Advanced or metastatic biliary tract cancer in Japan: a study using the Japan Medical Data Center payer claims database

Aim: Biliary tract cancers are aggressive, with poor prognosis. This study describes clinical characteristics, treatment patterns and healthcare resource utilization in patients with metastatic biliary tract cancer in Japan. Materials & methods: This cohort-based study collected data from the Japan Medical Data Center claims database (2014-2018). Results: A total of 325 patients were included; 65.2% were male and the mean age was 59.2 years. A 47.6% had an Elixhauser Comorbidity Index score ≥5. Most frequent regimens were gemcitabine + cisplatin (52.9%) for first-line therapy and tegafur + gimeracil + oteracil for second-line therapy (48.6%) and third-line therapy (27.2%). Approximately 77% of patients had ≥1 hospital admission, with a median length of 57 days. Conclusion: This study provides insights on the characteristics and burden of metastatic biliary tract cancer in Japan, highlighting high disease burden in a younger population.

Second-line treatments in advanced biliary tract cancer: systematic literature review of efficacy, effectiveness and safety

Background: A systematic review was conducted to understand clinical, economic and health-related quality-of-life outcomes in second-line biliary tract cancer. Materials & methods: The review followed established recommendations. The feasibility of network meta-analysis revealed limited networks, thus synthesis was limited to a summary of reported ranges, percentiles and medians. Results: The review included 62 trials and observational studies highly variable with respect to key baseline characteristics. Commonly evaluated second-line treatments included fluoropyrimidine-, gemcitabine- and S-1-based regimens. Across active treatment arms, median overall survival ranged from 3.5 to 15.0 months (median: 6.9), median progression-free survival from 1.4 to 6.5 months (median: 2.9) and objective response from 0 to 36.4%. Outcomes were similar between study types, with a few notable outliers. Treatment-related/-emergent adverse events were infrequently reported; no studies reported economic or health-related quality-of-life outcomes. Conclusions: Biliary tract cancer is a difficult-to-treat disease with poor prognosis. Despite evolving treatment landscapes, more recent studies did not show clinical outcome improvement, highlighting an unmet need among advanced/metastatic patients.

Survival of older patients with advanced biliary tract cancers by disease site

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Background: Biliary tract cancers (BTC) arise from the epithelial lining of the biliary tree and include intrahepatic and extrahepatic cholangiocarcinoma, gallbladder cancer, and sometimes cancer of the ampulla of Vater. Although this is a closely related group of diseases, comparisons of risk factors, treatment, and mortality by disease site are limited. Methods: This retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims. Patients aged ≥66 years with a pathologically confirmed diagnosis of advanced (stage III or IV) BTC from 2010 to 2015 were included and followed up through 2016. Patients with any SEER-reported cancer in the prior 2 years were excluded. Any outpatient systemic treatment during follow-up was identified using Medicare claims. Patients were followed up until death, end of follow-up, subsequent primary cancer, or switch to managed care. The Kaplan-Meier estimator was used to estimate unadjusted median survival. A Cox proportional hazards model was used to identify factors associated with survival. Results: There were 2,891 patients in the cohort (Table). Factors significantly associated with worse survival included older age, presence of mobility limitations, living in an area with > 30% of the people below poverty, higher comorbidity burden, and stage IV BTC (vs stage III). Factors significantly associated with better survival included history of cancer, intrahepatic BTC (vs extrahepatic), or ampulla of Vater BTC (vs extrahepatic). Conclusions: Survival in BTC is poor and many patients do not receive outpatient systemic therapy. Patients with gallbladder and extrahepatic BTC had worse median survival and were less likely to receive systemic therapy than those with intrahepatic or ampulla of Vater BTC. Fewer ampulla of Vater patients present with Stage IV disease which could be a contributing factor to the significantly longer survival. Prior work has demonstrated an association between history of some types of cancer and survival; additional research is needed to better understand this finding. [Table: see text]

Survival by line of therapy of older patients with advanced biliary tract cancer (BTC)

