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Maduka RC, Canavan ME, Walters SL, Ermer T, Zhan PL, Kaminski MF, Li AX, Pichert MD, Salazar MC, Prsic EH, Boffa DJ. Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer. Cancer Med 2024; 13:e7028. [PMID: 38711364 DOI: 10.1002/cam4.7028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics. METHODS Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models. RESULTS Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001). CONCLUSIONS There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.
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Affiliation(s)
- Richard C Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center Advanced Training Program for Physician Scientist, NIH T32 Fellowship, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maureen E Canavan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samantha L Walters
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael F Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew X Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Matthew D Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michelle C Salazar
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth H Prsic
- Palliative Care Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Udelsman BV, Canavan ME, Zhan PL, Ely S, Park HS, Boffa DJ, Mase VJ. Overall survival in low-comorbidity patients with stage I non-small cell lung cancer who chose stereotactic body radiotherapy compared to surgery. J Thorac Cardiovasc Surg 2024; 167:822-833.e7. [PMID: 37500052 DOI: 10.1016/j.jtcvs.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/10/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To evaluate trends in the utilization of stereotactic body radiotherapy (SBRT) and to compare overall survival (OS) of patients with early-stage non-small cell lung cancer (NSCLC) undergoing SBRT versus those undergoing surgery. METHODS The National Cancer Database was queried for patients without documented comorbidities who underwent surgical resection (lobectomy, segmentectomy, or wedge resection) or SBRT for clinical stage I NSCLC between 2012 and 2018. Peritreatment mortality and 5-year OS were compared among propensity score-matched cohorts. RESULTS A total of 30,658 patients were identified, including 24,729 (80.7%) who underwent surgery and 5929 (19.3%) treated with SBRT. Between 2012 and 2018, the proportion of patients receiving SBRT increased from 15.9% to 26.0% (P < .001). The 30-day mortality and 90-day mortality were higher among patients undergoing surgical resection versus those receiving SBRT (1.7% vs 0.3%, P < .001; 2.8% vs 1.7%, P < .001). In propensity score-matched patients, OS favored SBRT for the first several months, but this was reversed before 1 year and significantly favored surgical management in the long term (5-year OS, 71.0% vs 41.8%; P < .001). The propensity score-matched analysis was repeated to include only SBRT patients who had documented refusal of a recommended surgery, which again demonstrated superior 5-year OS with surgical management (71.4% vs 55.9%; P < .001). CONCLUSIONS SBRT is being increasingly used to treat early-stage lung cancer in low-comorbidity patients. However, for patients who may be candidates for either treatment, the long-term OS favors surgical management.
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Affiliation(s)
- Brooks V Udelsman
- Division of Thoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif.
| | - Maureen E Canavan
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Conn
| | - Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Sora Ely
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Conn
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Vincent J Mase
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Udelsman BV, Jang A, Muniappan A, Zhan PL, Bao X, Chen T, Gaissert HA. Perioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: a propensity matched analysis. J Thorac Dis 2024; 16:1180-1190. [PMID: 38505043 PMCID: PMC10944756 DOI: 10.21037/jtd-23-591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/04/2023] [Indexed: 03/21/2024]
Abstract
Background Non-intubated thoracoscopic surgery with spontaneous breathing is rarely utilized, but may have several advantages over standard intubation, especially in those with significant cardiopulmonary comorbidities. In this study we evaluate the safety, feasibility, and 3-year survival of thoracoscopic surgery without endotracheal intubation for oncologic and non-oncologic indications. Methods All consecutive patients [2018-2022] selected for lung resection or other pleural space intervention under local anesthesia and sedation were compared to a cohort undergoing elective thoracoscopic procedures with endotracheal intubation. A propensity-score matched cohort was used to compare perioperative outcomes and 3-year overall survival. Results A total of 72 patients underwent thoracoscopic surgery without intubation compared to 1,741 who were intubated. Non-intubated procedures included 19 lobectomies (26.4%), 9 segmentectomies (12.5%), 25 wedge resections (34.7%), and 19 pleural or mediastinal resections (26.4%). Non-intubated patients had a lower average body mass index (BMI; 24.6 vs. 27.1 kg/m2, P<0.001) and a higher comorbidity burden. Primary lung cancer was the indication in 30 (41.7%) non-intubated patients. The non-intubated cohort had no operative or 30-day mortality. After propensity-score matching, there was no significant difference in pre-operative factors. In propensity-score matched analysis, non-intubated patients had shorter median total operating room time (109 vs. 159 min, P<0.001) and procedure time (69 vs. 119 min, P<0.001). Peri-operative morbidity was rare and did not differ between intubated and non-intubated patients. There was no significant difference in 3-year survival associated with non-intubation in the propensity-score matched cohorts (95% vs. 89%, P=0.10) or in a Cox proportional hazard model [hazard ratio (HR), 1.15; 95% confidence interval (CI): 0.36-3.67; P=0.81]. Conclusions Non-intubated thoracoscopic surgery is safe and feasible in carefully selected patients for both benign and oncologic indications.
