International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers

OBJECTIVE

The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma.

SUMMARY BACKGROUND DATA

Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization.

METHODS

We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics.

RESULTS

Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients.

CONCLUSIONS

There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.

Hospital Volume Predicts Guideline-Concordant Care in Stage III Esophageal Cancer

BACKGROUND

Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally.

METHODS

From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling.

RESULTS

The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89).

CONCLUSIONS

Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement.

Evidence and implementation gaps in management of sentinel node-positive melanoma in the United States

BACKGROUND

Melanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node-positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node-positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer-accredited centers.

METHODS

In a retrospective cohort study of adults with sentinel lymph node-positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals.

RESULTS

Among 10,240 sentinel lymph node-positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB-C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44-0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08-2.67), treatment at a high- or moderate-volume center (odds ratio_high = 1.49, 95% confidence interval = 1.05-2.12; odds ratio_moderate = 1.32, 95% confidence interval = 1.05-1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27-1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node.

CONCLUSION

At a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.

Adherence to quality measures improves survival in esophageal cancer in a retrospective cohort study of the national cancer database from 2004 to 2016

Background

We assessed adherence to four novel quality measures in patients with stage III esophageal cancer, a leading cause of death among GI malignancies.

Methods

We performed a retrospective cohort study of 22,871 stage III esophageal cancer patients identified from the National Cancer Database (NCDB) between 2004 and 2016. Four quality measures were defined from published guidelines: administration of induction therapy, >15 lymph nodes sampled, surgery within 60 days of neoadjuvant treatment, and R0 resection. The association of patient demographic and treatment variables with measure adherence was assessed using multiple logistic regression. Risk of all-cause mortality was assessed comparing adherent and non-adherent cases using Cox modeling. Kaplan-Meier survival estimates of groups that adhered to zero to four out of four quality measures were performed.

Results

Adherence was high for neoadjuvant treatment (93.7%), timing of surgery (85.7%) and completeness of resection (92.0%), but low for nodal evaluation (45.9%). Medicaid insurance status was associated with decreased odds of adherence for neoadjuvant treatment [odds ratio (OR) 0.73, 95% confidence interval (CI): 0.54–0.99], nodal evaluation (OR 0.81, 95% CI: 0.68–0.96), and completeness of resection (OR 0.71, 95% CI: 0.54–0.92). From 2010 to 2016, when compared to cases from 2004 to 2005, there was a progressive increase in the odds of adequate induction therapy, nodal staging, and completeness of resection, but a progressive decrease in odds of well-timed surgery. Adherence was associated with decreased all-cause mortality for induction therapy, nodal staging, and R0 resection, but not for timing of surgery. Survival improved as the number of quality measures an individual patient adhered to increased.

Conclusions

Adherence to quality measures is associated with improved survival in patients with stage III esophageal cancer. Understanding variability in measure adherence may identify targets for quality improvement initiatives.

Quality assurance in melanoma care: guideline-based quality indicators for melanoma - implementation, evaluation and update process

BACKGROUND

In 2018, an update of the German evidence-based (S3) guidelines "Diagnosis, Therapy and Follow-up of Melanoma" first issued in 2013 was published under the auspices of the German Guideline Program in Oncology. The update also included a revision of existing guideline-based quality indicators (QIs).

PATIENTS AND METHODS

Using a standardized multi-step process, the guideline-derived QIs were revised by a multidisciplinary, interprofessional working group based on the strong (level A) recommendations contained in the guideline update as well as on a systematic literature search for international indicators and on the outcomes of existing QIs as reported by certified German skin cancer centers.

RESULTS

Based on the original set of twelve guideline-based QIs agreed upon in 2013, the working group developed an updated set containing nine indicators. Four QIs were kept unchanged; two were modified; two were removed; and three new QIs were added. Unlike 2013, the working group was now able to incorporate the outcomes of QIs previously implemented at the various skin cancer centers.