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Background: Overall survival (OS) in advanced or metastatic BTC has not been adequately described outside the clinical trial setting. Further, real-world descriptions of OS by line of therapy, including in patients who do not receive systemic chemotherapy, are not widely available. In this study, we used data from a recent cohort of US patients available in the SEER-Medicare linked database to examine OS from diagnosis of advanced or metastatic BTC as well as from initiation of first- and second-line treatment. Methods: Patients with advanced or metastatic BTC diagnosed between 2010 and 2013 were identified in SEER-Medicare, with follow-up through 2014. Demographic and clinical characteristics were analyzed. The Kaplan-Meier estimator was used to describe OS from diagnosis among all patients, OS from diagnosis among patients who did not receive systemic treatment, and OS by line of treatment, from date of treatment initiation. The Cox proportional hazards model was used to identify demographic and clinical factors associated with survival. Results: Of the 1,461 eligible patients aged ≥66 years, 39% had gallbladder, 22% had intrahepatic, 22% had extrahepatic, and 9% had ampulla of Vater cancer. More than two-thirds of patients had stage IV disease, and 38% of patients (n = 558) received systemic chemotherapy. Systemic treatment patients were somewhat younger, more likely to be white, have stage IV cancer and less likely to have mobility limitations (24% vs. 38%) than patients who did not receive systemic treatment. Among all patients, unadjusted median OS from diagnosis was 5.6 months (95% CI 5.0-6.1). Among patients who were not treated, unadjusted median survival was 3.3 months (n = 903; 95% CI 2.8-4.0) from diagnosis. When OS was evaluated by line of treatment, median OS was 8.2 months (n = 558; 95% CI 7.6-9.0) from first-line initiation and 5.6 months (n = 220; 95% CI 4.6-6.5) from second-line initiation. Conclusions: Among newly diagnosed, older US patients, less than half receive systemic treatment for their advanced BTC, and outcomes among both treated and untreated patients remain poor. There is an immediate need for better therapies to treat patients with advanced BTC.

A Real-World Claims Analysis of Costs and Patterns of Care in Treated Patients with Glioblastoma Multiforme in the United States

BACKGROUND

Patients with glioblastoma multiforme (GBM) have a poor prognosis and high likelihood of recurrence. Routine care for incident cases in the United States involves surgical resection, followed by radiation therapy (RT) with concurrent and adjuvant temozolomide. Real-world data reporting the treatments and health care burden associated with GBM are limited.

OBJECTIVE

To assess patterns of care, health care resource utilization (HCRU), and costs associated with treatment of GBM in the United States.

METHODS

This study is a retrospective claims database analysis. Adult patients with a GBM diagnosis (index date) between January 1, 2010, and June 30, 2016, who had undergone brain surgery within 90 days of the index date, had received temozolomide and/or RT up to 90 days after index date, and had at least 6 months of continuous enrollment before the index date, were identified. Patients were excluded if they had (a) another primary cancer within 6 months pre-index, (b) secondary brain metastases, or (c) received temozolomide and/or RT pre-index. Baseline characteristics, treatments, HCRU, and costs were reported. First-line therapy began upon first receipt of RT and/or temozolomide after index date; second-line therapy began when a new drug was added > 28 days after initiation of first-line therapy or when there was a treatment gap > 90 days. Treatment regimens, duration of treatment (corrected group prognosis method), HCRU, and costs were reported descriptively in the 0- to 6-month and 7- to 12-month periods following initiation of first-line and second-line therapy.

