hundred twenty-four patients met inclusion criteria, among whom 107 (86.3%) were treated with neoadjuvant chemotherapy, whereas chemoradiation (n = 8) and targeted therapy (n = 9) were less common. In cases with N1 disease, 8/38 (21.0%) required proximal pulmonary arterial control, whereas this was necessary in only 2/88 (2.3%) of N2 cases (P = .001). Likewise, sleeve resection and arterioplasty were needed more frequently during resection of N1 disease (7/38, 18.4%) versus N2 disease (0/88, P < .001). Increased nodal response to therapy was associated with greater likelihood of requiring change in vascular approach (P = .011).

Conclusions

After induction therapy, N1 disease was associated with greater need for complex surgical maneuvers than N2 disease. Likewise, substantial treatment response was associated with increased intraoperative technical challenges. Recognizing such factors enables surgical teams to engage in appropriate operative planning to ensure patient safety.

Is the Critical Care Resuscitation Unit Sustainable: A 5-Year Experience of a Beneficial and Novel Model

Background. The 6-bed critical care resuscitation unit (CCRU) is a unique and specialized intensive care unit (ICU) that streamlines the interhospital transfer (IHT—transfer between different hospitals) process for a wide range of patients with critical illness or time-sensitive disease. Previous studies showed the unit successfully increased the number of ICU admissions while reducing the time of transfer in the first year of its establishment. However, its sustainability is unknown. Methods. This was a descriptive retrospective analysis of adult, non-trauma patients who were transferred to an 800-bed quaternary medical center. Patients transferred to our medical center between January 1, 2014 and December 31, 2018 were eligible. We used interrupted time series (ITS) and descriptive analyses to describe the trend and compare the transfer process between patients who were transferred to the CCRU versus those transferred to other adult inpatient units. Results. From 2014 to 2018, 50,599 patients were transferred to our medical center; 31,582 (62%) were non-trauma adults. Compared with the year prior to the opening of the CCRU, ITS showed a significant increase in IHT after the establishment of the CCRU. The CCRU received a total of 7,788 (25%) IHTs during this period or approximately 20% of total transfers per year. Most transfers (41%) occurred via ground. Median and interquartile range [IQR] of transfer times to other ICUs (156 [65–1027] minutes) were longer than the CCRU (46 [22–139] minutes, $P<0.001$ ). For the CCRU, the most common accepting services were cardiac surgery (16%), neurosurgery (11%), and emergency general surgery (10%). Conclusions. The CCRU increases the overall number of transfers to our institution, improves patient access to specialty care while decreasing transfer time, and continues to be a sustainable model over time. Additional research is needed to determine if transferring patients to the CCRU would continue to improve patients’ outcomes and hospital revenue.

Molecular Tumor Board Review and Improved Overall Survival in Non-Small-Cell Lung Cancer

With the introduction of precision medicine, treatment options for non-small-cell lung cancer have improved dramatically; however, underutilization, especially in disadvantaged patients, like those living in rural Appalachian regions, is associated with poorer survival. Molecular tumor boards (MTBs) represent a strategy to increase precision medicine use. UK HealthCare at the University of Kentucky (UK) implemented a statewide MTB in January 2017. We wanted to test the impact of UK MTB review on overall survival in Appalachian and other regions in Kentucky.

METHODS

We performed a case-control study of Kentucky patients newly diagnosed with non-small-cell lung cancer between 2017 and 2019. Cases were reviewed by the UK MTB and were compared with controls without UK MTB review. Controls were identified from the Kentucky Cancer Registry and propensity-matched to cases. The primary end point was the association between MTB review and overall patient survival.

RESULTS

Overall, 956 patients were included, with 343 (39%) residing in an Appalachian region. Seventy-seven (8.1%) were reviewed by the MTB and classified as cases. Cox regression analysis showed that poorer survival outcome was associated with lack of MTB review (hazard ratio [HR] = 8.61; 95% CI, 3.83 to 19.31; P < .0001) and living in an Appalachian region (hazard ratio = 1.43; 95% CI, 1.17 to 1.75; P = .004). Among individuals with MTB review, survival outcomes were similar regardless of whether they lived in Appalachia or other parts of Kentucky.

CONCLUSION

MTB review is an independent positive predictor of overall survival regardless of residence location. MTBs may help overcome some health disparities for disadvantaged populations.

Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma

Importance

Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery.

Objective

To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma.

Design, Setting, and Participants

In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020.

Exposures

Treatment facility characteristics.

Main Outcomes and Measures

Overall survival.

Results

The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977).

Conclusions and Relevance

In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

CONTEXT

The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.

METHODS

Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.

FINDINGS

Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.

CONCLUSIONS

Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

Regional and facility disparities in androgen deprivation therapy for prostate cancer from a multi-institutional Japan-wide database

OBJECTIVES

To examine the differences in prognosis of prostate cancer patients receiving primary androgen deprivation therapy by region and facility type using a Japan-wide database.

METHODS

Data on patients treated with primary androgen deprivation therapy between 2001 and 2003 from a nationwide community-based database established by the Japan Study Group of Prostate Cancer were obtained. Clinicopathological characteristics and prognostic variables, including progression, cancer-specific survival and overall survival, were compared according to region and facility type where the patients were treated.

