The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging.

The American Joint Committee on Cancer (AJCC) staging manual has become the benchmark for classifying patients with cancer, defining prognosis, and determining the best treatment approaches. Many view the primary role of the tumor, lymph node, metastasis (TNM) system as that of a standardized classification system for evaluating cancer at a population level in terms of the extent of disease, both at initial presentation and after surgical treatment, and the overall impact of improvements in cancer treatment. The rapid evolution of knowledge in cancer biology and the discovery and validation of biologic factors that predict cancer outcome and response to treatment with better accuracy have led some cancer experts to question the utility of a TNM-based approach in clinical care at an individualized patient level. In the Eighth Edition of the AJCC Cancer Staging Manual, the goal of including relevant, nonanatomic (including molecular) factors has been foremost, although changes are made only when there is strong evidence for inclusion. The editorial board viewed this iteration as a proactive effort to continue to build the important bridge from a "population-based" to a more "personalized" approach to patient classification, one that forms the conceptual framework and foundation of cancer staging in the era of precision molecular oncology. The AJCC promulgates best staging practices through each new edition in an effort to provide cancer care providers with a powerful, knowledge-based resource for the battle against cancer. In this commentary, the authors highlight the overall organizational and structural changes as well as "what's new" in the Eighth Edition. It is hoped that this information will provide the reader with a better understanding of the rationale behind the aggregate proposed changes and the exciting developments in the upcoming edition. CA Cancer J Clin 2017;67:93-99. © 2017 American Cancer Society.

The Pivotal Leadership of Doctors R. Lee Clark and Murray M. Copeland in Transforming the Commission on Cancer (1955-1965).

In September 1959, Dr. Clark was appointed as Chair and Dr. Murray M Copeland as Vice Chair of the Committee on Cancer. With their typical leadership style to improve the functions and value of organizations, they reorganized and revitalized the Committee on Cancer during the next 6 years. Thus, Drs. Clark and Copeland and the Committee members developed more uniform standards of cancer registries, implemented the American Joint Committee on Cancer Staging and End Results Reporting (with Dr. Copeland as Chair), published a revised Manual for Cancer Programs (which defined minimum standards requisite for approval of a cancer service), established a new regionalization program (with liaison surgeons from each state), and planned all the cancer educational programs for the College's annual Clinical Congress and Sectional Meetings. Importantly, Clark and Copeland led a 10-year strategic plan (called the "Program of the Sixties") to expand and revitalize the scale and scope of the Committee's activities and to reorganize the Committee structure by including liaison members from other physician, oncologic, and hospital organizations. As Dr. Clark completed his 5-year tenure as Committee Chair in October 1964, he formally recommended a reorganization of the Committee on Cancer to assume an even greater role in the cancer community as the Commission on Cancer. As the new Committee Chair, Dr. Copeland shepherded this recommendation to the ACS Board of Regents, which was approved and implemented in July 1965. The Regents emphasized that the functions and activities of the Committee on Cancer had become so complex and far reaching (under Clark's and Copeland's leadership) that its many subcommittees had already assumed duties of committee stature. Dr. Copeland thus became the first Chair of the Commission on Cancer until October 1965, when Dr. John Cline became Chair. For his contributions to the cancer field and to the College of Surgeons, Dr. Clark received their Distinguished Service Award in October 1969 "for his life-long devotion to the treatment of patients and to research in cancer, for notable service to this College, particularly as Chairman of the Cancer Commission from 1960 to 1964."

Treatment delays from transfers of care and their impact on breast cancer quality measures.