RESULTS

Baseline characteristics were comparable between patients receiving temozolomide and/or RT. Patients receiving RT without chemotherapy tended to be older, be retired, and have more baseline comorbidities. Of the 4,071 patients receiving first-line therapy for GBM, most (73.0%) received temozolomide + RT; 24.4% received RT; and 2.5% received temozolomide monotherapy. Of those receiving first-line therapy, 1,283 (31.5%) patients subsequently received second-line therapy: 39.4% received bevacizumab monotherapy; 28.9% received bevacizumab combination therapy (temozolomide, 45.2% of patients; irinotecan, 24.3%; and temozolomide + lomustine, 15.4%); 15.5% received temozolomide monotherapy; and 13.7% received other systemic cancer therapies. The proportion of patients with hospitalizations increased from 2.9% (4-6 months pre-index) to 20.8% in the 3 months before the index date (likely due to diagnostic procedures) and 28.1% in the first 6 months after index (likely due to surgery) and then decreased to 13.3% in the 7- to 12-month period after index. Mean total per-patient costs at 6 and 12 months were $117,325 and $162,550 (first line) and $126,128 and $243,833 (second line). Costs in all time periods were largely driven by costs of RT/systemic cancer therapy.

CONCLUSIONS

Most patients with newly diagnosed GBM received treatment according to recommendations. However, relatively few patients received second-line therapy, and the HCRU burden and costs associated with both lines of therapy were substantial. Novel therapies for GBM are required to improve treatment options and outcomes in these patients.

DISCLOSURES

This study was funded by Bristol-Myers Squibb (Princeton Pike, NJ). Neither honoraria nor payments were provided for authorship. Norden received consultancy fees relating to this study from Bristol-Myers Squibb. Dastani, Korytowsky, Le, Singh, and You are employees of Bristol-Myers Squibb. Dastani and Korytowsky are shareholders of Bristol-Myers Squibb. Bobiak was an employee of Bristol-Myers Squibb at the time of this study. Preliminary data from this study were previously presented at the International Society for Pharmacoeconomics and Outcomes Research 22nd Annual International Meeting in Boston, MA, May 20-24, 2017.

Treatment patterns and survival among patients with extensive disease small cell lung cancer (ED-SCLC)

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Background: There has been little change to the ED-SCLC treatment landscape in the past 30 years. Patients with ED-SCLC have limited treatment options after recurrence and poor overall survival (OS). Prior work has described OS in patients with ED-SCLC but did not report OS beyond first-line (1L) therapy. Methods: This study used linked data from the Surveillance, Epidemiology, and End Results program and Medicare claims. Patients aged ≥66 years with a first primary, pathologically confirmed ED-SCLC diagnosis between 01/01/2007 and 12/31/2011 and who had Medicare Parts A and B coverage were included. Patients were followed from diagnosis until death, end of follow-up, second primary cancer diagnosis, or switch to managed care coverage. OS from ED-SCLC diagnosis and from initiation of 1L and second-line (2L) outpatient chemotherapy were estimated. Cox proportional hazards models were used to identify factors associated with OS from diagnosis. Results: Of 5498 patients with ED-SCLC (mean age: 75 years [range: 66, 98]) included in this study, 49% were male, 86% were white, 40% had ≥1 indicator of mobility limitations, and 23% lived in an area with high poverty (≥20%). Median OS for all patients was 4.7 months (untreated [n = 2484]: 1.3 months; treated with outpatient chemotherapy within 90 days of diagnosis [n = 3014]: 8.3 months). Among all patients, factors associated with shorter OS included older age, male sex, ≥1 indicator of mobility limitations, and residence in a high poverty area. In the 3014 patients who received 1L outpatient chemotherapy (86% platinum/etoposide; 4% platinum/irinotecan; 10% other), median OS from initiation of 1L therapy was 7.9 months overall (platinum/etoposide: 8.0 months; platinum/irinotecan: 7.8 months; other: 6.4 months). A total of 1162 patients received 2L chemotherapy (38% topotecan monotherapy; 28% platinum regimens; 34% other). Median OS from initiation of 2L therapy was 4.4 months overall (topotecan: 4.0 months; platinum regimens: 6.4 months; other: 3.7 months). Conclusions: OS was poor in this cohort of real-world patients with ED-SCLC especially in those not treated with outpatient chemotherapy. These findings underscore the need for new treatments for this population.

