Strengths and limitations of large databases in lung cancer radiation oncology research

Timing of postoperative radiation therapy for major salivary gland cancers

BACKGROUND

The impact of timing of PORT initiation for major salivary gland cancers on survival is unknown. We aim to examine the impact of PORT timeliness on overall survival (OS) of patients with major salivary gland cancers.

METHODS

This was a cross-sectional analysis using data from the National Cancer Database (2004-2017) and included patients with major salivary gland cancer treated with surgery and PORT.

RESULTS

In total, 5701 patients were included (3133 [55%] male, 4644 [82%] white, mean age 59 ± 16 years). For the overall cohort, PORT >6 weeks was not associated with decreased OS (1.00 aHR, 95% CI 0.89-1.11). When specifically examining patients with mucoepidermoid carcinoma, PORT >6 weeks was associated with a decreased OS (1.27 aHR, 95% CI 1.01-1.58).

CONCLUSIONS

Overall, this analysis did not demonstrate a survival benefit for initiating PORT within 6 weeks for patients with salivary gland malignancies. Subset analysis did support initiating PORT within 6 weeks after resection for patients with mucoepidermoid carcinomas. This was not demonstrated in other major salivary gland cancer histologies.

The effect of allergies on outcomes following shoulder arthroplasty: A national database analysis of 154,478 patients

Background

The objective of this study is to investigate the effect of allergies on complications following total shoulder arthroplasty (TSA).

Materials and Methods

All data were collected by using the PearlDiver national database to identify patients who had undergone TSA (anatomic or reverse) between 1 January 2010 and 31 October 2021. Patients were stratified into two groups: allergies and no allergies. Comparisons were made regarding complications and revision surgeries. Complications were compared at 30 and 90 days. Revisions were compared at 1, 5 and 10 years postoperatively.

Results

This study identified 28,182 patients with allergies and 126,296 patients without allergies. Patients with allergies were more likely to require revision surgery at all time points analyzed (p < 0.001). Patients with allergies were more likely to have sepsis within 30 (OR 1.53 [1.30-1.80], p < 0.001) and 90 days (1.71 [1.51-1.94], p < 0.001) postoperatively. Patients with allergies were more likely to experience a wound complication within 30 (1.89 [1.58-2.26], p < 0.001) and 90 days (1.81 [1.58-2.08], p < 0.001). The allergy group experienced higher rates of prosthetic joint infections (PJI) (2.14 [1.81-2.54], p < 0.001) and implant complications at 90 days (1.52 [1.42-1.62], p < 0.001).

Discussion

Patients with allergies were more likely to require revision surgery, experience wound complications, sepsis and PJI following TSA.

Primary adrenal sarcomas: A national analysis of epidemiological trends, treatment patterns, and outcomes

BACKGROUND AND OBJECTIVES

Primary adrenal sarcoma (PAS) is an exceedingly rare malignancy with limited data available on its epidemiology, management, and outcomes. This study aimed to characterize the national incidence, treatment patterns, and survival of PAS utilizing a National Cancer Database.

METHODS

The National Cancer Database was queried for patients diagnosed with primary adrenal tumors from 2004 to 2019. Cases with sarcoma histology were identified as PAS. Annual incidence trends, histological distribution, treatment modalities (surgery, chemotherapy, radiation therapy), perioperative outcomes, and overall survival (OS) were analyzed.

RESULTS

Of 7213 primary adrenal tumor cases, 332 (4.6%) were PAS. The most common histological subtypes were leiomyosarcoma (37.3%), hemangiosarcoma (27.1%), and sarcoma not otherwise specified (6.0%). Most cases (71.7%) presented as locoregional disease. Treatment included surgery alone (47.8%), surgery plus chemotherapy and/or radiation (27.1%), chemotherapy/radiation alone (13.3%), or no treatment (13.9%). For surgical cases, the median length of stay was 5 days, the 30-day readmission rate was 3.36%, and the 30/90-day mortality rates were 3.65% and 9.90%, respectively. The 5-year OS rate for surgery alone was 43%, with a median OS of 34.6 months. For surgery with radiation/chemotherapy, the 5-year OS rate was 37.3%, with a median OS of 35.4 months.

CONCLUSIONS

This largest analysis of PAS to date demonstrates that most cases present as locoregional disease amenable to surgical resection, with favorable outcomes. The role of adjuvant therapy remains unclear, as no significant survival difference was observed between surgery alone and multimodal treatment.

The contribution of household income to rectal cancer patient characteristics, treatment, and outcomes from 2010 to 2020

Background

There is a paucity of recent literature investigating the sole effect of income level on the treatment and survival of patients with rectal cancer.

Methods

We analyzed all cases of rectal cancer in the Rectal Cancer PUF of the NCDB from 2010 to 2020. We utilized the Median Income Quartiles 2016-2020 to define our income levels. The two lower quartiles were combined to create a lower income group, with the upper two quartiles creating the higher income group. The total cohort included 201,329 patients, with 116,843 and 84,486 in the higher and lower income groups, respectively.

Results

Lower income patients were more often black (17 % vs 6 %), lived farther from the nearest hospital (33.5 miles vs 25.7 miles) despite being more likely to live in urban areas (25 % vs 7 %), and had lower levels of private insurance (36 % vs 49 %). They underwent more APRs (17 % vs 14 %) and had a 13 % higher chance of undergoing an open operation (OR 1.13, CI 1.09-1.17). Higher income patients had a 12 % reduction in 90-day (OR 0.88, 95 % CI 0.82-0.96) and overall mortality (OR 0.88, 95 % CI 0.86-0.89).

Conclusions

Clinicians should be aware that lower income patients are often faced with unique challenges that may impact care delivery.

The impact of time between surgery and adjuvant chemoradiotherapy in advanced oral cavity squamous cell carcinoma

Objective

In advanced oral squamous cell carcinoma (OSCC), adjuvant therapy (AT) is an important part of the treatment to ensure extended locoregional control after primary surgical resection. The impact of the time interval between surgery and AT on the oncological prognosis remains unclear, particularly in high-risk constellations. The aim of this study is to categorize treatment delays and to determine their impact on the oncological prognosis within the context of the histopathological risk parameters of patients with advanced OSCC.