RESULTS

Among 19 162 patients, 7102 (37.1%) and 12 060 (62.9%) men were in urban and rural areas, respectively, and 3556 (18.6%), 13 623 (71.1%) and 1983 (10.3%) patients were enrolled from academic centers, non-academic hospitals and urological clinics, respectively. The risks of progression, cancer-specific mortality and all-cause mortality were comparable between urban and rural areas in propensity-score matched analysis. Risks of progression, cancer-specific mortality and all-cause mortality in urological clinics were higher than those in academic centers in propensity-score matched analysis.

CONCLUSIONS

Our findings suggest that Japan facility type, but not geographical regions, might affect the prognosis of prostate cancer patients receiving primary androgen deprivation therapy.

Primary Small Cell Carcinoma of the Kidney: Disease Characteristics and Treatment Outcomes

Background: Primary small cell carcinoma of the kidney (PSCCK) is exceedingly rare and data on disease characteristics and outcomes are sparse. This study examines a nationally-representative cancer registry to better characterize PSCCK. Methods: We queried the National Cancer Database to identify patients with histology-confirmed PSCCK from 2004 to 2015. Adjusted Cox proportional hazards regression and Kaplan–Meier analyses were employed to assess predictors of mortality and estimate median survival time, respectively. Results: A total of 110 patients were included (47:53% female:male, 77% ≥60 years of age, 86% Caucasian). Significant predictors of mortality included female sex, age 60–69 years, treatment at an Integrated Network Cancer Program, stage cM1, and lack of surgical and chemoradiotherapy treatment. Independent protective factors were high socioeconomic status and treatment at an Academic Research Program. The estimated median overall survival time was 9.31 (95% CI 7.28–10.98) months for all patients. No differences in estimated survival time were observed across individual treatment modalities among those patients who underwent treatment (p = 0.214). Conclusions: PSCCK is an aggressive malignancy with a median survival time of less than one year. Future studies that correlate clinical tumor staging with specific treatment modalities are needed to optimize and individualize management.

Treatment at Integrated Centers Might Bridge the Academic-Community Survival Gap in Patients With Metastatic Non-Small Cell Carcinoma of the Lung

BACKGROUND

Non-small cell lung cancer (NSCLC) is responsible for the most cancer-related deaths in the United States. A better understanding of treatment-related disparities and ways to address them are important to improving survival for patients with metastatic NSCLC.

MATERIALS AND METHODS

We performed a retrospective analysis using the National Cancer Database. Included in this analysis were 107,116 patients with metastatic NSCLC who were treated at academic centers (AC), community-based centers (CC), and integrated centers (IC) between 2004 and 2015. The primary end point was overall survival, with comparisons of AC, CC, and IC.

RESULTS

The survival disparity between AC and CC continued to grow over the study period, from a 5.7% difference in 2-year survival to a 7.5% difference. Treatment at IC was initially associated with survival similar to CC (hazard ratio [HR], 0.93), however, later in the study period treatment at IC improved (HR, 0.74) outpacing the improvement in survival in CC (HR, 0.82) but not to the same degree as the improvement in AC (HR, 0.64). The improvement in survival at IC was noted predominantly in patients with adenocarcinoma (HR, 0.72; P < .001) but not in squamous-cell carcinoma (HR, 0.89; P value not significant).

CONCLUSION

Treatment of metastatic NSCLC at IC was associated with improved survival during our study period compared with treatment at CC. This appeared to be histology-dependent, suggesting a treatment-related improvement in survival because over this period newer therapies were preferentially available for adenocarcinoma. Integrating care across treatment facilities might be one way to bridge the growing gap in survival between AC and CC.

Chemotherapy and Survival in Patients with Primary High-Grade Extremity and Trunk Soft Tissue Sarcoma

The use of upfront chemotherapy for primary localized soft tissue sarcoma (STS) of the extremity and trunk is debated. It remains unclear if chemotherapy adds clinical benefit, which patients are likely to benefit, and whether the timing of therapy affects outcomes. We used the National Cancer Database (NCDB) to examine the association between overall survival (OS) and chemotherapy in 5436 patients with the five most common subtypes of STS with primary disease localized to the extremity or trunk, mirroring the patient population of a modern phase 3 clinical trial of neoadjuvant chemotherapy. We then examined associations between timing of multi-agent chemotherapy (neoadjuvant or adjuvant) and OS. We used a Cox proportional hazards model and propensity score matching (PSM) to account for covariates including demographic, patient, clinical, treatment, and facility factors. In the overall cohort, we observed no association between multi-agent chemotherapy or its timing and improved OS. Multi-agent chemotherapy was associated with improved OS in several subgroups, including patients with larger tumors (>5 cm), those treated at high-volume centers, or those who received radiation. We also identified an OS benefit to multi-agent chemotherapy among the elderly (>70 years) and African American patients. Multi-agent chemotherapy was associated with improved survival for patients with tumors >5 cm, who receive radiation, or who receive care at high-volume centers. Neither younger age nor chemotherapy timing was associated with better outcomes. These 'real-world' findings align with recent randomized trial data supporting the use of multi-agent chemotherapy in high-risk patients with localized STS.

Low Rates of Chemotherapy Use for Primary, High-Grade Soft Tissue Sarcoma: A National Cancer Database Analysis

BACKGROUND

There is conflicting evidence regarding the role of chemotherapy for high-grade soft tissue sarcoma (STS) in adults. We sought to characterize patterns of chemotherapy use, including multiagent and neoadjuvant chemotherapy, in the United States.