PURPOSE: Despite delays between diagnosis and surgery adversely affecting survival, patients frequently transfer their breast cancer care between institutions. This study was performed to assess the prevalence and effect of such transfers of care (TsOC) on the time to surgery, and its impact on current time-dependent breast cancer quality metrics at Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC)-accredited institutions. METHODS: Patients having non-metastatic invasive breast cancer diagnosed between 2006 and 2015 at CoC and NAPBC centers ("reporting facilities") in the National Cancer Database were reviewed. TsOC refer to transferring into or out of a reporting facility between diagnosis and surgery. RESULTS: Among 622,793 patients, 36.6% of patients transferred care. TsOC add 7.3, 7.8, 8.7, and 9.8 days in time to surgery, chemotherapy, radiotherapy, and endocrine therapy, respectively (p's < 0.0001). On multivariable analysis, the odds of surgery occurring > 90 days from diagnosis were greatest for patients undergoing unilateral or bilateral mastectomy, Black or Hispanic patients, and those having TsOC (ORs > 1.73, p's < 0.0001). TsOC increase the odds of non-compliance, per patient, for chemotherapy, radiotherapy and endocrine therapy time-dependent measures by 65.4%, 25.6%, and 56.5%, respectively (p < 0.0001). CONCLUSIONS: TsOC for newly diagnosed breast cancers to or from an accredited facility result in delays in time to surgery which can affect compliance with time-dependent quality measures. Facilities frequently receiving transferred patients may be most adversely affected. Although non-compliance with these quality measures is low, institutions and accrediting bodies should be aware of these associations in order to comply with time-dependent standards.

Incident Cases Captured in the National Cancer Database Compared with Those in U.S. Population Based Central Cancer Registries in 2012-2014.

BACKGROUND: The National Cancer Database (NCDB) is a hospital-based cancer registry that includes diagnostic, staging, treatment, and outcomes data for newly diagnosed cancer patients in the United States. The NCDB data include 31 million records for patients diagnosed between 1985-2015. A Participant User File based on a subset of these data has been available to researchers at facilities accredited by the Commission on Cancer since 2010. This study aimed to compare the number of incident cancer cases in the NCDB with a national population cancer registry. METHODS: Incident cancer cases in the NCDB in 2012-2014 were compared with the number of cancer cases in the United States Cancer Statistics data for the 2012-2014 diagnosis years. Comparisons were made by primary site and other factors. RESULTS: In 2012-2014, the NCDB captured 72% of the cancer cases in the United States, which was slightly higher than the 67% and 69% reported respectively in two prior assessments. Among the top 10 major cancer sites, the highest coverage (80%) was found for breast cancer, and the lowest was found for melanoma of the skin (52%) and prostate (58%). Colon, bladder, and kidney and renal pelvis cancers had relatively high coverage of 71%, 70% and 78%, respectively, whereas lung and bronchus had slightly lower coverage (65%). CONCLUSIONS: The NCDB coverage of U.S. cancer cases has remained relatively high (72%), but differences remain by cancer site and other factors that should be taken into account by users of the NCDB data.

Impact of Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers.

PURPOSE: This study was designed to determine whether accreditation by the National Accreditation Program for Breast Centers (NAPBC) is associated with improved performance on six breast quality measures pertaining to adjuvant treatment, needle/core biopsy, and breast conservation therapy rates at Commission on Cancer (CoC) centers. METHODS: National Cancer Database 2015 data were retrospectively reviewed to compare patients treated at CoC centers with and without NAPBC accreditation for compliance on six breast cancer quality measures. Mixed effects modeling determined performance on the quality measures adjusting for patient, tumor, and facility factors. RESULTS: Of 1308 CoC facilities, 484 (37%) were NAPBC-accredited and 111,547 patients (48%) were treated at NAPBC centers. More than 80% of patients treated at both NAPBC and non-NAPBC centers received care in compliance with breast quality measures. NAPBC centers achieved significantly higher performance on four of the five quality measures than non-NAPBC centers at the patient level and on five of six measures at the facility level. For two measures, needle/core biopsy before surgical treatment of breast cancer and breast conservation therapy rate of 50%, NAPBC centers were twice as likely as non-NAPBC centers to perform at the level expected by the CoC (respectively odds ratio [OR] 1.96, 95% confidence interval [CI] 1.85-2.08, p < 0.0001; and OR 2.05, 95% CI 1.94-2.15, p < 0.0001). CONCLUSIONS: While NAPBC accreditation at CoC centers is associated with higher performance on breast quality measures, the majority of patients at all centers receive guideline-concordant care. Future studies will determine whether higher performance translates into improved oncologic and patient-reported outcomes.