Methods

In this single-institutional retrospective cohort study, all patients treated for OSCC between 2016 and 2021 and who received postoperative chemoradiation (POCRT) were included. Patients were divided into two groups: Group I: ≤ 6 weeks between surgery and POCRT; and Group II: > 6 weeks between surgery and POCRT.

Results

Overall, 202 patients were included (Group I: 156 (77.2%) vs. Group II: 46 (22.8%)). There were no statistically significant differences in epidemiological aspects and histopathological risk factors between the two groups. The maximum time to initiation of POCRT was 11 weeks. Delayed POCRT initiation had no statistically significant influence on the 5-year OS (61.6% vs. 57.3%, p = 0.89), locoregional control rate (38.6% vs. 43.3%, p = 0.57), and RFS (32.3% vs. 30.4%, p = 0.21). On multivariate analysis, extracapsular spread (HR: 2.21, 95% CI: 1.21 - 4.04, p = 0.01) and incomplete surgical resection (HR: 2.01, 95% CI: 1.10 - 3.69, p = 0.02) were significantly correlated with OS. For RFS, ECS (HR: 1.82, 95% CI: 1.15 - 2.86, p = 0.01), incomplete resection (HR: 1.67, 95% CI: 1.04 - 2.71, p = 0.04), and vascular infiltration of the tumor (V-stage; HR: 2.15, 95% CI: 1.08 - 4.27, p = 0.03) were significant risk predictors.

Conclusion

Delays in POCRT initiation up to 11 weeks after surgical resection for advanced OSCC were not statistically significantly associated with impaired survival. In cases of prolonged surgical treatment due to management of complications, a small delay in AT beyond the recommended time limit may be justified and AT should still be pursued.

Sex-Based Differences in Melanoma Survival Improvement from 2004 to 2018

Background: Melanoma is the deadliest form of skin cancer and its incidence and mortality vary by sex, age, race, and socioeconomic status. Relatively few studies, however, have characterized disparities in survival improvement across these demographic groups in melanoma.

METHODS

Survival data from the Surveillance, Epidemiology, and End Results (SEER) database were obtained from 2004 to 2018. The compiled data were analyzed for cancer-specific survival (CSS) to produce multivariable Cox regressions that estimate sex-based survival disparities across patient demographic groups. Additionally, time-to-progression and survival analyses were conducted for a cohort of patients with carcinoma-in situ (CIS) that developed into melanoma.

RESULTS

In both female and male patients, melanoma diagnosis in more recent years (2014-2018 versus 2004-2008) was associated with an improved CSS, with females demonstrating an HR of 0.55 (95% CI: 0.49-0.60) and males demonstrating an HR of 0.49 (0.46-0.53). The trend remained consistent upon analyzing the effects of both sex and race on survival improvement for White and Hispanic males and females, but the results were not significant for Black and Asian patients. Joint sex and age analysis demonstrated significant reductions in HR across all age groups for female and male patients with a diagnosis in more recent years. Analysis of lesions progressing from CIS to melanoma (high-risk CIS) demonstrated an increased OR for males over females (OR: 1.70; 95% CI: 1.55-1.85), while survival analysis demonstrated no difference between sexes in the HR. Finally, for male patients, high-risk CIS demonstrated worse CSS compared to female patients with high-risk CIS (OR: 1.43; 95% CI: 1.15-1.79).

CONCLUSION

Overall, melanoma survival has improved in recent years, though some patient subgroups have experienced a lower improvement in survival from 2004 to 2018.

Integration of pan-omics technologies and three-dimensional in vitro tumor models: an approach toward drug discovery and precision medicine

Despite advancements in treatment protocols, cancer is one of the leading cause of deaths worldwide. Therefore, there is a need to identify newer and personalized therapeutic targets along with screening technologies to combat cancer. With the advent of pan-omics technologies, such as genomics, transcriptomics, proteomics, metabolomics, and lipidomics, the scientific community has witnessed an improved molecular and metabolomic understanding of various diseases, including cancer. In addition, three-dimensional (3-D) disease models have been efficiently utilized for understanding disease pathophysiology and as screening tools in drug discovery. An integrated approach utilizing pan-omics technologies and 3-D in vitro tumor models has led to improved understanding of the intricate network encompassing various signalling pathways and molecular cross-talk in solid tumors. In the present review, we underscore the current trends in omics technologies and highlight their role in understanding genotypic-phenotypic co-relation in cancer with respect to 3-D in vitro tumor models. We further discuss the challenges associated with omics technologies and provide our outlook on the future applications of these technologies in drug discovery and precision medicine for improved management of cancer.

Social determinants as predictors of resection and long-term mortality in Black patients with non-small cell lung cancer

BACKGROUND

Minorities diminished returns theory posits that socioeconomic attainment conveys fewer health benefits for Black than White individuals. The current study evaluates the effects of social constructs on resection rates and survival for non-small cell lung cancer (NSCLC).

METHODS

Patients with potentially resectable NSCLC stage IA to IIIA were identified using the 2004 to 2017 National Cancer Database. Patients were stratified into quartiles based on population-level education and income. Logistic regression was used to predict risk-adjusted resection rates. Mortality was assessed with Cox proportional hazard modeling.

RESULTS

Of the 416,025 patients identified, 213,643 (51.4%) underwent resection. Among White patients, the lowest income (adjusted odds ratio 0.76, 95% confidence interval 0.74-0.78, P < .01) and education quartiles (adjusted odds ratio 0.82, 95% confidence interval 0.79-0.84, P < .01) were associated with decreased odds of resection. The lowest education quartile among Black patients was not associated with lower resection rates. The lowest income quartile (adjusted odds ratio 0.67, 95% CI 0.61-0.74, P < .01) was associated with reduced resection. White patients in the lowest education and income quartiles experienced increased hazard of 5-year mortality (adjusted hazard ratio 1.13, 95% CI 1.11-1.15, P < .01 and adjusted hazard ratio 1.08, 95% CI 1.06-1.11, P < .01 respectively). In Black patients, there were no significant differences in 5-year survival between Black patients in the highest education and income quartiles and those in the lowest quartiles.