Bone metastases and skeletal-related events from neuroendocrine tumors

Neuroendocrine tumors (NETs) metastasize to bone; however, a multi-institution evaluation of the natural history and complications of bone metastases across multiple NET subtypes has not, to our knowledge, previously been conducted. At two tertiary academic centers, we identified patients with bone metastases from databases of patients with a diagnosis of NET between 2004 and 2008. Detection of bone metastases, occurrence of skeletal-related events (SREs), and interventions were analyzed using summary statistics and categorical methods. Time-to-event data were assessed using Kaplan-Meier estimates and log-rank tests. Between 2004 and 2008, 82 out of 691 NET patients (12%) were reported to have bone metastases. Of the 82 patients with bone metastases, 55% were men and their median age was 49. Bone metastases occurred in 25% of pheochromocytomas and paragangliomas, 20% of high-grade neuroendocrine carcinomas, 9% of carcinoid tumors, and 8% of pancreatic NETs. At time of detection of bone metastases, 60% reported symptoms, including pain; 10% developed cord compression, 9% suffered a pathological fracture, and 4% developed hypercalcemia. Occurrence of SREs did not differ significantly with regard to tumor histology. Of patients with bone metastases, 67 (82%) received at least one form of bone-directed treatment, 50% received radiation, 45% received a bisphosphonate, 18% underwent surgery, 11% received (131)I-MIBG, 5% received denosumab, and 46% were treated with more than one treatment modality. Bone metastases occur in a substantial number of patients diagnosed with NETs. Patients are often symptomatic and many develop SREs. Given the recent therapeutic advances and increasing life expectancy of patients with NETs, development of guidelines for surveillance and clinical care of bone metastases from NETs is needed.

Characterization of HER2 testing and treatment patterns among patients with gastric cancer in the United States using the Oncology Services Comprehensive Electronic Records (OSCER) database

36

Background: There is a paucity of data related to HER2 testing and treatment patterns among gastric cancer patients in a real-world setting. Our primary objectives were to (1) identify the proportion of gastric cancer patients who received HER2 testing, the proportion of patients with HER2+ve tumors, and the proportion of HER2+ve patients who received trastuzumab; (2) describe treatment patterns among gastric cancer patients, including the proportion of patients who received surgery and/or radiation with chemotherapy; (3) identify the proportion of patients who received singlet, doublet, or triplet chemotherapy treatments and specific first- and second-line regimens. Methods: The study participants were randomly selected to undergo a detailed chart review from a source population of patients included in the OSCER database who were diagnosed with gastric cancer from 2009 to 2013. OSCER is a data warehouse of electronic medical records from 565 community and hospital-affiliated oncology clinics in the U.S. from 2004 forward. All patients were required to have metastatic gastric cancer at the time of the chart review and have been treated with chemotherapy to be included. Descriptive statistics were used to characterize HER2 testing and treatment patterns. Results: The study patients (n=238) were mostly male (62%), Caucasian (58%), >65 years of age (57%), with the following stage distribution at diagnosis (Stage II: 7%; Stage III: 11%; Stage IV: 63%; unknown: 19%). HER2 testing was documented in n=121/238 (51%), of which n=30/121(25%) were HER2+ve. Among HER2+ve patients, n=20/30 (67%) received trastuzumab. Of the total sample (n=238), 79% were treated with only chemotherapy, 4% received chemotherapy and surgery, 15% received chemotherapy and radiation, and 2% received all three treatments. First-line treatment was as follows: singlet (17%); doublet (33%), triplet (38%), other (12%). Conclusions: Only half of patients were tested for HER2 status; however, the use of trastuzumab among HER2+ve patients was high. Chemotherapy alone was the primary treatment in this population.