PATIENTS AND METHODS

Using the National Cancer Database, we identified 19,969 adult patients who underwent surgical resection for primary high-grade STS from 2004 to 2016. Using logistic regression, we examined factors associated with overall, multiagent, and neoadjuvant chemotherapy use.

RESULTS

Chemotherapy was administered to 22% (n=4,377) of the study population. Among patients treated using chemotherapy, 85% received multiagent treatment and 47% received neoadjuvant treatment. On multivariate analysis, factors associated with chemotherapy use included tumor size, depth, histology, and primary site; receipt of radiation treatment; younger age; higher patient income; and academic treatment facility. Factors associated with multiagent chemotherapy use included tumor histology, tumor primary site, and younger age. Factors associated with neoadjuvant chemotherapy use included tumor size, depth, margin status, and primary site; receipt of radiation treatment; higher patient income; academic treatment facility type; and distance to treatment facility. Treatment at a high-volume facility was the only factor associated with overall, multiagent, and neoadjuvant chemotherapy use. No significant temporal trend was seen in overall, multiagent, or neoadjuvant chemotherapy use.

CONCLUSIONS

Overall chemotherapy use was low (22%). The variability in chemotherapy use was driven by clinical, patient, demographic, and facility factors. Among patients treated with chemotherapy, the use of multiagent chemotherapy was high (85%), and nearly half received neoadjuvant therapy. There was a discrepancy in the use of chemotherapy-including neoadjuvant and multiagent chemotherapy-between high- and low-volume treatment centers.

Are academic hospitals better at treating metastatic colorectal cancer?

BACKGROUND

There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer.

METHODS

Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model.

RESULTS

Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P < .001; respectively). Similar results were seen after stratifying by metastatic site and treatment type.

CONCLUSION

The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.

The Academic Facility Type Is Associated With Improved Overall Survival for Early-Stage Lung Cancer

BACKGROUND

Early-stage non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. The overall survival rate for early-stage NSCLC may be determined by the healthcare facility type where patients receive their lung cancer treatment.

METHODS

A total of 103,748 cases with the American Joint Committee on Cancer clinical stage I and II NSCLC that were reported to the National Cancer Database at over 1150 facilities were analyzed in this study. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazards models were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting was used to adjust for facility volume and patient-related baseline differences between facility types.

RESULTS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly better median overall survival (63.2 months) compared with patients who received care at community healthcare facilities (54.2 months) (hazard ratio, 0.86; 95% confidence interval, 0.82-0.91; P < .0001). The surgical quality outcomes for NSCLC surgery, including 30-day mortality, 90-day mortality, and the median number of lymph nodes removed were significantly better for patients treated at the academic facility types.

CONCLUSIONS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly higher overall median survival compared with patients treated at community facility types. The short-term surgical quality outcomes were significantly better for patients who underwent surgery for early-stage NSCLC at academic facility types.

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients

Purpose

The aim of this study was to identify the association between Thailand’s insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand.

Patients and Methods

Medical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox’s regression and matching propensity score analysis was used to analyze data.

Results

This study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (OR_adj) = 0.94, 95% confidence interval (CI) = 0.65–1.37), undergoing lobectomy (OR_adj = 0.59, 95% CI = 0.24–1.46), and recurrent-free survival (adjusted hazard ratio (HR_adj) =1.20, 95% CI = 0.88–1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HR_adj = 1.61, 95% CI = 1.22–2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort.

Conclusion

Thai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Survival outcome of non-small cell lung cancer patients: Comparing results between the database of the Comprehensive Cancer Center Zürich and the Epidemiological Cancer Registry Zurich and Zug

BACKGROUND

Cancer cases among the population of the canton Zurich, are registered in the Cancer Registry of the cantons of Zurich and Zug (KKR). The Thoracic Oncology Center, founded in 2011 is one of 17 multidisciplinary centers within the Comprehensive Cancer Center Zurich (CCCZ).

METHODS

The aim of the current study is to quantify the mortality risk of patients with NSCLC and identify differences on survival and other factors between patients receiving their primary treatment at the CCCZ and those treated elsewhere and registered by KKR. The differential effect between CCCZ and KKR cohorts on survival: overall, by stage, sex and age, is explored. Stratified log-rank and Wilcoxon tests, Cox models and restricted mean survival times (RMST) are estimated. Propensity score matching (PSM) is also used to adjust for confounding factors.

RESULTS

Analysis included 848 NSCLC cases from the CCCZ and 1759 from the KKR, diagnosed between January 2011 and December 2015. At a median follow-up of 57 months, overall survival (OS) was significantly superior for patients treated at the CCCZ compared to KKR [Median OS: 36.0 months (95%CI: 31.0-45.0) and 12.0 months (95%CI: 11.0-13.0), respectively, stratified log-rank p < 0.001; adjusted HR = 1.31, (95% CI: 1.18-1.46), difference in RMST up to 72 months: 13.8 months (95%CI: 11.5-16.2), p < 0.001]. The effect of cohort was significant for stages III and IV (overall and also by sex and age). After PSM OS remained significantly superior for patients treated at the CCCZ compared to KKR.

CONCLUSIONS

The survival probability for patients in the CCCZ cohort was superior to that of patients in the canton Zürich treated outside the center. This analysis provides further evidence of the importance of the volume of experience and the availability of a multidisciplinary organization and research environment, as delivered by a comprehensive cancer center, on the outcome of patients with NSCLC.