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Affiliation(s)
- Brooks V. Udelsman
- Division of Thoracic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Anna Jang
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Peter L. Zhan
- Division of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Xiaodong Bao
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA, USA
| | - Tongyan Chen
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A. Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Zhan PL, Canavan ME, Ermer T, Pichert MD, Li AX, Maduka RC, Udelsman BV, Nemeth A, Boffa DJ. ASO Visual Abstract: Association Between Metastatic Pattern and Prognosis in Stage IV Gastric Cancer-Potential for Stage Classification Reform. Ann Surg Oncol 2023; 30:4192. [PMID: 37029870 DOI: 10.1245/s10434-023-13397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Affiliation(s)
- Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Maureen E Canavan
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, CT, USA
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew D Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew X Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Richard C Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Brooks V Udelsman
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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Zhan PL, Canavan ME, Ermer T, Pichert MD, Li AX, Maduka RC, Udelsman BV, Nemeth A, Boffa DJ. Association Between Metastatic Pattern and Prognosis in Stage IV Gastric Cancer: Potential for Stage Classification Reform. Ann Surg Oncol 2023:10.1245/s10434-023-13287-9. [PMID: 36869917 DOI: 10.1245/s10434-023-13287-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE This study aims to clarify the association between metastatic pattern and prognosis in stage IV gastric cancer, with a focus on patients presenting with metastases limited to nonregional lymph nodes. METHODS In this retrospective cohort study, the National Cancer Database was used to identify patients ≥ 18 years of age diagnosed with stage IV gastric cancer between 2016 and 2019. Patients were stratified according to pattern of metastatic disease at diagnosis: nonregional lymph nodes only ("stage IV-nodal"), single systemic organ ("stage IV-single organ"), or multiple organs ("stage IV-multi-organ"). Survival was assessed by Kaplan-Meier curves and multivariable Cox models in unadjusted and propensity score-matched samples. RESULTS Overall, 15,050 patients were identified, including 1,349 (8.7%) stage IV-nodal patients. Most patients in each group received chemotherapy [68.6% of stage IV-nodal patients, 65.2% of stage IV-single organ patients, and 63.5% of stage IV-multi-organ patients (p = 0.003)]. Stage IV-nodal patients exhibited better median survival (10.5 months, 95% CI 9.7-11.9, p < 0.001) than single organ (8.0, 95% CI 7.6-8.2) and multi-organ (5.7, 95% CI 5.4-6.0) patients. In the multivariable Cox model, stage IV-nodal patients also exhibited better survival (HR 0.79, 95% CI 0.73-0.85, p < 0.001) than single organ (reference) and multi-organ (HR 1.27, 95% CI 1.22-1.33, p < 0.001) patients. CONCLUSIONS Nearly 9% of clinical stage IV gastric cancer patients have their distant disease confined to nonregional lymph nodes. These patients were managed similarly to other stage IV patients but experienced a better prognosis, suggesting opportunities to introduce M1 staging subclassifications.