Dosing patterns for octreotide LAR in neuroendocrine tumor (NET) patients: NCCN NET outcomes database

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Background: Among patients (pts) with neuroendocrine histology, 10 mg – 30 mg of octreotide-LAR administered intramuscularly every 4 weeks is FDA-approved for the long term treatment of severe diarrhea and flushing episodes associated with metastatic carcinoid tumors and pancreatic VIPomas. In clinical practice, higher doses and/or more frequent administration is often prescribed for pts who experience refractory symptoms (e.g., flushing and/or diarrhea) on the maximal labeled dose. Methods: National Comprehensive Cancer Network (NCCN) created a comprehensive longitudinal database to characterize pts treated for NETs. This database was queried to identify pts presenting to 7 NCCN institutions, from 2004 to 2010, with a confirmed carcinoid or pancreatic NET (pNET) diagnosis who received octreotide LAR. The primary aim of this analysis was to describe octreotide LAR dosing patterns when beyond label recommendations, clinical characteristics, reasons for dose increase, and maximal dose. Results: Among 1,886 pts in the database, 271 carcinoid and pNET pts received octreotide LAR. 40% of carcinoid pts (n=82) and 23% of pNET pts (n=15) received octreotide LAR above-label dosing, defined by dose and/or frequency greater than 30 mg every 4 weeks. The primary tumor sites among carcinoid pts receiving above label dosing were small bowel (n=40), colorectal (n=4), and unknown (n=34). Reasons for above label dosing among carcinoid pts included uncontrolled symptoms (n=53, 65%), tumor progression (n=21, 25%), high urine 5-HIAA (n=1, 1%) and unknown (n=7, 9%). The most common dose/frequency combinations for carcinoid pts were 40 mg every 4 weeks (32 pts, 39%), 40 mg every 3 weeks (15 pts, 18%), and 30 mg every 2 weeks (14 pts 17%). Among pNET pts, reasons for change included uncontrolled symptoms (n=5, 33%), tumor progression (n=9, 60%), and unknown (n=1, 7%). The most common maximal dose/frequency combinations among pNET pts were 40mg every 4 weeks (n=5, 33%), 30mg every 2 weeks (n=4, 27%), and 60 mg every 4 weeks (n=4, 27). Conclusions: Above label dosing of octreotide LAR is common in NCCN institutions. The primary indication is refractory carcinoid syndrome. Prospective studies are planned to validate this strategy.

Treatment of liver metastases in patients with neuroendocrine tumors: A National Comprehensive Cancer Network analysis

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Background: The choice of therapy in patients with hepatic metastases from neuroendocrine tumors is controversial. The purpose of this study was to describe the utilization of liver resection and other locoregional therapies in the management of NET hepatic metastases in NCCN centers. Methods: The National Comprehensive Cancer Network (NCCN) Neuroendocrine Tumor Database tracks longitudinal care for patients treated at seven specialty cancer centers in the U.S. from 2004 to 2010. Patient and tumor characteristics, as well as the use of liver-directed therapy (LDT) in patients with neuroendocrine liver metastases (NELM) were evaluated. Results: Among 907 patients presenting with metastatic disease, 606 patients presenting with newly diagnosed disease or previously diagnosed disease with first distant recurrence of NELM were evaluated. LDT was used during some component of the patient care in only 43% of patients with NELM, the remainder received only systemic or no therapy. LDT varied by extent of disease (p=0.002) with a higher proportion of patients with liver-only disease receiving LDT (45%) compared to those with liver and extrahepatic disease (26%). There was a significant difference in LDT by functional tumor status (Χ2=6.84, p=0.03) and primary site of disease (Χ2=14.95, p=0.001) where a higher proportion of patients with hormonally functional tumors received LDT when compared to non-functional tumors (48% vs 42%) as well as those with primary small bowel carcinoid vs pancreatic NET (56% vs 39%). Among those treated with LDT, 39% underwent surgical resection, 57% intra-arterial therapy (IAT), and 4% ablation alone. Major hepatectomy was performed in 21%, multiple resections in 13%, and resection combined with ablation in 24% of patients receiving surgical therapy. Among the 147 patients treated with IAT, 52% received standard chemoembolization, 23% bland embolization, and 18% yttrium-90 therapy. Conclusions: Even at specialty centers less than half of patients received LDT, among which one-fifth had a hepatic resection. Future studies on this cohort will measure outcomes based on type of LDT.