TIDieR checklist evaluation of clinical trial intervention reporting for recent FDA-approved anticancer medications

IMPORTANCE

Clear and comprehensive descriptions of clinical trial interventions are necessary to translate new results into clinical practice. The TIDieR checklist was developed to be a minimum set of key items considered essential to high-quality reporting of clinical trial interventions.

OBJECTIVE

To determine the quality of reporting of recent Food and Drug Administration (FDA)-approved oncology interventions.

DESIGN

Cross-sectional investigation.

SETTING/PARTICIPANTS/INTERVENTION

Recent, FDA-approved haematology/oncology anticancer interventions.

MAIN OUTCOME MEASURE

Quality of reporting.

RESULTS

Across all included trials (n=96), a median of 8-9 (out of 12) TIDieR items were reported. Seven TIDieR items had >90% adherence, including individual-level and study-level modifications of drugs and dosing schedules. Three items were less often reported: intervention provider, including training and expertise (7/192, 3.6%); trial institution infrastructure (0/192, 0.0%); and how intervention compliance was assessed (59/192, 30.7%). Publication of a protocol improved intervention reporting (p<0.001).

CONCLUSIONS

In this analysis of clinical trials of recent, FDA-approved anticancer interventions, we found good adherence to the TIDieR checklist. These studies were homogeneous in their structure and included information; some TIDieR items were always or never/rarely reported. Clinical trial effect sizes may not translate to real-world practice for a number of reasons. Thus, to aid the translation of trial effect sizes to real-world practice, we recommend authors adhere to the TIDieR checklist and describe the infrastructure of trial centres and describe who provided the intervention, along with their expertise.

Closing the gap: Contribution of surgical best practices to outcome differences between high- and low-volume centers for lung cancer resection

Background

Clinical outcomes for resected early‐stage non‐small cell lung cancer (NSCLC) are superior at high‐volume facilities, but reasons for these differences remain unclear. Understanding these differences and optimizing outcomes across institutions are critical to the management of the increasing incidence of these cases. We evaluated the extent to which surgical best practices account for resected early‐stage NSCLC outcome differences between facilities according to case volume.

Methods

We performed a retrospective cohort study for clinical stage 1 or 2 NSCLC undergoing surgical resection from 2004 to 2013 using the National Cancer Database (NCDB). Surgical best practices (negative surgical margins, lobar or greater resection, lymph node (LN) dissection, and examination of > 10 LNs) were compared between the highest and lowest quartile volumes.

Results

A total of 150,179 patients were included in the cohort (89% white, 53% female, median age 68 years). In a multivariate model, superior overall survival (OS) was observed at highest volume centers compared to lowest volume centers (hazard ratio (HR) = 0.89; 95% CI, 0.82‐0.96; P = .002). After matching for surgical best practices, there was no significant OS difference (HR = 0.95; 95% CI, 0.87‐1.05; P = .32). Propensity score‐adjusted HR estimates indicated that surgical best practices accounted for 54% of the numerical OS difference between low‐volume and high‐volume centers. Each surgical best practice was independently associated with improved OS (all P ≤ .001).

Conclusion

Quantifiable and potentially modifiable surgical best practices largely account for resected early‐stage NSCLC outcome differences observed between low‐ and high‐volume centers. Adherence to these guidelines may reduce and potentially eliminate these differences.

The Impact of Radiotherapy Facility Volume on the Survival and Guideline Concordance of Patients With Muscle-invasive Bladder Cancer Receiving Bladder-preservation Therapy

OBJECTIVES

Higher facility surgical volume predicts for improved outcomes in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. We investigated the association between facility radiotherapy (RT) case volume and overall survival (OS) for patients with MIBC who received bladder-preserving RT, and the relationship with adherence to National Comprehensive Cancer Network (NCCN) guidelines for bladder preservation.

METHODS

The National Cancer Database was used to identify patients diagnosed with nonmetastatic MIBC from 2004 to 2015 and received RT at the reporting center. Facility case volume was defined as the total MIBC patients treated with RT during the period. Facilities were stratified into high-volume facility (HVF) or low-volume facility at the 80th percentile of RT case volume. OS was assessed using Kaplan-Meier analysis. Rates of compliance with NCCN guidelines regarding the use of transurethral resection of the bladder tumor before RT, planned use of concurrent chemotherapy, and total RT dose were compared. Cox proportional hazard model was used to evaluate predictors of OS.

RESULTS

There were 7562 patients included. No differences in age, Charlson-Deyo score, T stage, or node-positive rates were observed between groups. HVFs exhibited greater compliance with NCCN guidelines for bladder preservation (P<0.0001). Treatment at an HVF was associated with the improved OS for all patients (P=0.001) and for the subset of patients receiving NCCN-recommended RT doses (P=0.0081). Volume was an independent predictor of OS (P=0.002).

CONCLUSIONS

Treatment at an HVF is associated with improved OS and greater guideline-concordant management among patients with MIBC.

Type and case volume of health care facility influences survival and surgery selection in cases with early-stage non-small cell lung cancer

BACKGROUND

With the expansion of non-small cell lung cancer (NSCLC) screening methods, the percentage of cases with early-stage NSCLC is anticipated to increase. Yet it remains unclear how the type and case volume of the health care facility at which treatment occurs may affect surgery selection and overall survival for cases with early-stage NSCLC.