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Affiliation(s)
- Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Maureen E Canavan
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew D Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew X Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Richard C Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Brooks V Udelsman
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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Zhan PL, Canavan ME, Ermer T, Pichert MD, Li AX, Maduka RC, Kaminski MF, Boffa DJ. Nonregional Lymph Nodes as the Only Metastatic Site in Stage IV Esophageal Cancer. JTO Clin Res Rep 2022; 3:100426. [PMID: 36444359 PMCID: PMC9700291 DOI: 10.1016/j.jtocrr.2022.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/29/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Metastatic involvement of at least one nonregional lymph node currently renders patients with esophageal cancer as having stage IV disease. However, the management and outcomes of patients whose sole determinant of stage IV status is nonregional lymph nodes (abbreviated as "stage IV-nodal" disease) have not been fully characterized. Methods In this retrospective cohort study, the National Cancer Database was queried to identify patients 18 years of age or older who were diagnosed with stage IV esophageal cancer between 2016 and 2019. Survival was assessed by Kaplan-Meier analysis and Cox models in the overall sample and a propensity-matched sample. Patients with "stage IV-nodal" disease were compared with patients with systemic metastases involving a single organ or multiple organs. Results Overall, 11,589 patients with clinical stage IV esophageal cancer were identified, including 1331 (11.5%) patients with stage IV-nodal disease. Patients with stage IV-nodal disease were more likely to receive chemotherapy (77%) than those with single systemic organ metastases (64%) and multiorgan metastases (63%) (p < 0.0001); patients with stage IV-nodal disease were also more likely to receive radiation (49%) than those with single systemic organ metastases (40%) and multiorgan metastases (39%) (p < 0.0001). Squamous cell carcinoma (OR = 1.58, 95% confidence interval [CI]: 1.34-1.86, p < 0.0001) and academic facility type (OR = 1.24, 95% CI: 1.09-1.4, p = 0.0009) were associated with higher likelihood of the stage IV-nodal presentation. Patients with stage IV-nodal disease experienced superior survival (hazard ratio = 0.72, 95% CI: 0.66-0.78, p < 0.0001) than those with stage IV-single systemic metastases (reference group) and stage IV-multiorgan disease (hazard ratio = 1.30, 95% CI: 1.24-1.37). Conclusions Approximately 12% of patients with stage IV esophageal cancer lack systemic metastases at presentation. These patients with stage IV-nodal disease are more likely to receive treatment and experience superior survival. Further study of the stage IV-nodal population and consideration of a potential stage IV subclassification system is justified.
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Affiliation(s)
- Peter L. Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E. Canavan
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew D. Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael F. Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
- Corresponding author Address for correspondence: Daniel J. Boffa, MD, MBA, Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, P.O. Box 208062, New Haven, Connecticut 06520-8062.
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Pichert MD, Canavan ME, Maduka RC, Li AX, Ermer T, Zhan PL, Kaminski M, Udelsman BV, Blasberg JD, Park HS, Goldberg SB, Boffa DJ. Immunotherapy After Chemotherapy and Radiation for Clinical Stage III Lung Cancer. JAMA Netw Open 2022; 5:e2224478. [PMID: 35925606 PMCID: PMC9353596 DOI: 10.1001/jamanetworkopen.2022.24478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The 2017 international PACIFIC trial established a role for immunotherapy after chemoradiation for unresectable stage III non-small cell lung cancer (NSCLC). However, in the US, patients with NSCLC commonly differ from clinical trial populations in terms of age, health, access to care, and treatment course, which may all factor into the efficacy of immunotherapy. OBJECTIVE To determine the outcomes of immunotherapy use in unresectable stage III NSCLC in the general US population. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed the National Cancer Database for patients diagnosed with clinical stage III NSCLC between 2015 and 2017 with follow-up through the end of 2018 who were treated with chemotherapy and radiation. Data were analyzed January 2022. MAIN OUTCOMES AND MEASURES Mortality hazard in a multivariable Cox proportional hazards model and survival among a propensity-matched sample treated with chemotherapy and radiation, with and without immunotherapy. RESULTS A total of 23 811 patients with clinical stage III NSCLC with median (IQR) age 66 (59-72) years met inclusion criteria (10 454 [43.9%] women; 564 [2.4%] Asian, 2930 [12.3%] Black, 20 077 [84.3%] White patients), including 209 (16.1%) patients with multiple comorbidities and 1297 (5.4%) immunotherapy recipients. Immunotherapy after chemotherapy and radiation was associated with reduced mortality (hazard ratio [HR], 0.74; 95% CI, 0.67-0.82; P < .001). Among a propensity-matched sample, immunotherapy was associated with superior 3-year survival (52% [1297 patients at 0 months, 56 patients at 36 months] vs 44% [2594 patients at 0 months, 173 patients at 36 months]; P < .001). The treatment of 833 patients who received immunotherapy (64.2%) differed from the PACIFIC trial protocol, including 221 patients (17.0%) who received radiation doses outside of the protocol range and 731 patients (56.4%) who started immunotherapy more than 6 weeks after radiation was completed. The survival advantage of immunotherapy persisted when initiated up to 12 weeks after radiation was completed (HR, 0.75; 95% CI, 0.61-0.92). Among patients who received radiation outside the PACIFIC protocol range, the survival advantage of immunotherapy was not significant (HR, 0.87; 95% CI, 0.69-1.01). CONCLUSIONS AND RELEVANCE In this cohort study, immunotherapy after chemotherapy and radiation for stage III NSCLC was associated with a survival advantage in the general US population despite two-thirds of patients treated differently than the PACIFIC protocol. The findings suggest there may be flexibility in the timing of immunotherapy initiation after radiation; further study is warranted to clarify the clinical benefits of immunotherapy.
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Affiliation(s)
- Matthew D. Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E. Canavan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Peter L. Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Brooks V. Udelsman
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Henry S. Park
- Department of Therapeutic Radiology, Yale School of Medicine, Smilow Cancer Hospital at Yale, New Haven, Connecticut
| | - Sarah B. Goldberg
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Ermer T, Canavan ME, Maduka RC, Li AX, Salazar MC, Kaminski MF, Pichert MD, Zhan PL, Mase V, Kluger H, Boffa DJ. Association Between Food and Drug Administration Approval and Disparities in Immunotherapy Use Among Patients With Cancer in the US. JAMA Netw Open 2022; 5:e2219535. [PMID: 35771575 PMCID: PMC9247736 DOI: 10.1001/jamanetworkopen.2022.19535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Clinical trials and compassionate use agreements provide selected patients with access to potentially life-saving treatments before approval by the Food and Drug Administration (FDA). Approval from the FDA decreases a number of access barriers; however, it is unknown whether FDA approval is associated with increases in the equitable use of novel therapies and reductions in disparities in use among patients with cancer in the US. OBJECTIVE To assess the association between FDA drug approval and disparities in the use of immunotherapy across health, sociodemographic, and socioeconomic strata before and after approval of the first checkpoint inhibitors for the treatment of patients with cancer in the US. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the National Cancer Database to examine the use of immunotherapy across health, sociodemographic, and socioeconomic strata before and after FDA approval of the first checkpoint inhibitor therapies. A total of 402 689 patients 20 years or older who were diagnosed with stage IV non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), or melanoma of the skin between January 1, 2007, and December 31, 2018 (specific years varied by tumor type), were included. EXPOSURES Patient health (Charlson-Deyo comorbidity score and age), sociodemographic characteristics (sex, race, and ethnicity), and socioeconomic (insurance status and household income based on zip code of residence) characteristics. MAIN OUTCOMES AND MEASURES The association of patient characteristics with receipt of immunotherapy was evaluated in the 4 years before and the 3 years immediately after FDA approval using multivariable logistic regression modeling. RESULTS Among 402 689 patients (median [IQR] age, 68 [60-76 years]; 225 081 men [55.9%]), 347 233 had NSCLC, 43 714 had RCC, and 11 742 patients had melanoma. A total of 47 527 patients (11.8%) were Black, 15 763 (3.9%) were Hispanic, 375 874 (93.3%) were non-Hispanic, 335 833 (83.4%) were White, and 16 553 (4.1%) were of other races. Before FDA approval, 6271 patients (3.2%) with NSCLC, 1155 patients (4.8%) with RCC, and 504 patients (8.6%) with melanoma received immunotherapy compared with 23 908 patients (15.6%) with NSCLC, 3890 patients (19.7%) with RCC, and 1143 patients (19.3%) with melanoma after FDA approval. Before FDA approval, sociodemographic and socioeconomic characteristics were associated with variable immunotherapy