CONCLUSION

Among Black patients with NSCLC, educational attainment is not associated with increased resection rates. In addition, higher education and income were not associated with improved 5-year survival. The diminished gains experienced by Black patients, compared to Whites patients, illustrate the presence of pervasive race-specific mechanisms in observed inequalities in cancer outcomes.

Comparison of Capture Rates of the National Cancer Database Across Race and Ethnicity

Importance

The National Cancer Database (NCDB) is an invaluable and widely used resource for cancer research, but the current state of representation of different racial and ethnic groups compared with the United States Cancer Statistics (USCS) database is unknown.

Objective

To examine whether Hispanic and American Indian or Alaska Native individuals have lower representation in the NCDB compared with the USCS database.

Design, Setting, and Participants

This multicenter, retrospective cohort study assessed individuals diagnosed with breast, colorectal, lung, and prostate cancer from January 1, 2004, to December 31, 2006, and January 1, 2017, to December 31, 2019, in the NCDB and USCS databases. Data analysis was performed from September 2022 to October 2023.

Exposure

Time.

Main Outcomes and Measures

The primary outcome was the absolute percentage change (APC) in capture rate across the study period.

Results

The cohort included 5 175 007 individuals (0.50% American Indian or Alaska Native, 3.10% Asian or Pacific Islander, 12.01% Black, 6.58% Hispanic, and 77.81% White) who were diagnosed with breast, colorectal, lung, and prostate cancer. Capture rates were the lowest for individuals who were Hispanic (40.83% in 2004-2006 and 54.75% in 2017-2019; P < .001) or American Indian or Alaska Native (20.72% in 2004-2006 and 41.41% in 2017-2019; P < .001). The APCs were positive for both racial categories across all 4 cancers. However, overall APCs for Hispanic individuals (13.92%) remained lower than the overall APCs of White individuals (22.23%; P < .001). The APCs were greater for American Indian or Alaska Native individuals than for White individuals for prostate (14.68% vs 11.57%) and breast (21.61% vs 17.90%) cancer (P < .001), but the APCs for American Indian or Alaska Native individuals were lower than for White individuals for lung cancer (24.54% vs 33.03%; P < .001).

Conclusions and Relevance

In this cohort study of individuals diagnosed with cancer in the NCDB, Hispanic and American Indian or Alaska Native individuals diagnosed with breast, colorectal, lung, and prostate cancer were undercaptured in the NCDB, but their representation improved over time. Increased study is needed to determine where these populations predominantly seek cancer care.

Disparities in primary pancreatic adenocarcinoma survival by Medicaid-status: A national population-based risk analysis

BACKGROUND

Pancreatic adenocarcinoma (PAC) has one of the highest mortality rates among all malignancies. While previous research has analyzed socioeconomic factors' effect on PAC survival, outcomes of Medicaid patients are understudied.

METHODS

Using the SEER-Medicaid database, we studied non-elderly, adult patients with primary PAC diagnosed between 2006 and 2013. Five-year disease-specific survival analysis was performed using the Kaplan-Meier method and adjusted analysis using Cox proportional-hazards regression.

RESULTS

Among 15,549 patients (1799 Medicaid, 13,750 non-Medicaid), Medicaid patients were less likely to receive surgery (p < .001) and more likely to be non-White (p < .001). The 5-year survival of non-Medicaid patients (8.13%, 274 days [270-280]) was significantly higher than that of Medicaid patients (4.97%, 152 days, [151-182], p < .001). Among Medicaid patients, those in high poverty areas had significantly lower survival rates (152 days [122-154]) than those in medium poverty areas (182 days [157-213], p = .008). However, non-White (152 days [150-182]) and White Medicaid patients (152 days [150-182]) had similar survival (p = .812). On adjusted analysis, Medicaid patients were still associated with a significantly higher risk of mortality (aHR 1.33 [1.26-1.41], p < .0001) compared to non-Medicaid patients. Unmarried status and rurality were associated with a higher risk of mortality (p < .001).

DISCUSSION

Medicaid enrollment prior to PAC diagnosis was generally associated with a higher risk of disease-specific mortality. While there was no difference in the survival between White and non-White Medicaid patients, Medicaid patients living in high poverty areas were shown to be associated with poor survival.

Improving trial generalizability using observational studies

Complementary features of randomized controlled trials (RCTs) and observational studies (OSs) can be used jointly to estimate the average treatment effect of a target population. We propose a calibration weighting estimator that enforces the covariate balance between the RCT and OS, therefore improving the trial-based estimator's generalizability. Exploiting semiparametric efficiency theory, we propose a doubly robust augmented calibration weighting estimator that achieves the efficiency bound derived under the identification assumptions. A nonparametric sieve method is provided as an alternative to the parametric approach, which enables the robust approximation of the nuisance functions and data-adaptive selection of outcome predictors for calibration. We establish asymptotic results and confirm the finite sample performances of the proposed estimators by simulation experiments and an application on the estimation of the treatment effect of adjuvant chemotherapy for early-stage non-small-cell lung patients after surgery.

Is cancer stage data missing completely at random? A report from a large population-based cohort of non-small cell lung cancer

Introduction

Population-based datasets are often used to estimate changes in utilization or outcomes of novel therapies. Inclusion or exclusion of unstaged patients may impact on interpretation of these studies.

Methods

A large population-based dataset in Ontario, Canada of non-small cell lung cancer patients was examined to evaluate the characteristics and outcomes of unstaged patients compared to staged patients. Multivariable Poisson regression was used to evaluate differences in patient-level characteristics between groups. Kaplan-Meier estimates of survival and log-rank statistics were utilized.