METHODS

A total of 332,175 cases with the American Joint Committee on Cancer (AJCC) TNM stage I and stage II NSCLC who were reported to the National Cancer Data Base (NCDB) by 1302 facilities were studied. Facility type was characterized in the NCDB as community cancer program (CCP), comprehensive community cancer program (CCCP), academic/research program (ARP), or integrated network cancer program (INCP). Each facility type was dichotomized further into high-volume or low-volume groups based on the case volume. Multivariate Cox proportional hazard models, the logistic regression model, and propensity score matching were used to evaluate differences in survival and surgery selection among facilities according to type and volume.

RESULTS

Cases from ARPs were found to have the longest survival (median, 16.4 months) and highest surgery rate (74.8%), whereas those from CCPs had the shortest survival (median, 9.7 months) and the lowest surgery rate (60.8%). The difference persisted when adjusted by potential confounders. For cases treated at CCPs, CCCPs, and ARPs, high-volume facilities had better survival outcomes than low-volume facilities. In facilities with better survival outcomes, surgery was performed for a greater percentage of cases compared with facilities with worse outcomes.

CONCLUSIONS

For cases with early-stage NSCLC, both facility type and case volume influence surgery selection and clinical outcome. Higher surgery rates are observed in facilities with better survival outcomes.

Training in robotic thoracic surgery-the European way

The increasing demand for robot-assisted thoracic surgery (RATS) in Europe requires a structured and standardized training module. Until now, Intuitive Surgical Inc. (Sunnyvale, CA, USA) has delivered the only available robotic surgery platform. Although the training program that is organized by Intuitive is divided in an initial and an advanced course, the success of the training depends on many external factors. Until now the training focused on experienced thoracic surgeons. The aim of this article is to offer a stepwise training module, which can be adopted by experienced open (thoracotomy) surgeons or video-assisted thoracic (VATS) surgeons but is primarily meant for thoracic surgery fellows and residents, as it is our sincere opinion that we should focus on training for this type of surgery as early in their careers as possible. In order to maintain surgical technique and minimize the chance of complications, on-going training and certification of the surgeons and the team is deemed necessary.

Treatment strategies and clinical outcomes of locally advanced pancreatic cancer patients treated at high-volume facilities and academic centers

Purpose

Locally advanced pancreatic cancer (LAPC) treatment has varying practice patterns with poor outcomes. We investigated treatment using single-agent chemotherapy and multiagent chemotherapy (MAC) with or without radiation therapy (RT) at high-volume facilities (HVFs) and academic centers (ACs).

Methods and Materials

The National Cancer Database was used to obtain data on 10,139 patients with LAPC. HVF was defined as the top 5% of facilities per number of patients treated at each facility. Univariate and multivariable (MVA) analysis Cox regressions were performed to identify the impact of HVF, AC, MAC, and RT on overall survival (OS).

Results

The median age of patients was 66 years (range, 22-90); 50.1% were male and 49.9% female. Of the patients, 46.1% received MAC, 53.8% received single-agent chemotherapy, 45.7% received RT, 54.3% did not receive RT, and 5% underwent surgical resection. The median follow-up was 48.8 months. On MVA, treatment at HVFs and ACs remained significantly associated with improved OS, with a hazard ratio (HR) of 0.84 (P < .001) and 0.94 (P = .004), respectively. The median OS for HVF treatment compared with low-volume facilities was 14.3 versus 11.2 months, respectively (P < .001). The median OS for AC treatment versus non-AC was 12.1 versus 10.8 months, respectively (P < .001). Additionally, on MVA, receipt of RT and MAC remained significantly associated with improved OS (HR: 0.76; P < .001; and HR: 0.73; P < .001, respectively). MVA for receipt of surgery showed that MAC is a significant predictor for receiving surgery (odds ratio: 1.29; P = .009).

Conclusions

Our results build on a growing literature supporting RT and MAC in treating LAPC. Additionally, we believe that-in the absence of prospective data-this makes a strong case for considering MAC with RT at ACs and HVFs for treating LAPC.

Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival

BACKGROUND

Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established.

OBJECTIVE

We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma.

METHODS

Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile.

RESULTS

Facility case volume was significantly associated with long-term patient survival (P < .0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities.

LIMITATIONS

Disease-specific survival was not available.

CONCLUSIONS

Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.

Patient and Facility Demographics Related Outcomes in Early-Stage Non-Small Cell Lung Cancer Treated with Radiofrequency Ablation: A National Cancer Database Analysis

PURPOSE

To determine facility and patient demographics associated with survival in early-stage non-small cell lung cancer (NSCLC) treated with radiofrequency (RF) ablation.

MATERIALS AND METHODS

The National Cancer Database was queried for cases of stage 1a NSCLC treated with RF ablation without chemotherapy or radiotherapy from 2004 to 2014. High-volume centers (HVCs) were defined as the top 95^th percentile of facilities by number of procedures performed. Overall survival (OS) was estimated with the Kaplan-Meier method, and comparisons between survival curves were performed with the log-rank test. Propensity score-matched cohort analysis was performed. P values less than .05 were considered statistically significant.