Trends in Regionalization of Care and Mortality For Patients Treated With Radical Cystectomy.

BACKGROUND: Regionalization to higher volume centers has been proposed as a mechanism to improve short-term outcomes following complex surgery. OBJECTIVE: The objective of this study was to assess trends in regionalization and mortality for patients undergoing radical cystectomy (RC). RESEARCH DESIGN: An observational study of patients receiving RC in the United States from 2004 to 2013. SUBJECTS: Data for patients receiving RC were extracted from the National Cancer Database. MEASURES: The primary exposure was hospital volume; low-volume hospitals (LVH) included those with <5 RC/year and high-volume hospitals (HVH) were those with ≥30 RC/year. Trends in the volume were assessed, as were 30- and 90-day mortality. Cochrane-Armitage tests were performed for volume, and propensity score-weighted proportional hazard regression was used to assess mortality. RESULTS: A total of 47,028 RC were performed in 1162 hospitals from 2004 to 2013. The proportion of RC at LVH declined from 29% to 17% (P<0.01), whereas that of HVH increased from 16% to 33% (P<0.01). Unadjusted 30- (P=0.02) and 90-day (P<0.001) mortality decreased, and the absolute decrease was greatest at LVH (4.8% vs. 2.6%, P=0.03), whereas rates for HVH remained stable (1.9% vs. 1.4%, P=0.34). Following risk-adjustment, relative to treatment at HVH, treatment at LVH was associated with increased 30-day (hazard ratio: 1.66, 95% CI: 1.53-1.80) and 90-day mortality (hazard ratio: 1.37, 95% confidence interval: 1.30-1.44). CONCLUSIONS: Regionalization of RC to HVH was observed from 2004 to 2013. Treatment at LVH was associated with 66% and 33% relative increases in hazard of death at 30 and 90 days, respectively. These findings support the selective referral of complex cases to higher volume centers.

Lack of Cancer Recurrence Data in Large Databases: A National Survey of Hospital Cancer Registries.

BACKGROUND: Cancer recurrence information is not routinely collected by the US cancer registries. Prior research suggests hospital characteristics, staff qualifications, and chart access may be contributing factors but this has not been explored nationally. This study aimed to understand issues underlying poor collection of recurrence information and to identify targets for improvement. METHODS: A survey was sent to Commission on Cancer hospitals to investigate reasons for variations in recurrence data collection, examine resources allocated, and assess coding variability. Descriptive and multivariate analyses were performed. RESULTS: Eight hundred and forty-five of 1417 surveys to Commission on Cancer hospitals were analyzed. Sixty-nine percent reported annually examining charts for recurrence ("investigating" hospitals). They more likely had experienced registrars (91% versus 84%, P < 0.05), integrated electronic medical records (75% versus 68%, P < 0.05) and chart access to in-network hospitals (80% versus 73%, P < 0.05). Thirty-seven percent reported ability to follow-up using medical records on <50% of patients. Reasons for noncollection included inability to accurately collect (37%), limited resources (44%), and low priority (18%). Odds of being an investigating hospital increased with the percentage of patients who could be followed up with medical records (90%-100% OR = 6.72). There were minimal differences among hospitals in registry caseload and resources. 79.5% reported that without prior recurrence documentation, they would code the patient as not having a recurrence, 8.8% would change all recurrence variables to "unknown," and 7.2% would leave them blank. CONCLUSIONS: Those tasked with collecting recurrence information report significant barriers concerning data access, data quality, adequate resources, and coding variability. A unified effort is needed to improve collection.

Assessment of hospital-level adjusted breast cancer sentinel lymph node positivity rates.