Results

In our Ontario cohort of 51,152 patients with NSCLC, 11.2% (n=5,707) were unstaged, and there was evidence that stage data was not missing completely at random. Those without assigned stage were more likely than staged patients to be older (RR [95%CI]), (70-79 vs. 20-59: 1.51 [1.38-1.66]; 80+ vs. 20-59: 2.87 [2.62-3.15]), have a higher comorbidity index (Score 1-2 vs 0: 1.19 [1.12-1.27]; 3 vs. 0: 1.49 [1.38-1.60]), and have a lower socioeconomic class (4 vs. 1 (lowest): 0.91 [0.84-0.98]; 5 vs. 1 (lowest): 0.89 [0.83-0.97]). Overall survival of unstaged patients suggested a mixture of early and advanced stage, but with a large proportion that are probably stage IV patients with more rapid death than those with reported stage IV disease.

Conclusion

In this case study, evaluation of stage-specific health care utilization and outcomes for staged patients with stage IV disease at the population level may have a bias as a distinct subset of stage IV patients with rapid death are likely among those without a documented stage in administrative data.

Extent of Surgery for Follicular Thyroid Carcinoma

OBJECTIVES

To examine the association between the extent of surgery and overall survival in follicular thyroid cancer (FTC) patients.

STUDY DESIGN

Retrospective analysis of the National Cancer Database (NCDB).

METHODS

Patients who underwent surgical intervention for FTC from 2004 to 2015 were selected. Patients were >18 years old, with tumor size 1-4 cm, no other malignancies, and >0 follow up time. Patients were divided into two cohorts based on extent of surgery: lobectomy (≥1 lobe resected) and thyroidectomy (total or near total resection). Pearson's chi-squared analysis was used to compare cohorts. Kaplan-Meier survival and Cox hazards models were utilized to determine overall survival between two cohorts with p < 0.05 used for significance.

RESULTS

A total of 6871 patients were identified with FTC, of which 1507 patients underwent lobectomy and 5364 patients underwent total thyroidectomy. There were no significant differences in patient demographics, comorbidity index, local spread, or tumor grade. Patients undergoing lobectomy had mean survival of 12.94 versus 12.71 years for those undergoing thyroidectomy. Extent of surgery was not associated with a significant difference in survival (5 years OS = 96% in lobectomy and 95.5% in total thyroidectomy, p = 0.08). Stratification by tumor grade resulted in no significant difference in survival between lobectomy and thyroidectomy.

CONCLUSION

Survival time was not significantly different in patients with more extensive resection of FTC.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:993-999, 2023.

The association of race/ethnicity in male breast cancer survival within similar comorbidity cohorts

BACKGROUND

Concomitant disease is associated with poor breast cancer survival in women and is more prevalent in racial/ethnic minority groups than individuals who are non-Hispanic White. The purpose of this study was to determine if race/ethnicity is associated with survival among men with breast cancer when stratifying analyses by level of comorbidity.

METHODS

We used the California Cancer Registry to identify 1730 cases of men and 259,828 cases of women with breast cancer and documented Charlson Comorbidity Index (CCI). Kaplan-Meier survival and Cox regression analyses were used to compare breast cancer-specific survival and risk of mortality for African American/Black, Hispanic, and Asian/Pacific Islander men with White women and White men.

RESULTS

When compared with White women, Black men with a CCI of 0 (hazard ratio [HR], 3.09; 95% CI, 1.10-1.16) and a CCI of 2+, (HR, 2.51; 95% CI, 1.42-4.42) had an increased risk of mortality when compared with White women. When compared with White men, African American men with a CCI of 0 (HR, 2.36; 95% CI, 1.45-3.85) and 2+ (HR, 2.44; 95% CI, 1.26-4.74) had an increased unadjusted risk of mortality, but these disparities were neutralized when controlling for sociodemographic and clinical factors.

CONCLUSIONS

Black men with both low and high levels of concomitant disease have an increased risk of mortality when compared with both White men and women, but demographic and clinical factors are contributors to this disparity.

Driving quality improvement through better data: The story of New Zealand's radiation oncology collection

Aotearoa/New Zealand is one of the first nations in the world to develop a comprehensive, high-quality collection of radiation therapy data (the Radiation Oncology Collection, ROC) that is able to report on treatment delivery by health region, patient demographics and service provider. This has been guided by radiation therapy leaders, who have been instrumental in overseeing the establishment of clear and robust data definitions, a centralised database and outputs delivered via an online tool. In this paper, we detail the development of the ROC, provide examples of variation in practice identified from the ROC and how these changed over time, then consider the ramifications of the ROC in the wider context of cancer care quality improvement. In addition to a review of relevant literature, primary data were sourced from the ROC on radiation therapy provided nationally in New Zealand between 2017 and 2020. The total intervention rate, number of fractions and doses are reported for select cancers by way of examples of national variation in practice. Results from the ROC have highlighted areas of treatment variation and have prompted increased uptake of hypofractionation for curative prostate and breast cancer treatment and for palliation of bone metastases. Future development of the ROC will increase its use for quality improvement and ultimately link to a real time cancer services database.

Increased Utilization of Stereotactic Body Radiotherapy is Associated with Decreased Disparities and Improved Survival for Early-Stage NSCLC

INTRODUCTION

We sought to determine if increased use of stereotactic body radiation therapy (SBRT) was associated with decreased disparities in the receipt of definitive treatment for early-stage non-small cell lung cancer (NSCLC).

METHODS

The National Cancer Database (NCDB) was utilized to determine the proportion of patients with NSCLC receiving surgery, SBRT, or no definitive treatment for clinical cT1-2aN0M0 NSCLC from 2004-2017. Univariable and multivariable logistic regressions were used. Age-adjusted mortality rates were calculated using the Surveillance, Epidemiology, and End Result (SEER) database.

RESULTS

From 2004 to 2017, the proportion of early-stage NSCLC undergoing no definitive treatment declined from 22% to 10.5% (P<.001), while the proportion receiving SBRT increased from 1% (0.9%-1.3%) to 22% (21.4%-22.3%; P<.001). Among Whites, the proportion undergoing no definitive treatment decreased from 21% to 10% (P<.001), as compared to Blacks, which had a higher decrease, of 32% to 15% (P<.001). The proportion of Blacks receiving SBRT increased from 1% (0.3%-1.7%) to 22% (20.8%-23.5%) (P<.001). Between 2011 and 2017 likelihood of Blacksreceiving curative therapy increased compared to Whites [OR: 0.55 (0.48-0.64) to 0.70 (0.62-0.79; P<.001]. Furthermore, the age-adjusted mortality rate of early-stage NSCLC decreased from 4.3 (4.0-4.5) in 2004 to 0.8 (0.7-0.9) in 2017 (P<.001).