CONCLUSIONS

Close cooperation between guideline group and certification commission allows for the implementation of guideline-based QIs in cancer care. Measured outcomes form the basis for updating both the guidelines and the QI development process. They provide information about the care of cancer patients in a real-world setting as well as on guideline adherence and the feasibility of QIs themselves. This is a dynamic process that can be described in a transparent manner and that requires regular updating.

Use of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma

BACKGROUND

For patients with sentinel node-positive melanoma (SNPM), randomized trials, first reported in 2015, found no benefit for routine completion lymph node dissection (CLND) in selected patients. This study examines time trends in CLND and explores institutional and clinical factors associated with CLND.

STUDY DESIGN

The National Cancer Database was queried for patients older than 18 years from 2012 to 2016 with SNPM. A high-volume center was defined as >80th percentile for number of sentinel node procedures. Poisson regression assessed temporal trends and identified patient, pathologic, and institutional characteristics associated with CLND.

RESULTS

From 2012 to 2016, we identified 7,146 patients with SNPM. The proportion of patients undergoing CLND was steady in 2012 to 2014 (61% to 63%), but decreased to 57% in 2015 and 50% in 2016 (p < 0.0001). The proportion of patients with SNPM who underwent CLND decreased over time for both high- (66% to 52%; p < 0.0001) and lower-volume centers (55% to 45%; p = 0.06). Female sex (relative risk [RR] 0.97; p < 0.001) and increasing age (RR 0.98; p < 0.0001) were associated with lower likelihood of CLND. Increased Breslow depth (RR 1.015; p = 0.006), ulceration (RR 1.067; p = 0.02), and high-volume centers (RR 1.180; p < 0.0001) were associated with higher likelihood of CLND. Regional differences in likelihood of CLND were also present (p < 0.0001).

CONCLUSIONS

Completion lymph node dissection in SNPM decreased over time, with the greatest change in 2016. Several patient, pathologic, and institutional characteristics were associated with likelihood of CLND. As evidence supports close observation for selected patients, efforts should be undertaken to improve and standardize patient selection for CLND across institutions caring for patients with melanoma.

Disparities in the management of cutaneous malignant melanoma. A population-based high-resolution study

Population-based cancer registry data from three Spanish areas were used to assess the patterns of care and adherence to guidelines for cutaneous malignant melanoma. We included 934 cases diagnosed in 2009-2013. Completeness of the pathology reports, imaging for detecting distant metastasis and the use of sentinel lymph node biopsy (SLNB) were analysed. The proportion of pathology reports that mentioned the essential pathological features required for T staging was 93%, ranging across geographic areas from 81% to 98% (p < 0.001). The percentage of low-risk patients who underwent no imaging studies, as proposed by guidelines, or only chest imaging ranged among areas from 0.6% to 84% (p < 0.001). Of the patients with clinically node-negative melanoma >1 mm thick and no distant metastases, 68% underwent SLNB, varying by area from 61% to 78% (p = 0.017). This study revealed wide geographic variation in different aspects of melanoma care. The use of a standardised structured pathology report could strengthen the completeness of reporting. Improvement strategies should also include efforts to reduce overuse of imaging in low-risk patients and to increase the adherence to guidelines recommendations on the use of SLNB.

Quality assurance in melanoma care: The EU-MELACARE study

BACKGROUND

A significant disparity regarding survival outcome for melanoma among European regions is well recognized and access to high quality care for European melanoma patients needs to be improved. There is an unmet need for the implementation of minimal standard of care within defined clinical pathways and Quality Assurance (QA) indicators.

OBJECTIVE

The EU-MELACARE study aims to identify shared variables for cutaneous melanoma cases recorded in melanoma registries across Europe.

MATERIAL AND METHODS

Opinion leaders involved in melanoma data registration and care quality analysis in 34 European countries were invited to respond to an expert survey covering questions regarding the melanoma registration practice in their countries and the characteristics, coverage and variables collected by the relevant melanoma registries.

RESULTS

Data regarding 13 melanoma registries from 11 European countries contributed to the study. The majority (61,5%) were population based registries and more than half (62%) had national coverage. The included registries collected a median of 38 variables (Interquartile Range, IRQ 21-76). We identified 24 shared variables available in >70% of registries.