BACKGROUND/OBJECTIVES: Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival. METHODS: Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004-2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles. RESULTS: Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low- and high-tercile hospitals had statistically worse survival. CONCLUSIONS: There is a wide variation in hospital SLNB positivity rates. Hospitals with lower- or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment.

More Frequent Surveillance Following Lung Cancer Resection Is Not Associated With Improved Survival: A Nationally Representative Cohort Study.

OBJECTIVE: To evaluate whether an association exists between the intensity of surveillance following surgical resection for non-small cell lung cancer (NSCLC) and survival. BACKGROUND: Surveillance guidelines following surgical resection of NSCLC vary widely and are based on expert opinion and limited evidence. METHODS: A Special Study of the National Cancer Database randomly selected stage I to III NSCLC patients for data reabstraction. For patients diagnosed between 2006 and 2007 and followed for 5 years through 2012, registrars documented all postsurgical imaging with indication (routine surveillance, new symptoms), recurrence, new primary cancers, and survival, with 5-year follow-up. Patients were placed into surveillance groups according to existing guidelines (3-month, 6-month, annual). Overall survival and survival after recurrence were analyzed using Cox Proportional Hazards Models. RESULTS: A total of 4463 patients were surveilled with computed tomography scans; these patients were grouped based on time from surgery to first surveillance. Groups were similar with respect to age, sex, comorbidities, surgical procedure, and histology. Higher-stage patients received more surveillance. More frequent surveillance was not associated with longer risk-adjusted overall survival [hazard ratio for 6-month: 1.16 (0.99, 1.36) and annual: 1.06 (0.86-1.31) vs 3-month; P value 0.14]. More frequent imaging was also not associated with postrecurrence survival [hazard ratio: 1.02/month since imaging (0.99-1.04); P value 0.43]. CONCLUSIONS: These nationally representative data provide evidence that more frequent postsurgical surveillance is not associated with improved survival. As the number of lung cancer survivors increases over the next decade, surveillance is an increasingly important major health care concern and expenditure.

Use of Breast Imaging After Treatment for Locoregional Breast Cancer (AFT-01).

BACKGROUND: Annual mammography is recommended after breast cancer treatment. However, studies suggest its under-utilization for Medicare patients. Utilization in the broader population is unknown, as is the role of breast magnetic resonance imaging (MRI). Understanding factors associated with imaging use is critical to improvement of adherence to recommendations. METHODS: A random sample of 9835 eligible patients receiving surgery for stages 2 and 3 breast cancer from 2006 to 2007 was selected from the National Cancer Database for primary data collection. Imaging and recurrence data were abstracted from patients 90 days after surgery to 5 years after diagnosis. Factors associated with lack of imaging were assessed using multivariable repeated measures logistic regression with generalized estimating equations. Patients were censored for death, bilateral mastectomy, new cancer, and recurrence. RESULTS: Of 9835 patients, 9622, 8702, 8021, and 7457 patients were eligible for imaging at surveillance years 1 through 4 respectively. Annual receipt of breast imaging declined from year 1 (69.5%) to year 4 (61.0%), and breast MRI rates decreased from 12.5 to 5.8%. Lack of imaging was associated with age 80 years or older and age younger than 50 years, black race, public or no insurance versus private insurance, greater comorbidity, larger node-positive hormone receptor-negative tumor, excision alone or mastectomy, and no chemotherapy (p < 0.005). Receipt of breast MRI was associated with age younger than 50 years, white race, higher education, private insurance, mastectomy, chemotherapy, care at a teaching/research facility, and MRI 12 months before diagnosis (p < 0.05). CONCLUSION: Under-utilization of mammography after breast cancer treatment is associated with sociodemographic and clinical factors, not institutional characteristics. Effective interventions are needed to increase surveillance mammography for at-risk populations. ClinicalTrials.gov Identifier: NCT02171078.

Association Between Intensity of Posttreatment Surveillance Testing and Detection of Recurrence in Patients With Colorectal Cancer.