RESULTS

In the final cohort, 967 cases were included. Estimated median survival and follow-up were 33.1 and 62.5 months, respectively. Of 305 facilities, 15 were determined to be HVCs, treating 13 or more patients from 2004 to 2014. A total of 335 cases (34.6%) were treated at HVCs. On multivariate Cox regression analysis, treatment at an HVC was independently associated with improved OS (hazard ratio [HR] = 0.766; P = .006). After propensity score adjustment, 1-, 3-, and 5-year OS was 89.8%, 51.2%, and 27.7%, respectively, for patients treated at HVCs, compared to 85.2%, 41.5%, and 19.6%, respectively, for patients treated at non-HVCs (P = .015). Increasing age (HR = 1.012; P = .013) and higher T-classification (HR = 1.392; P < .001) were independently associated with worse OS.

CONCLUSION

Patients with early-stage NSCLC treated with RF ablation at HVCs experienced a significant increase in OS, suggesting regionalization of lung cancer management as a means of improving outcomes.

Survival trends among non-small-cell lung cancer patients over a decade: impact of initial therapy at academic centers

Background

Treatment of non‐small‐cell lung cancer (NSCLC) has been rapidly advancing over the last decade. Academic centers are considered equipped with better expertise. NSCLC outcome trends in novel therapeutic era and impact of initial treatment at academic centers have not been reported.

Methods

The National Cancer Database (NCDB) was used to identify NSCLC incident cases from 2004 to 2013. Overall survival (OS) was plotted by year of diagnosis and type of initial treatment center, accounting for several factors available in NCDB.

Results

A total of 1 150 722 NSCLC patients were included and separated by initial treatment center type (academic: 31.5%; nonacademic: 68.5%). Median follow‐up and OS for all patients were 11.8 months (range: 0‐133.6 months) and 13.1 months (95% CI: 13.08‐13.17), respectively. Median OS improved significantly for those diagnosed in 2010‐2013 (14.8 months [95% CI: 14.7‐14.9]) as compared to 2004‐2009 (12.4 months [95% CI: 12.3‐12.5]) (P < 0.001). Treatment at academic centers was associated with improved OS (multivariate HR for OS = 0.929 [95% CI: 0.92‐0.94], P < 0.0010). Four‐year OS for academic and nonacademic cohorts was 28.5%% and 22.1%, respectively (P < 0.001), and the difference was more pronounced in stage I to III NSCLC.

Conclusion

In this largest analysis, thus far, NSCLC survival has improved over time, and type of initial treatment center significantly influences survival. Identifying and removing barriers to obtaining initial treatment of NSCLC at academic medical centers could improve OS.

Patient choice for high-volume center radiation impacts head and neck cancer outcome

Background

Studies suggest treatment outcomes may vary between high (HVC)‐ and low‐volume centers (LVC). Radiation therapy (RT) for head and neck cancer (HNC) requires weeks of treatment, the inconvenience of which may influence a patient's choice for treatment location. We hypothesized that receipt of RT for HNC at a HVC would influence outcomes compared to patients evaluated at a HVC, but who chose to receive RT at a LVC.

Methods

From 1998 to 2011, 1930 HNC patients were evaluated at a HVC and then treated with RT at either a HVC or LVC. Time‐to‐event outcomes and treatment factors were compared.

Results

Median follow‐up was 34 months. RT was delivered at a HVC for 1368 (71%) patients and at a LVC in 562 (29%). Patients were more likely to choose HVC‐RT if they resided in the HVC's county or required definitive RT (all P < 0.001). HVC‐RT was associated with a significant improvement in 3‐year LRC (84% vs 68%), DFS (68% vs 48%), and OS (72% vs 57%) (all P < 0.001). On multivariate analysis (MVA), HVC‐RT independently predicted for improved LRC, DFS, and OS (all P < 0.05).

Conclusions

In patients evaluated at a HVC, the choice of RT location was primarily influenced by their residing distance from the HVC. HVC‐RT was associated with improvements in LRC, DFS, and OS in HNC. As treatment planning and delivery are technically demanding in HNC, the choice to undergo treatment at a HVC may result in more optimal delivered dose, RT duration, and outcome.

How to get the best from robotic thoracic surgery

The application of Robotic technology in thoracic surgery has become widespread in the last decades. Thanks to its advanced features, the robotic system allows to perform a broad range of complex operations safely and in a comfortable way, with valuable advantages related to low invasiveness. Regarding lung tumours, several studies have shown the benefits of robotic surgery including lower blood loss and improved lymph node removal when compared with other minimally invasive techniques. Moreover, the robotic instruments allow to reach deep and narrow spaces permitting safe and precise removal of tumours located in remote areas, such as retrosternal and posterior mediastinal spaces with outstanding postoperative and oncological results. One controversial finding about the application of robotic system is its high capital and running costs. For this reason, a limited number of centres worldwide are able to employ this groundbreaking technology and there are limited possibilities for the trainees to acquire the necessary skills in robotic surgery. Therefore, a training programme based on three steps of learning, associated with a solid surgical background and a consistent operating activity, are required to obtain effective results. Putting this highest technological innovation in the hand of expert surgeons we can assure safe and effective procedures getting the best from robotic thoracic surgery.

The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (OR_adj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (OR_adj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (OR_adj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.