Baseline demographics of neuroendocrine tumor patients presenting to seven National Comprehensive Cancer Network (NCCN) institutions: Development of a multi-institutional outcomes database

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Background: Diagnostic strategies, management paradigms, and clinical outcomes of patients with neuroendocrine tumors (NETs) are diverse and poorly characterized. The National Comprehensive Cancer Network (NCCN) created a comprehensive database to characterize patients treated for NETs at seven participating institutions. Preliminary results from the database are reported. Methods: Member IRB approval was obtained to identify patients at least 18 years of age presenting to each of seven NCCN institutions between 2004 and 2007 with pathologically confirmed newly or previously diagnosed NETs via hospital medical records. Eligible patients included those with carcinoid (any site); goblet cell or adenocarcinoid; composite carcinoid; poorly differentiated gastrointestinal small cell tumor; pancreatic NET; NET of unknown primary site; pheochromocytoma; and paraganglioma. Baseline demographic characteristics were summarized for this analysis. Results: Among the 2,798 patients identified with a NET diagnosis, patients most frequently presented with carcinoid tumor (53%), pancreatic NET (26%) and NET of unknown primary site (8%). Median age at diagnosis was 56 (SD=14). Fifty-three percent of patients were female. Most (86%) were Caucasian and 8% were African American. Thirty percent of patients were diagnosed with NET before presenting to the NCCN. Among these, the median time between initial NET diagnosis and presentation to the NCCN was 2 years (SD=6). Significant differences in provider specialty referral patterns were observed between institutions. The institutional point of entry for the majority of patients was medical oncology (institutional range: 17-93%) or surgery (institutional range: 3-62%). Conclusions: The baseline demographic characteristics of NET patients in this new database are consistent with those previously reported in population-based registries. The database will provide a valuable resource for further exploration of patterns of diagnosis, treatment, and consistency with established guidelines, as well as clinical outcomes in patients with this condition.

Description of initial treatment for newly diagnosed metastatic carcinoid (cNET) and pancreatic neuroendocrine (pNET) patients

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Background: There is limited descriptive information regarding treatment (tx) patterns for NET from clinic practice data. The primary aim of this analysis was to describe initial tx among NET pts as a first step in understanding tx patterns for NET. Methods: The National Comprehensive Cancer Network (NCCN) Oncology Outcomes Database was queried to identify newly diagnosed pts presenting to 7 NCCN institutions with a confirmed metastatic cNET or pNET diagnosis in 2004 or 2005. Pts with a minimum of 5 years of follow up or confirmed death were included in the analysis. Pt demographics, clinical characteristics, initial tx, and 5-year survival were described. Results: Among 187 cNET pts, 52% were male, median age at diagnosis was 58, and 51% alive. Approximately 58% had a known primary tumor; 65% of which were in the small bowel. Most cNET pts (85%) presented with symptoms, 33% had carcinoid syndrome. Initial tx included surgical therapy in 43%, drug therapy in 41%, and other therapies in 16%. The majority (82%) had imaging prior to treatment, among which 79% had a CT scan and 35% had somatostatin receptor scintigraphy (SRS). The most frequent biomarker test was for CGA (performed in 64 pts, elevated in 53). Of 76 cNET pts receiving initial drug therapy, 82% were treated with a somatostatin analog (SA); others received chemotherapy or targeted therapy. Kaplan-Meier (K-M) curves indicated a 5-year survival of 62% and 56% among pts receiving surgery or drug therapy as initial tx, respectively. Among 104 pNET pts, 61% were male, median age at diagnosis was 54, and 41% alive. Approximately 82% presented with symptoms among which 25% were hormone related. Among the 84% of pts imaged prior to treatment, CT scan was most common (79%) and 38% had SRS. The most common initial tx among pNET pts was drug therapy (56%); 60% received a SA; 31% received chemotherapy. Only 25% underwent surgery as initial tx. K-M curves indicated a 5-year survival of 63% among surgical pts in contrast to 31% for pts whose initial tx was drug therapy. Conclusions: Initial tx among the majority of pts was either surgery or drug therapy. Among cNET and pNET pts receiving drug therapy, 82% (n=62) and 60% (n=35) respectively, received an SA.