Importance: Surveillance testing is performed after primary treatment for colorectal cancer (CRC), but it is unclear if the intensity of testing decreases time to detection of recurrence or affects patient survival. Objective: To determine if intensity of posttreatment surveillance is associated with time to detection of CRC recurrence, rate of recurrence, resection for recurrence, or overall survival. Design, Setting, and Participants: A retrospective cohort study of patient data abstracted from the medical record as part of a Commission on Cancer Special Study merged with records from the National Cancer Database. A random sample of patients (n=8529) diagnosed with stage I, II, or III CRC treated at a Commission on Cancer-accredited facilities (2006-2007) with follow-up through December 31, 2014. Exposures: Intensity of imaging and carcinoembryonic antigen (CEA) surveillance testing derived empirically at the facility level using the observed to expected ratio for surveillance testing during a 3-year observation period. Main Outcomes and Measures: The primary outcome was time to detection of CRC recurrence; secondary outcomes included rates of resection for recurrent disease and overall survival. Results: A total of 8529 patients (49% men; median age, 67 years) at 1175 facilities underwent surveillance imaging and CEA testing within 3 years after their initial CRC treatment. The cohort was distributed by stage as follows: stage I, 25.0%; stage II, 35.2%; and stage III, 39.8%. Patients treated at high-intensity facilities-4188 patients (49.1%) for imaging and 4136 (48.5%) for CEA testing-underwent a mean of 2.9 (95% CI, 2.8-2.9) imaging scans and a mean of 4.3 (95% CI, 4.2-4.4) CEA tests. Patients treated at low-intensity facilities-4341 patients (50.8%) for imaging and 4393 (51.5%) for CEA testing-underwent a mean of 1.6 (95% CI, 1.6-1.7) imaging scans and a mean of 1.6 (95% CI, 1.6-1.7) CEA tests. Imaging and CEA surveillance intensity were not associated with a significant difference in time to detection of cancer recurrence. The median time to detection of recurrence was 15.1 months (IQR, 8.2-26.3) for patients treated at facilities with high-intensity imaging surveillance and 16.0 months (IQR, 7.9-27.2) with low-intensity imaging surveillance (difference, -0.95 months; 95% CI, -2.59 to 0.68; HR, 0.99; 95% CI, 0.90-1.09) and was 15.9 months (IQR, 8.5-27.5) for patients treated at facilities with high-intensity CEA testing and 15.3 months (IQR, 7.9-25.7) with low-intensity CEA testing (difference, 0.59 months; 95% CI, -1.33 to 2.51; HR, 1.00; 95% CI, 0.90-1.11). No significant difference existed in rates of resection for cancer recurrence (HR for imaging, 1.22; 95% CI, 0.99-1.51 and HR for CEA testing, 1.12; 95% CI, 0.91-1.39) or overall survival (HR for imaging, 1.01; 95% CI, 0.94-1.08 and HR for CEA testing, 0.96; 95% CI, 0.89-1.03) among patients treated at facilities with high- vs low-intensity imaging or CEA testing surveillance. Conclusions and Relevance: Among patients treated for stage I, II, or III CRC, there was no significant association between surveillance intensity and detection of recurrence. Trial Registration: clinicaltrials.gov Identifier: NCT02217865.

Assessing the relative influence of hospital and surgeon volume on short-term mortality after radical cystectomy.