CONCLUSIONS

Increased utilization of SBRT significantly increased the proportion of patients receiving curative therapy for early-stage NSCLC and was associated with an improvement in mortality.  Furthermore, the use of SBRT reduced previously seen disparities in receipt of treatment between Whites and Blacks. SBRT was also associated with decreased mortality from early-stage NSCLC.

The role of adjuvant radiation therapy in older patients with node-positive vulvar cancer: A national cancer database analysis

OBJECTIVE

We sought to evaluate whether the survival benefit of adjuvant radiotherapy in patients with node-positive vulvar cancer is maintained in older patients, who comprise a large subgroup of patients with vulvar cancer.

METHODS

The National Cancer Database (NCDB) was queried for patients aged 65 years or older, who were diagnosed with vulvar squamous cell carcinoma from 2004 to 2017 and underwent surgery with confirmed node-positive disease. Statistical analysis was performed with propensity-score matching, chi-square test, log-rank test, Kaplan-Meier, and multivariable Cox proportional regression.

RESULTS

A total of 2396 patients were analyzed, and 1517 (63.3%) received adjuvant radiotherapy. Median follow-up was 73 months. Median age at diagnosis was 77 years (range 65-90). In the propensity score-matched cohort, five-year overall survival (OS) was 29%. Five-year OS was 33% in patients who received surgery followed by adjuvant radiotherapy and 26% in patients who received surgery alone (p < 0.0001). Multivariable analysis continued to demonstrate a survival benefit associated with the addition of adjuvant radiotherapy (OR 0.77 [95% CI 0.69-00.87], p < 0.001). Adjuvant radiotherapy was associated with improved OS among patients aged 65-84 (5-year OS 35% vs 29%, p = 0.0004), but not in patients aged 85 years and older (5-year OS 20% vs 19%, p = 0.32).

CONCLUSION

This NCDB study suggests that in older patients with node-positive vulvar cancer, radiotherapy continues to be a vital component of multimodality therapy. However, a comprehensive and geriatrics-specific approach is crucial for treating older adults with node-positive vulvar cancer, as the benefit of adjuvant radiotherapy may be compromised by treatment-related morbidity/toxicity.

Disaggregation of Asian American and Pacific Islander Women With Stage 0-II Breast Cancer Unmasks Disparities in Survival and Surgery-to-Radiation Intervals: A National Cancer Database Analysis From 2004 to 2017

PURPOSE

Aggregation of Asian Americans (AAs) with Native Hawaiians and Other Pacific Islanders (NHPIs) masks significant health disparities. We evaluated overall survival (OS) and surgery-to-radiation intervals (STRIs) among AA and NHPI women with early-stage breast cancer.

METHODS

This National Cancer Database study included women with stage 0-II breast cancer diagnosed between 2004 and 2017. STRI was defined as days from surgery to radiation. Patients were stratified by adjuvant treatment. AAs were disaggregated into geographically relevant subpopulations: East, South, and Southeast Asians. Kaplan-Meier estimates and log-rank tests assessed survival. Cox proportional hazard and linear regression were adjusted for clinical and sociodemographic factors.

RESULTS

In total, 578,927 women were included (median age 61 years, median follow-up 65 months, and 10-year OS 83%). AA and NHPI 10-year OS was 91% overall; subpopulation 10-year OS was 92% for East Asian, 90% for South Asian, 90% for Southeast Asian, and 83% for NHPI. On multivariable analysis, compared with non-Hispanic White, NHPI women had worse survival (adjusted hazard ratio [aHR] = 1.38; 95% CI, 1.09 to 1.77); all AA subpopulations had improved survival: East Asian (aHR = 0.57; 95% CI, 0.48 to 0.69), South Asian (aHR = 0.66; 95% CI, 0.51 to 0.84), and Southeast Asian (aHR = 0.78; 95% CI, 0.65 to 0.94). The AA and NHPI median STRI for was 73 days overall; the disaggregated median STRI was 68 days for East Asian, 80 days for South Asian, 77 days for Southeast Asians, and 81 days for NHPI. On adjusted analysis, compared with non-Hispanic White, Southeast Asians and NHPI had longer STRI by 6.6 (95% CI, 4.3 to 8.9) and 10.0 (95% CI, 5.8 to 14) days, respectively.

CONCLUSION

Breast cancer disparities exist among disaggregated AA and NHPI subpopulations. Data disaggregation insights may lead to interventions to overcome these disparities, such as optimizing time-to-treatment for select populations.

Head Pitch Angular Velocity Discriminates (Sub-)Acute Neck Pain Patients and Controls Assessed with the DidRen Laser Test

Understanding neck pain is an important societal issue. Kinematic data from sensors may help to gain insight into the pathophysiological mechanisms associated with neck pain through a quantitative sensorimotor assessment of one patient. The objective of this study was to evaluate the potential usefulness of artificial intelligence with several machine learning (ML) algorithms in assessing neck sensorimotor performance. Angular velocity and acceleration measured by an inertial sensor placed on the forehead during the DidRen laser test in thirty-eight acute and subacute non-specific neck pain (ANSP) patients were compared to forty-two healthy control participants (HCP). Seven supervised ML algorithms were chosen for the predictions. The most informative kinematic features were computed using Sequential Feature Selection methods. The best performing algorithm is the Linear Support Vector Machine with an accuracy of 82% and Area Under Curve of 84%. The best discriminative kinematic feature between ANSP patients and HCP is the first quartile of head pitch angular velocity. This study has shown that supervised ML algorithms could be used to classify ANSP patients and identify discriminatory kinematic features potentially useful for clinicians in the assessment and monitoring of the neck sensorimotor performance in ANSP patients.

Adjuvant Chemotherapy Might Be Recommended to Patients With Positive Margin After Gastrectomy: A 20-Year Retrospective Analysis in a Single Center

Background

Margin positivity after gastric cancer resection is associated with poorer outcomes. However, the prognostic factors and the choice of postoperative adjuvant treatment of patients with positive margin (PM) after gastrectomy are still being debated.