Post-Treatment Mortality After Surgery and Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer

Purpose In early-stage non-small cell lung cancer (NSCLC), post-treatment mortality may influence the comparative effectiveness of surgery and stereotactic body radiotherapy (SBRT), with implications for shared decision making among high-risk surgical candidates. We analyzed early mortality after these interventions using the National Cancer Database. Patients and Methods We abstracted patients with cT1-T2a, N0, M0 NSCLC diagnosed between 2004 and 2013 undergoing either surgery or SBRT. Thirty-day and 90-day post-treatment mortality rates were calculated and compared using Cox regression and propensity score-matched analyses. Results We identified 76,623 patients who underwent surgery (78% lobectomy, 20% sublobar resection, 2% pneumonectomy) and 8,216 patients who received SBRT. In the unmatched cohort, mortality rates were moderately increased with surgery versus SBRT (30 days, 2.07% v 0.73% [absolute difference (Δ), 1.34%]; P < .001; 90 days, 3.59% v 2.93% [Δ, 0.66%]; P < .001). Among the 27,200 propensity score-matched patients, these differences increased (30 days, 2.41% v 0.79% [Δ, 1.62%]; P < .001; 90 days, 4.23% v 2.82% [Δ, 1.41%]; P < .001). Differences in mortality between surgery and SBRT increased with age, with interaction P < .001 at both 30 days and 90 days (71 to 75 years old: 30-day Δ, 1.87%; 90-day Δ, 2.02%; 76 to 80 years old: 30-day Δ, 2.80%; 90-day Δ, 2.59%; > 80 years old: 30-day Δ, 3.03%; 90-day Δ, 3.67%; all P ≤ .001). Compared with SBRT, surgical mortality rates were higher with increased extent of resection (30-day and 90-day multivariate hazard ratio for mortality: sublobar resection, 2.85 and 1.37; lobectomy, 3.65 and 1.60; pneumonectomy, 14.5 and 5.66; all P < 0.001). Conclusion Differences in 30- and 90-day post-treatment mortality between surgery and SBRT increased as a function of age, with the largest differences in favor of SBRT observed among patients older than 70 years. These representative mortality data may inform shared decision making among patients with early-stage NSCLC who are eligible for both interventions.

Lung Cancer Screening and Its Impact on Surgical Volume

Lung cancer screening has demonstrated a reduction in lung cancer mortality by 20%. Annual low-dose computed tomography examination in high-risk individuals is now recommended by multiple national health care organizations and is covered under Medicare and Medicaid services. The impact of this public health intervention is projected to increase the case load for the thoracic surgery workforce.

Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity

BACKGROUND

Surgical trainee association with operative outcomes is controversial. Studies are conflicting, possibly due to insufficient control of confounding variables such as operative time, case complexity, and heterogeneous patient populations. As operative complications worsen long-term outcomes in oncologic patients, understanding effect of trainee involvement during laparoscopic colectomy for cancer is of utmost importance. Here, we hypothesized that resident involvement was associated with worsened 30-day mortality and 30-day overall morbidity in this patient population.

METHODS

Patients undergoing laparoscopic colectomy for oncologic diagnosis from 2005 to 2012 were assessed using the American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score matching accounted for demographics, comorbidities, case complexity, and operative time. Attending only cases were compared to junior, middle, chief resident, and fellow level cohorts to assess primary outcomes of 30-day mortality and 30-day overall morbidity.

RESULTS

A total of 13,211 patients met inclusion criteria, with 4075 (30.8%) cases lacking trainee involvement and 9136 (69.2%) involving a trainee. Following propensity matching, junior (PGY 1-2) and middle level (PGY 3-4) resident involvement was not associated with worsened outcomes. Chief (PGY 5) resident involvement was associated with worsened 30-day overall morbidity (15.5 vs. 18.6%, p = 0.01). Fellow (PGY > 5) involvement was associated with worsened 30-day overall morbidity (16.0 vs. 21.0%, p < 0.001), serious morbidity (9.3 vs. 13.5%, p < 0.001), minor morbidity (9.8 vs. 13.1%, p = 0.002), and surgical site infection (7.9 vs. 10.5%, p = 0.006). No differences were seen in 30-day mortality for any resident level.

CONCLUSION

Following propensity-matched analysis of cancer patients undergoing laparoscopic colectomy, chief residents, and fellows were associated with worsened operative outcomes compared to attending along cases, while junior and mid-level resident outcomes were no different. Further study is necessary to determine what effect the PGY surgical trainee level has on post-operative morbidity in cancer patients undergoing laparoscopic colectomy in the context of multiple collinear factors.

Patterns of care of brain tumor-related epilepsy. A cohort study done in Italian Epilepsy Center

Epilepsy is the most common comorbidity in patients with brain tumors.

STUDY AIMS

To define characteristics of brain tumor-related epilepsy (BTRE) patients and identify patterns of care. Nationwide, multicenter retrospective cohort study. Medical records of BTRE patients seen from 1/1/2010 to 12/31/2011, followed for at least one month were examined. Information included age, sex, tumor type/treatments, epilepsy characteristics, antiepileptic drugs (AEDs). Time to modify first AED due to inefficacy and/or toxicity was assessed with the Kaplan-Meier method and Cox proportional hazard models were used to identify predictors of treatment outcome. Enrolled were 808 patients (447 men, 361 women) from 26 epilepsy centers. Follow-up ranged 1 to 423 months (median 18 months). 732 patients underwent surgery, 483 chemotherapy (CT), 508 radiotherapy. All patients were treated with AEDs. Levetiracetam was the most common drug. 377 patients (46.7%) were still on first drug at end of follow-up, 338 (41.8%) needed treatment modifications (uncontrolled seizures, 229; side effects, 101; poor compliance, 22). Treatment discontinuation for lack of efficacy was associated with younger age, chemotherapy, and center with <20 cases. Treatment discontinuation for side effects was associated with female sex, enzyme-inducing drugs and center with > 20 cases. About one-half of patients with BTRE were on first AED at end of follow-up. Levetiracetam was the most common drug. A non enzyme-inducing AED was followed by a lower risk of drug discontinuation for SE.