administration by tumor type. For example, among those with NSCLC, Black patients were less likely to receive immunotherapy than White patients (odds ratio [OR], 0.78; 95% CI ,0.71-0.85; P < .001); among those with RCC, uninsured patients were less likely to receive immunotherapy than privately insured patients (OR, 0.31; 95% CI, 0.20-0.48; P < .001). After FDA approval, most disparities persisted, but several narrowed (eg, Black patients with NSCLC: OR, 0.87 [95% CI, 0.83-0.91; P < .001]; uninsured patients with RCC: OR, 0.60 [95% CI, 0.48-0.75; P < .001]). Although many disparities remained, some gaps across socioeconomic characteristics appeared to widen (eg, patients with NSCLC in the lowest vs highest income quartile: OR, 0.80; 95% CI, 0.76-0.83; P < .001), and new gaps emerged (eg, Black patients with RCC: OR, 0.82; 95% CI, 0.72-0.93; P = .003). CONCLUSIONS AND RELEVANCE In this cohort study, disparities in immunotherapy use existed across a number of sociodemographic and socioeconomic characteristics among patients with NSCLC, RCC, and melanoma before FDA approval, including during the important period when clinical trials were accruing patients. Although FDA approval was associated with a significant increase in the use of immunotherapy, gaps persisted, suggesting that FDA approval may not eliminate disparities in the use of novel therapies.
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Affiliation(s)
- Theresa Ermer
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Maureen E. Canavan
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Matthew D. Pichert
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter L. Zhan
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Vincent Mase
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Harriet Kluger
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Zhan PL, Canavan ME, Ermer T, Pichert MD, Li AX, Maduka RC, Boffa DJ. Association of Insurance Status and Extent of Organ Involvement With Survival Among Patients With Stage IV Cancer. JAMA Netw Open 2022; 5:e2217581. [PMID: 35713907 PMCID: PMC9206181 DOI: 10.1001/jamanetworkopen.2022.17581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study examines the association of insurance status and extent of metastatic organ involvement with survival among patients with stage IV cancer to better understand outcome disparities in the US.
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Affiliation(s)
- Peter L. Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E. Canavan
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew D. Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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10
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Pichert MD, Canavan ME, Maduka RC, Li AX, Ermer T, Zhan PL, Kaminski M, Udelsman BV, Blasberg JD, Mase VJ, Dhanasopon AP, Boffa DJ. Revisiting Indications for Brain Imaging During the Clinical Staging Evaluation of Lung Cancer. JTO Clin Res Rep 2022; 3:100318. [PMID: 35540711 PMCID: PMC9079298 DOI: 10.1016/j.jtocrr.2022.100318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/09/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Available guidelines are inconsistent as to whether patients with newly diagnosed clinical stage II NSCLC should receive routine brain imaging. Methods The National Cancer Database was queried for the prevalence of isolated brain metastases among patients with newly diagnosed NSCLC in 2016 and 2017. Patients with metastases in locations other than the brain were excluded. The prevalences were then stratified by clinical T and N classifications and further stratified into a summary stage, which was calculated based on T and N classifications. The summary stage represents the clinical stage that would have been available at the time of decision for brain imaging. Results A total of 6,949 of 149,958 patients (4.6%) with clinical stages I, II, III, or brain-limited stage IV NSCLC had dissemination limited to the brain. As T and N stages increased, prevalence of brain metastases generally increased. Among patients with node-negative (N0) NSCLC, the prevalence of brain-only metastases increased from 1.2% in patients with T1a to 3.8% among patients with T4 (p < 0.001). Among patients with T1a, the prevalence of brain-only metastases increased from 1.2% for patients with N0 to 7.9% for patients with N3 (p < 0.001). The prevalence of brain-limited metastases generally increased with increasing summary stage. The prevalence of brain-only metastases among patients with stage IA was 1.7% whereas that among patients with stage IIIA was 6.7% (p < 0.001). Of note, the prevalence of brain-limited metastases was approximately 6% for both summary stages II and III. Conclusions Considering the similarity in prevalence of isolated brain metastases and the potential hazards associated with brain imaging in early stage NSCLC, practitioners may consider a more liberal use of brain imaging when interpreting conflicting guidelines.