Methods

A single-center, retrospective analysis was conducted for patients with PM after gastrectomy from the China National Cancer Center Gastric Cancer Database (NCCGCDB) from 1998 to 2018. Univariate and multivariate Cox regression analyses were performed to identify prognostic factors of overall survival (OS) and recurrence-free survival (RFS).

Results

A total of 449 patients were included in the study, including 192 (42.8%) in the proximal PM group (PPM), 205 (45.7%) in the distal PM group (DPM), and 52 (11.6%) in the bilateral PM group (BPM). The 3- and 5-year OS rates for the PM patients investigated were 47.5% and 39.3%, respectively, and the 3- and 5-year RFS rates were 60.0% and 53.6%, respectively. Multivariate Cox regression analysis proved total gastrectomy (hazard ratio (HR): 1.783, 95%CI: 1.133–2.805, p = 0.012), pT4 (HR: 5.264, 95%CI: 1.493–18.565, p = 0.01), pN2 (HR: 2.263, 95%CI: 1.164–4.397, p = 0.016), pN3 (HR: 2.327, 95%CI: 1.233–4.393, p = 0.009), and combined resection (HR: 1.952, 95%CI: 1.256–3.034, p = 0.003) to be independent risk factors of OS, and pT3 (HR: 9.257, 95%CI: 1.152–74.386, p = 0.036) and pT4 (HR: 11.361, 95%CI: 1.469–87.847, p = 0.020) to be independent risk factors for RFS. Adjuvant chemotherapy prolonged OS in the PPM group (p = 0.032) and prolonged RFS in the PPM group (p < 0.001) and the DPM group (p = 0.035) compared with surgery alone.

Conclusions

Advanced pathologic stage was associated with poor prognosis, and postoperative adjuvant chemotherapy might be recommended in PM patients after gastrectomy. Still, further prospective trials are warranted to verify and support our conclusions.

Adjuvant Chemotherapy in Patients with Node-Negative Non-Small Cell Lung Cancer with Satellite Pulmonary Nodules in the Same Lobe

Background

According to the eighth TNM (tumor-node-metastasis) staging system, the presence of separate tumor nodules in the same lobe is designated as a T3 descriptor. However, it remains unclear whether adjuvant chemotherapy confers survival advantages in this setting.

Methods

We retrospectively identified 142 pathologic T3N0M0 patients with additional pulmonary nodules in the same lobe from a single-institutional database from 2004 to 2019. The main outcomes were overall survival and recurrence-free survival. Multivariable Cox regression was used to identify the benefit of adjuvant chemotherapy while adjusting for other variables.

Results

Sixty-one patients received adjuvant chemotherapy (adjuvant group) and 81 patients did not receive adjuvant therapy after surgery (surgery-only group). There were no demonstrable differences between the 2 groups regarding hospital mortality and postoperative complications, indicating that treatment selection had not significantly occurred. However, the use of adjuvant chemotherapy was associated with improved 5-year overall survival (70% vs. 59%, p=0.006) and disease-free survival (60% vs. 46%, p=0.040). A multivariable Cox model demonstrated that adjuvant chemotherapy was associated with a survival advantage (adjusted hazard ratio, 0.54; p<0.001). In exploratory analyses of subgroups, the effect of adjuvant chemotherapy seemed to be insufficient in those with small main tumors (<4 cm).

Conclusion

Adjuvant chemotherapy was associated with better survival in T3 cancers with an additional tumor nodule in the same lobe. However, the role of adjuvant chemotherapy in patient subgroups with small tumors or those without risk factors should be determined via large studies.

Treatment Interruptions During Stereotactic Body Radiotherapy for Prostate Cancer

Background

During the course of radiation treatment for prostate cancer, patients may have unintentional interruptions in their treatment course due to a wide variety of factors. Stereotactic body radiation therapy (SBRT) decreases the number of treatments compared to conventionally fractionated radiation; hence, it has the potential to decrease treatment delays and non-completion. This study sought to determine the incidence of treatment delay and characterize the etiology and length in a large cohort of men treated with SBRT for their prostate cancer.

Methods

One thousand three hundred and thirty-six patients treated with SBRT from 2008 to 2021 at the Georgetown University Hospital for prostate cancer were included in this retrospective study. A treatment delay was defined as a patient requiring longer than 14 days to complete 5 fractions of SBRT. Non-completion was defined as patients treated with less than 5 fractions. In the patients who experienced delays, chart review was performed to characterize the length and etiology of each delay. Multivariate analysis was performed via binary logistic regression modeling on PSPP.

Results

All individuals in the cohort eventually completed the planned 5-fraction regimen. Thirty-three patients experienced a treatment delay. Median length of time to complete treatment was 11 days (range 5–155 days). In patients who experienced a delay, nearly half (45.5%) experienced only a one-day delay. The most common reason for a delay was a technical issue (48.5%), including the machine maintenance, fiducial misalignment, or inadequate pretreatment bowel preparation. Other reasons included unplanned breaks due to acute side effects (21.2%), logistical issues (18.2%), non-treatment related health issues (9.1%), and inclement weather (3.0%). There were no significant sociodemographic, oncologic, or treatment variables that predicted treatment interruption on multivariate analysis.

Conclusions

The incidence of treatment interruptions in patients undergoing SBRT for their prostate cancer was low. Most treatment delays were short.

Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review

BACKGROUND

Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014.

METHODS

National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected.

RESULTS

Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities.

CONCLUSION

Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed.

POLICY SUMMARY

This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.

Optimal care and survival for signet-ring cell and non-signet-ring cell gastric cancer are more achievable at academic cancer centers

BACKGROUND

Western literature lacks large-scale population studies comparing the influence of academic and high-volume (HV) versus low-volume (LV) cancer centers on gastric cancer oncologic outcomes.

METHODS

The National Cancer Database from 2004 to 2016 was used.