CONCLUSIONS

This study provides valuable specific information on information recorded for melanoma cases are registered within Europe. A core of shared variables has been identified, which will constitute the basis for a standardized set of QA indicators for assessing and monitoring melanoma care across European countries.

The Role of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma

PURPOSE AND METHODS

Completion lymph node dissection (CLND) for sentinel lymph node (SLN)-positive melanoma patients has been guideline-concordant standard of care since adoption of lymphatic mapping and SLN biopsy for the management of clinically node-negative melanoma patients more than 20 years ago. However, a trend for omission of CLND has been observed over the past decade, and we now have randomized, controlled clinical trial data to help guide treatment recommendations. Publication of these data prompted an American Society of Clinical Oncology-Society of Surgical Oncology 2018 clinical practice guideline update for these patients.

RESULTS AND CONCLUSIONS

Systematic review of current evidence supports a selective, individualized approach to CLND for SLN-positive melanoma. For low-risk, low-volume micrometastatic disease, SLN biopsy may be both diagnostic and therapeutic, and close clinical follow-up with imaging or CLND are reasonable options for appropriately selected patients. For higher-risk patients, omission of CLND requires careful consideration of risks versus benefits, relevant histopathology, and individualized patient discussion. This should address patient comorbidities and life expectancy, the predicted likelihood of additional positive nodes, availability of imaging surveillance, likelihood of adherence to imaging and clinical follow-up, consequences of regional recurrence, and the prognostic value of complete nodal staging and its impact on adjuvant therapy recommendations or clinical trial participation. Data on long-term outcomes, cost, and patient-reported quality of life measures are not yet available.

Evaluation of the Quality of Adjuvant Endocrine Therapy Delivery for Breast Cancer Care in the United States

Importance

Randomized trials in breast cancer have demonstrated the clinical benefits of adjuvant endocrine therapy (AET) in preventing recurrence and death. The examination of concordance with AET guidelines at a national level as a measure of quality of care is important.

Objective

To investigate temporal trends and factors related to receipt of AET for breast cancer.

Design, Setting, and Participants

This retrospective cohort study included 981 729 women with breast cancer in the National Cancer Database from January 1, 2004, to December 31, 2013. Women with stages I to III breast cancer who received all or part of their treatment at the reporting institution were included in the analysis.

Main Outcomes and Measures

Temporal changes in AET receipt (estimating the annual percentage change) and AET practice patterns (using logistic regression) and the effect of AET guideline concordance on survival of women with hormone receptor-positive (HR+) breast cancer (using the multivariable Cox proportional hazards model).

Results

Of the 981 729 eligible patients (mean [SD] age, 60.8 [13.3] years), 818 435 had HR+ and 163 294 had HR-negative (HR-) cancer. Among the patients with HR+ cancer, receipt of AET increased over time, from 69.8% in 2004 to 82.4% in 2013. Among patients with HR- cancer, receipt decreased from 5.2% in 2004 to 3.4% in 2013. Hospital-level adherence (≥80% of patients with HR+ cancer received AET) increased from 40.2% in 2004 to 69.2% in 2013. Receipt of AET varied significantly by age (lower in patients ≥80 years), race (lower in African American and Hispanic participants), geographic location (lower in West South Central, Mountain, and Pacific census regions), and receptor status (lower in patients with estrogen receptor-negative and progesterone receptor-positive cancer). Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt (only 45.0% in patients who received lumpectomy without radiotherapy). Receipt of AET was associated with a 29% relative risk reduction in mortality. Based on this effectiveness estimate, if all patients with HR+ cancer received AET, approximately 14 630 lives would have been saved over 10 years.

Conclusions and Relevance

From 2004 to 2013, underuse and misuse of AET have decreased for patients with breast cancer, but optimal use has not been achieved, and significant variation in care remains. The involvement of surgery and radiotherapy were among the most significant factors associated with optimal use, which underscores the benefits of team-based care to support guideline-concordant therapy.