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Affiliation(s)
- Matthew D. Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E. Canavan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut,Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard C. Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X. Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut,London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Peter L. Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Brooks V. Udelsman
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Vincent J. Mase
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew P. Dhanasopon
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut,Corresponding author. Address for correspondence: Daniel J. Boffa, MD, MBA, Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, New Haven, CT 06510.
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11
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Zhan PL, Jahromi BS, Kruser TJ, Potts MB. Stereotactic radiosurgery and fractionated radiotherapy for spinal arteriovenous malformations – A systematic review of the literature. J Clin Neurosci 2019; 62:83-87. [DOI: 10.1016/j.jocn.2018.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/22/2018] [Indexed: 11/29/2022]
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12
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Chung JD, Zhan PL. General solutions to decompose heterogeneous compositions using antibody afucosylation as a model system. Biotechnol Prog 2016; 33:500-510. [PMID: 28019689 DOI: 10.1002/btpr.2428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/16/2016] [Indexed: 11/05/2022]
Abstract
Methods involving the use of mathematical models of competitive ligand-receptor binding to characterize mixtures of ligands in terms of compositions and properties of the component ligands have been developed. The associated mathematical equations explicitly relate component ligand physical-chemical properties and mole fractions to measurable properties of the mixture including steady state binding activity, 1/Kd,apparent or equivalently 1/EC50, and kinetic rate constants kon,apparent and koff,apparent allowing: (1) component ligand physical property determination and (2) mixture property predictions. Additionally, mathematical equations accounting for combinatorial considerations associated with ligand assembly are used to compute ligand mole fractions. The utility of the methods developed is demonstrated using published experimental ligand-receptor binding data obtained from mixtures of afucosylated antibodies that bind FcγRIIIa (CD16a) to: (1) extract component ligand physical property information that has hitherto evaded researchers, (2) predict experimental observations, and (3) provide explanations for unresolved experimental observations. © 2017 American Institute of Chemical Engineers Biotechnol. Prog., 33:500-510, 2017.
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Affiliation(s)
- John D Chung
- Chung Bioengineering Consulting and Mendocino College, 3520 Rivera West Drive, Kelseyville, California, 95451
| | - Peter L Zhan
- Chung Bioengineering Consulting and Mendocino College, 3520 Rivera West Drive, Kelseyville, California, 95451
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Zhan PL, Chung JD. Challenges with afucosylation content in antibody-based drugs: Guidance provided by mathematical modeling. Biotechnol Prog 2015; 31:775-82. [PMID: 25644335 DOI: 10.1002/btpr.2056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 01/22/2015] [Indexed: 11/05/2022]
Abstract
The theory of competitive ligand-receptor binding has been used to analyze the effect of afucosylation-based antibody heterogeneity on Fc-FcγRIIIa ligand-receptor binding activity. In vitro activity is found to represent a linear combination of the component antibody activities, weighted by the relative concentrations of the different afucosylated antibody forms. An analysis of ELISA binding activity data has allowed for the dissection of the activity contributions of the different afucosylated antibodies, revealing that the heterogeneous afucosylated antibody exhibits greater activity, on a per mole basis, when compared to the homogeneous afucosylated antibody. The ratio of the afucosylated antibody equilibrium dissociation constants is computed to be KAF /KA ≈ 0.6-0.9, where KAF and KA denote the dissociation equilibrium constant of the heterogeneous and the homogeneous afucosylated antibodies, respectively. Our analysis also reveals that, in general, activity scales quadratically with the afucosylated glycan content of a sample. Linear activity-afucosylated glycan fraction correlations reported in the literature are shown to represent specific cases of this general scaling and result from oversimplifying the underlying antibody concentration distributions. The implications of our findings for drug development are also discussed.
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Affiliation(s)
- Peter L Zhan
- Dept. of Molecular Biochemistry & Biophysics, Yale University, New Haven, CT
| | - John D Chung
- Chung Bioengineering Consulting and Mendocino College, Ukiah, CA
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