RESULTS

22871 patients were studied. Patients with stage III signet-ring cell gastric carcinoma (SRGC) received neoadjuvant treatment (NAT) more frequently at academic and HV comprehensive cancer centers (OR: 4.27 and 2.42; p < 0.0001 and 0.009) compared to community centers. Patients with stage III non-SRGC (NSRGC) had a 2.4 times higher odds of receiving NAT at academic centers. The R1 resection rate for NSRGC was lower at academic centers (OR: 0.67; p = 0.0018). Lymph node harvest ≥15 nodes was 1.6 and 1.9 times higher at academic centers for NSRGC and SRGC, respectively. Patients treated at academic centers had a significantly improved overall survival (OS).

CONCLUSIONS

Treatment at academic centers is associated with significant improvements in oncologic metrics and OS.

Identifying Modifiable and Non-modifiable Risk Factors of Readmission and Short-Term Mortality in Osteosarcoma: A National Cancer Database Study

BACKGROUND

There are limited data to inform risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of osteosarcoma.

METHODS

We retrospectively reviewed patients (n = 5293) following surgical resection of primary osteosarcoma in the National Cancer Database (2004-2015). Univariate and multivariate methods were used to correlate variables with readmission and short-term mortality.

RESULTS

Of 210 readmissions (3.97%), risk factors independently associated with unplanned 30-day readmission included comorbidity burden (odds ratio [OR] 2.4, p = 0.042), Medicare insurance (OR 1.9, p = 0.021), and axial skeleton location (OR 1.5, p = 0.029). A total of 91 patients died within 90 days of their surgery (1.84%). Risk factors independently associated with mortality included age (hazard ratio 1.1, p < 0.001), increasing comorbidity burden (OR 6.6, p = 0.001), higher grade (OR 1.7, p = 0.007), increasing tumor size (OR 2.2, p = 0.03), metastatic disease at presentation (OR 8.5, p < 0.001), and amputation (OR 2.0, p = 0.04). Chemotherapy was associated with a decreased risk of short-term mortality (p < 0.001).

CONCLUSIONS

Several trends were clear: insurance status, tumor location and comorbidity burden were independently associated with readmission rates, while age, amputation, grade, tumor size, metastatic disease, and comorbidity burden were independently associated with short-term mortality.

Partial Gastrectomy is Associated with Improved Overall Survival in Signet-Ring Cell Gastric Cancer

BACKGROUND

Signet-ring cell gastric cancer (SRGC) is a histological variant of gastric adenocarcinoma (GAC) with a worse prognosis compared to non-signet-ring cell gastric cancer (NSRGC). To our knowledge, the overall survival (OS) among patients with SRGC undergoing total/near-total (TG) versus partial gastrectomy (PG) has never been reported from a large-scale Western database.

METHODS

We performed a retrospective analysis of patients with both SRGC and NSRGC using The National Cancer Database.

RESULTS

In total, 17,086 patients were included. Patients who underwent TG versus PG were 25.5% (n = 770) versus 74.5% (n = 2246) for SRGC, and 20.9% (n = 2943) versus 79.1% (n = 11,127) for NSRGC, respectively. Patients who had SRGC were more likely to undergo TG (25.5% versus 20.9% P< 0.0001). Patients with distal gastric tumors were less likely to undergo TG (16.5% versus 25.4% P < 0.0001). Patients undergoing PG for the SRGC histological variant had better OS (HR = 0.68, CI=0.61-0.76; P < 0.0001) versus those who underwent TG. Similarly, NSRGC patients undergoing PG also had improved OS, but to a lesser extent (HR = 0.91, CI = 0.85-0.96; P= 0.002). Overall, PG for GAC was associated with improved OS compared to TG, although the OS benefit is more profound in the SRGC histological variant (P < 0.0001).

CONCLUSIONS

Our results show that TG is not associated with improved OS in patients who undergo gastrectomy for GAC, even when adjusted for tumor location. The survival differences are more pronounced in the SRGC histology variant. The worst survival is observed in patients with SRGC who undergo TG after adjusting for different covariates.

Data Integration to Improve Real-world Health Outcomes Research for Non-Small Cell Lung Cancer in the United States: Descriptive and Qualitative Exploration

Background

The integration of data from disparate sources could help alleviate data insufficiency in real-world studies and compensate for the inadequacies of single data sources and short-duration, small sample size studies while improving the utility of data for research.

Objective

This study aims to describe and evaluate a process of integrating data from several complementary sources to conduct health outcomes research in patients with non–small cell lung cancer (NSCLC). The integrated data set is also used to describe patient demographics, clinical characteristics, treatment patterns, and mortality rates.

Methods

This retrospective cohort study integrated data from 4 sources: administrative claims from the HealthCore Integrated Research Database, clinical data from a Cancer Care Quality Program (CCQP), clinical data from abstracted medical records (MRs), and mortality data from the US Social Security Administration. Patients with lung cancer who initiated second-line (2L) therapy between November 01, 2015, and April 13, 2018, were identified in the claims and CCQP data. Eligible patients were 18 years or older and received atezolizumab, docetaxel, erlotinib, nivolumab, pembrolizumab, pemetrexed, or ramucirumab in the 2L setting. The main analysis cohort included patients with claims data and data from at least one additional data source (CCQP or MR). Patients without integrated data (claims only) were reported separately. Descriptive and univariate statistics were reported.

Results

Data integration resulted in a main analysis cohort of 2195 patients with NSCLC; 2106 patients had CCQP and 407 patients had MR data. The claims-only cohort included 931 eligible patients. For the main analysis cohort, the mean age was 62.1 (SD 9.27) years, 48.56% (1066/2195) were female, the median length of follow-up was 6.8 months, and for 37.77% (829/2195), death was observed. For the claims-only cohort, the mean age was 66.6 (SD 12.69) years, 52.1% (485/931) were female, the median length of follow-up was 8.6 months, and for 29.3% (273/931), death was observed. The most frequent 2L treatment was immunotherapy (1094/2195, 49.84%), followed by platinum-based regimens (472/2195, 21.50%) and single-agent chemotherapy (441/2195, 20.09%); mean duration of 2L therapy was 5.6 (SD 4.9, median 4) months. We describe challenges and learnings from the data integration process, and the benefits of the integrated data set, which includes a richer set of clinical and outcome data to supplement the utilization metrics available in administrative claims.