Prevalence of functional tumors in neuroendocrine carcinoma: An analysis from the NCCN NET database

4126

Background: Neuroendocrine tumors (NETs) are increasing in incidence and prevalence. Identification and treatment of specific clinical NET syndromes are established, yet there is uncertainty regarding the prevalence of NET with hormone-related symptoms versus nonfunctional tumors. Methods: The National Comprehensive Cancer Network (NCCN) created a comprehensive database to characterize patients (pts) treated for NETs. This database was queried to identify pts presenting to 7 NCCN institutions with a confirmed NET diagnosis: including carcinoid (cNET), pancreatic NET (pNET), NET not otherwise specified (NOS), and pheochromocytoma (PCC) between 2004 and 2010. The primary aim of this analysis was to describe demographic and clinical characteristics of NET pts by functional (fxn) status at diagnosis (dx). Results: Among 1244 NET pts, 26% (n=327) had an fxn tumor. Carcinoid syndrome (CS) occurred in 28% of cNET pts. The most common primary tumor sites among CS pts were small bowel (69%) and unknown (15%). Prevalence of hormonal syndrome (HS) among pNET pts was 22%, 24% among NOS pts and 37% among PCC pts. The majority of CS pts (74%), pNET HS pts (67%), and NOS HS pts (91%) had distant disease at dx, in contrast to 31% of PCC HS patients. Among CS pts with a known histologic grade, 91% were well differentiated (G1). Similarly, 86% of pNET HS and 67% of NOS HS pts with a known histologic grade had G1 NETs. The most common symptoms at dx among pts with CS included abdominal cramping (53%), change in bowel habits (48%), and flushing (40%). Among those tested, 85% of CS pts had a positive 5-HIAA test at dx. Among pNET HS pts, the most common symptoms present at dx were abdominal cramping (39%) and change in bowel habits (46%). The most common symptoms present at dx among NOS HS pts were abdominal cramping (35%), change in bowel habits (47%) and flushing (38%). Conclusions: Prevalence of CS in this NCCN database (28%) was slightly higher than the 10% previously reported in the literature. In contrast, the prevalence of HS among pNET pts (22%) was lower than previously reported. Approximately one quarter of cNET pts without metastatic disease had CS, warranting further analysis as CS most often occurs in the presence of liver metastasis.

Incidence and natural history of bone metastases in neuroendocrine tumors

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Background: Bone metastases (BM) occur in carcinoids and other neuroendocrine tumors (NET), however, a comparative analysis of the incidence and natural history of BM across different NET subtypes has not been performed. We retrospectively characterized BM incidence, complications, and management across five subtypes: carcinoid/unknown primary (CARC), pancreatic NET (PNET), pheochromocytomas/paragangliomas (PHEO), adrenal cortical carcinoma (ACC) and high grade NET (HGNET) using data collected in the context of the NCCN NET Outcomes Database.

Methods: 296 NET patients (pts) presenting at UCSF from 2004 to 2007 were retrospectively identified. Eligibility criteria included presentation on or after Jan 1, 2004, continued management at UCSF within one year of consultation, age over 18, and pathological confirmation of an eligible NET subtype. BM identified radiographically and/or pathologically, and classified as symptomatic (pain, pathologic fracture, or spinal cord compression) or asymptomatic. BM treatments (tx) included radiation, surgery, bisphosphonate and/or denosumab.