Impact of Surgeon Volume on Outcomes of Older Stage I Lung Cancer Patients Treated via Video-assisted Thoracoscopic Surgery

Surgeon procedure volume influences outcomes of patients undergoing cancer operations. Limited data are available, however, on the volume-outcome relationship for video-assisted thoracoscopic surgery (VATS) in the treatment of non-small cell lung cancer (NSCLC). In this study, we used population-based data to evaluate the extent to which surgeon volume is associated with postoperative and long-term oncological outcomes following VATS resection for older patients with early-stage NSCLC. Stage I NSCLC patients >65 years treated with VATS wedge, segmentectomy, or lobectomy between 2000 and 2010 were identified from the Surveillance, Epidemiology, and End Results registry linked to Medicare. Surgeon volume was grouped into tertiles (low, intermediate, and high). Outcomes included perioperative complications, intensive care unit admission, extended length of stay, perioperative (30-day) mortality, and long-term overall and lung cancer-specific survival. We used propensity score methods to compare adjusted survival of patients by surgical volume group. A total of 2295 study patients were identified. Patients treated by high-volume surgeons had decreased intensive care unit admissions (hazard ratio [HR]: 0.46, 95% CI: 0.41-0.51) and postoperative length of stay (HR: 0.75, 95% CI: 0.61-0.92). Adjusted analyses showed that overall (HR: 0.73, 95% CI: 0.62-0.87) and lung cancer-specific (HR: 0.76, 95% CI: 0.58-0.99) survival was better for patients treated by high-volume surgeons. Elderly stage I NSCLC patients undergoing VATS by high-volume surgeons have reduced postoperative complications and improved survival. Organization of care favoring referrals of VATS candidates to high-volume providers may help improve the outcomes of patients with early-stage lung cancer.

Location of Receipt of Initial Treatment and Outcomes in Long-Term Breast Cancer Survivors

Purpose

Cancer outcomes differ depending on where treatment is received. We assessed differences in outcomes in long-term breast cancer survivors at a specialty care hospital by location of their initial treatment.

Methods

We retrospectively examined a cohort of women diagnosed with invasive early-stage breast cancer who did not experience recurrence for at least 5 years after the date of diagnosis and were evaluated at The University of Texas MD Anderson Cancer Center between January 1997 and August 2008. The location of initial treatment was categorized as MD Anderson (MDA-treated) or other (OTH-treated). Outcomes analyzed included recurrence-free survival (RFS), distant relapse-free survival (DRFS), and overall survival (OS). The Kaplan-Meier product-limit method was used to compare outcomes between the two groups. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

Results

We identified 5,091 breast cancer survivors (median follow-up 8.6 years), of whom 89.1% were MDA-treated. The 10-year OS, RFS, and DRFS rates were 90.9%, 88.4%, and 89.0% in the MDA-treated group and 74.3%, 49.8%, and 52.7% in the OTH-treated group, respectively. We observed worse outcomes in the OTH-group in both the univariate analysis and the multivariable analysis (OS: HR = 4.8, 95% CI = 3.9–6.0; RFS: HR = 5.8, 95% CI = 4.8–7.0; DRFS: HR = 5.4, 95% CI = 4.5–6.6).

Conclusion

Long-term breast cancer survivors who initiated their treatment at MD Anderson had better outcomes. Location of initial treatment could be an independent risk factor for survival outcomes at specialty care hospitals. This analysis has limitations inherent to retrospective observational studies such as other unmeasured variables may be associated with worse prognosis.

Access to Accredited Cancer Hospitals Within Federal Exchange Plans Under the Affordable Care Act

Purpose The Affordable Care Act expanded access to health insurance in the United States, but concerns have arisen about access to specialized cancer care within narrow provider networks. To characterize the scope and potential impact of this problem, we assessed rates of inclusion of Commission on Cancer (CoC) -accredited hospitals and National Cancer Institute (NCI) -designated cancer centers within federal exchange networks. Methods We downloaded publicly available machine-readable network data and public use files for individual federal exchange plans from the Centers for Medicare and Medicaid Services for the 2016 enrollment year. We linked this information to National Provider Identifier data, identified a set of distinct provider networks, and assessed the rates of inclusion of CoC-accredited hospitals and NCI-designated centers. We measured variation in these rates according to geography, plan type, and metal level. Results Of 4,058 unique individual plans, network data were available for 3,637 (90%); hospital information was available for 3,531 (87%). Provider lists for these plans reduced into 295 unique networks for analysis. Ninety-five percent of networks included at least one CoC-accredited hospital, but just 41% of networks included NCI-designated centers. States and counties each varied substantially in the proportion of networks listed that included NCI-designated centers (range, 0% to 100%). The proportion of networks that included NCI-designated centers also varied by plan type (range, 31% for health maintenance organizations to 49% for preferred provider organizations; P = .04) but not by metal level. Conclusion A large majority of federal exchange networks contain CoC-accredited hospitals, but most do not contain NCI-designated cancer centers. These results will inform policy regarding access to cancer care, and they reinforce the importance of promoting access to clinical trials and specialized care through community sites.