Conclusions

The management of patients with NSCLC requires care from a multidisciplinary team, leading to a lack of a single aggregated data source in real-world settings. The availability of integrated clinical data from MRs, health plan claims, and other sources of clinical care may improve the ability to assess emerging treatments.

Predictors of In-Hospital Death in Patients with Lung Cancer Admitted for Acute Radiation Pneumonitis: A Healthcare Cost and Utilization Project (HCUP) Analysis

BACKGROUND

Radiation pneumonitis (RP) is a dose-limiting and potentially fatal toxicity of thoracic radiotherapy most often seen in patients treated for primary lung cancer. The purpose of this study was to identify predictors of in-hospital death among lung cancer patients admitted for acute RP in the Healthcare Cost and Utilization Project (HCUP) database.

MATERIALS AND METHODS

The HCUP National Inpatient Sample database was queried from 2012 through 2016 to capture adult lung cancer patients admitted to the hospital with a principal diagnosis of acute RP. Multivariate logistic regression modeling and χ² tests were used to determine predictors of in-hospital death.

RESULTS

Of the 882 patients with lung cancer admitted for RP, 67 patients (7.6%) died during the hospitalization and 90 patients (10.2%) required mechanical ventilation. Of those requiring mechanical ventilation, 38 patients (42.2%) died. The average age at hospitalization was 70.4 years (range, 35-90). Of those factors associated with death on univariate analysis, interstitial lung disease (odds ratio [OR] = 6.14; 95% confidence interval [CI], 1.9-19.4; P = .002), pulmonary hypertension (OR = 3.1; 95% CI, 1.6-6.2; P = .001), diabetes mellitus (OR = 2.0; 95% CI, 1.1-3.3; P = .013), and more affluent Zip Code (OR = 1.9; 95% CI, 1.1-3.2; P = .021) remained statistically significant on multivariate logistic regression.

CONCLUSION

In the largest reported cohort of patients with lung cancer hospitalized with a principal diagnosis of acute RP, the presence of interstitial lung disease, pulmonary hypertension, diabetes mellitus, and more affluent Zip Code were associated with in-hospital death. Comorbid diagnoses may be useful for risk-stratified management of inpatients with RP.

Treatment at an Academic Cancer Center Confers Better Survival by Stage for Signet-Ring Cell and Non-signet-Ring Cell Gastric Cancer

BACKGROUND

The literature lacks large-scale population studies comparing survival outcomes between signet-ring cell gastric carcinoma (SRGC) and non-SRGC (NSRGC) when treatment is delivered at academic versus community cancer centers.

METHODS

The National Cancer Database (NCDB) from 2004 to 2016 was queried to examine the association between treatment facility category and overall survival of patients who underwent gastrectomy for resectable gastric adenocarcinoma (GAC).

RESULTS

The study investigated 22,871 patients. Upstaging of resectable GAC to pathologic stage 4 was more evident at community centers (3.5%) than at academic centers (2.8%) for the NSRGC variant (p = 0.211), whereas it was comparable between the two facility categories for the SRGC variant (5.9% vs 6%, respectively). Patients with pathologic stage 1 or 3 NSRGC who underwent gastrectomy at academic programs had better overall survival (OS) (hazard ratio [HR], 0.68; p < 0.0001) than those who underwent gastrectomy at community centers (HR, 0.79; p < 0.0065). Similarly, patients with stage 2 SRGC had better OS when treated at academic versus community centers (HR, 0.54; p = 0.0019). No statistically significant improvement in OS was observed between patients with stage 2 NSRGC (HR, 0.84; p = 0.083) and those with stage 3 SRGC (HR, 0.78; p = 0.054) who were treated at academic centers. No survival benefit was demonstrated for stage 1 SRGC when academic and community centers were compared (p = 0.56).

CONCLUSIONS

This is the first study based on a large-scale database in the Western population that addressed the overall survival-by-stage of two distinct GAC histologic variants. Treatment at academic centers was associated with significant improvements in OS.

Quantifying treatment selection bias effect on survival in comparative effectiveness research: findings from low-risk prostate cancer patients

BACKGROUND

Comparative effectiveness research (CER) using national registries influences cancer clinical trial design, treatment guidelines, and patient management. However, the extent to which treatment selection bias (TSB) affects overall survival (OS) in cancer CER remains poorly defined. We sought to quantify the TSB effect on OS in the setting of low-risk prostate cancer, where 10-year prostate cancer-specific survival (PCSS) approaches 100% regardless of treatment modality.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients with low-risk prostate cancer (cT1-T2a, PSA < 10, and Gleason 6) who received radical prostatectomy (RP), brachytherapy (BT), or external beam radiotherapy (EBRT) from 2005 to 2015. The TSB effect was defined as the unadjusted 10-year OS difference between modalities that was not due to differences in PCSS. Propensity score matching was used to estimate the TSB effect on OS due to measured confounders (variables present in the database and associated with OS) and unmeasured confounders.

RESULTS

A total of 50,804 patients were included (8845 RP; 18,252 BT; 23,707 EBRT) with a median follow-up of 7.4 years. The 10-year PCSS for the entire cohort was 99%. The 10-year OS was 92.9% for RP, 83.6% for BT, and 76.9% for EBRT (p < 0.001). OS differences persisted after propensity score matching of RP vs. EBRT (7.4%), RP vs. BT (4.6%), and BT vs. EBRT (3.7%) (all p < 0.001). The TSB effect on 10-year OS was estimated to be 15.0% for RP vs. EBRT (8.6% measured, 6.4% unmeasured), 8.5% for RP vs. BT (4.8% measured, 3.7% unmeasured), and 6.5% for BT vs. EBRT (3.1% measured, 3.4% unmeasured).

CONCLUSIONS

Patients with low-risk prostate cancer selected for RP exhibited large OS differences despite similar PCSS compared to radiotherapy, suggesting OS differences are almost entirely driven by TSB. The quantities of these effects are important to consider when interpreting prostate cancer CER using national registries.