Results: BM identified in 36/296 (12%): 29% pts with HGNET (5/17), 10% pts with CARC (12/121), 7.4% pts with PNET (6/81), 17% pt with PHEO (11/66), 18% pt with ACC (2/11). BM occurred in 21 men/15 women; median age 54. 30/36 (83%) had stage IV disease at diagnosis (dx); 69% had BM at dx. 69% pts were eventually symptomatic: bone pain (24/25, 96%), cord compression (3/25, 12%) and/or pathologic fracture (6/25, 24%); 8/25 (32%) had more than one symptom from BM. Median survival from BM: 28 mo (21.1 mo if symptomatic; 34.3 mo if asymptomatic). Overall, 81% (29/36) pt received tx for BM: 53% XRT (19/36), 25% surgery (9/36), 39% bisphosphonate (14/36), and/or 11% denosumab (4/36).

Conclusions: 12% of pts with NET in this database developed BM. Most pts with BM experienced pain. Serious complications such as cord compression and/or pathological fracture occurred in 36% (9/25) suggesting that bisphosphonate and/or denosumab tx may be of value in these patients. Accrual to the database is ongoing.

Baseline demographics of patients with neuroendocrine tumors presenting to seven National Comprehensive Cancer Network (NCCN) institutions: Development of a multi-institutional outcomes database

187

Background: Diagnostic strategies, management paradigms, and clinical outcomes of patients with neuroendocrine tumors (NETs) are diverse and poorly characterized. The National Comprehensive Cancer Network (NCCN) created a comprehensive longitudinal database to characterize patients treated for NETs at seven participating institutions. Preliminary results from the database are reported.

Methods: Member IRB approval was obtained to identify patients at least 18 years of age presenting to each of seven NCCN institutions between 2004 and 2007 with pathologically confirmed newly or previously diagnosed NETs via hospital medical records. Eligible patients included those with carcinoid (any site); goblet cell or adenocarcinoid; composite carcinoid; poorly differentiated gastrointestinal small cell tumor; pancreatic NET; NET of unknown primary site; pheochromocytoma; and paraganglioma. Baseline demographic characteristics were summarized for this analysis.

Results: Among the 2,542 patients identified with a NET diagnosis, patients most frequently presented with carcinoid tumor (51%), pancreatic NET (27%) and NET of unknown primary site (8%). Median age at diagnosis was 55 (SD=13) and median age at first presentation to the NCCN was 57 (SD=13). Fifty-three percent of patients were female. Most (88%) were Caucasian and 8% were African American. Forty percent of patients were diagnosed with NET before presenting to the NCCN. Among these, the median time between initial NET diagnosis and presentation to the NCCN was 2 years (SD=6). Significant differences in provider specialty referral patterns were observed between institutions.

Conclusions: The baseline demographic characteristics of NET patients in this new database are consistent with those previously reported in population-based registries. The NCCN database will provide a valuable resource for further exploration of patterns of diagnosis, treatment, consistency with established guidelines, as well as clinical outcomes in patients with this condition. Existing differences among institutions in referral patterns will be further explored.

Correlates of baseline performance do not predict results of an intervention to improve preventive care

BACKGROUND

Cross-sectional analyses of baseline performance often inform the development of interventions to improve care. An implicit assumption in these studies is that factors associated with better performance at baseline may also be useful in predicting change in performance over time.

METHODS

We analyzed data collected from 1997-2002 at 77 practices in Northeast Ohio participating in an intervention to increase evidence-based preventive services delivery (PSD). Spearman's correlation coefficients and multivariable models assessed associations between practice-level characteristics (e.g., organizational structure, objectives, climate, and culture) and baseline PSD, and with final PSD controlling for baseline values. Patterns of associations for both outcomes were inspected for overlap.

RESULTS

The mean PSD rate was 36.8% (+/-8.8%) at baseline. This measure increased by an average of 4.9% (+/-6.3%) by the end of the intervention. Of eight practice characteristics correlated with either baseline performance or change from baseline in PSD, only two were common to both: characteristics associated with baseline PSD did not predict final PSD in multivariable models.

CONCLUSIONS

Correlates of baseline performance differ from those related to change in performance. Practice assessments that focus on factors associated with change may be more useful in developing and implementing interventions to improve care.