OBJECTIVES: To assess the relationship between surgeon (SV) and hospital volume (HV) on mortality after radical cystectomy (RC). PATIENTS AND METHODS: We queried the National Cancer Database (NCDB) for adult patients undergoing RC between 2010 and 2013. We calculated average volume for each surgeon and hospital. Using propensity-scored weights for combined volume groups with a proportional hazards regression model, we compared the associations between HV and SV with 90-day survival after RC. RESULTS: A total of 19 346 RCs were performed at 927 hospitals by 2 927 surgeons in the period 2010-2013. The median (interquartile range) HV and SV were 12.3 (5.0-35.5) and 4.3 (1.3-12.3) cases, respectively. For HV, 90-day unadjusted mortality was 8.5% in centres with <5 cases/year (95% confidence interval [CI] 7.7-9.3) and 5.6% in those with >30 cases/year (95% CI 5.0-6.2). For SV, 90-day mortality was 8.1% for surgeons with <5 cases/year (95% CI 7.6-8.6) and 4.0% for those with >30 cases/year (95% CI 2.8-5.2; all P < 0.05). The 30-day mortality rate was lowest for the combined HV-SV groups with HV >30, ranging from 1.6% to 2.1%. CONCLUSIONS: In hospitals reporting to the NCDB, volume was associated with improved mortality after RC. These associations appear to be driven by hospital- rather than surgeon-level effects. An elevated SV had a beneficial effect on mortality at the highest-volume hospitals. These findings inform efforts to regionalize complex surgical care and improve quality at community and safety net hospitals.

Adjusted Hospital Sentinel Lymph Node Positivity Rates in Melanoma: A Novel Potential Measure of Quality.

OBJECTIVE: Our objectives were to examine whether hospital characteristics are associated with lower- and higher-than-expected sentinel lymph node biopsy (SLNB) positivity rates and whether hospitals with lower- or higher-than-expected SLNB positivity rates have worse patient outcomes. BACKGROUND: Surgeon and pathologist SLNB technical errors may lead to incorrect melanoma staging. A hospital's SLNB positivity rate may reflect its SLNB proficiency for melanoma, but this has never been investigated. METHODS: Stage IA-III melanoma patients undergoing SLNB were identified from the National Cancer Data Base (2004-2010). Hospital-level SLNB positivity rates were adjusted for patient- and tumor factors. Hospitals were divided into terciles of adjusted SLNB positivity rates. Hospital characteristics (using multinomial logistic regression) and survival (using Cox modeling) were examined across terciles. RESULTS: Of 33,639 SLNB patients (from 646 hospitals), 2916 (8.7%) had at least 1 positive lymph node. Hospitals with lower- (low tercile) and higher-than-expected (high tercile) SLNB positivity rates were more likely to be low-volume hospitals (low tercile: relative risk ratio (RRR) = 2.57, P = 0.002; high tercile: RRR = 2.3, P = 0.004) compared to hospitals with expected rates (middle tercile). Stage I patients treated at lower-than-expected SLNB positivity rate hospitals had worse 5-year survival than those treated at expected SLNB positivity rate hospitals (90.0% vs 91.9%, P = 0.014; hazard ratio = 1.28, 95% CI: 1.05-1.57); survival differences were not observed by SLNB positivity rates for stage II/III. CONCLUSIONS: Adjusted hospital SLNB positivity rates varied widely. Surgery at hospitals with lower-than-expected SLNB positivity rates was associated with decreased survival. Hospital SLNB positivity rates may be a novel measure to confidentially report to hospitals for internal quality assessment.

Doubling of 30-Day Mortality by 90 Days After Esophagectomy: A Critical Measure of Outcomes for Quality Improvement.

OBJECTIVES: Our objectives were to (1) compare 30- and 90-day mortality rates after esophagectomy, (2) compare drivers of 30- and 90-day mortality, and (3) examine whether 90-day mortality affects hospital rankings. BACKGROUND: Operative mortality has traditionally been assessed at 30 days. Ninety-day mortality has been suggested as a more appropriate indicator of quality, particularly after complex cancer surgery. METHODS: Esophagectomies for nonmetastatic esophageal cancer patients diagnosed between 2007 and 2011 were identified in the National Cancer Data Base. Mortality rates were examined by patient demographics, tumor characteristics, and hospital procedural volume. Risk-adjusted hierarchical logistic regression models examined hospital performance for mortality. RESULTS: A total of 15,796 esophagectomy patients at 977 hospitals were available for analysis. Ninety-day overall mortality was more than double the 30-day mortality (8.9% vs 4.2%; P < 0.0001). In multivariate analysis, while both 30- and 90-day mortality were associated with patient factors such as age, comorbidity, and hospital volume, only 90-day mortality was influenced by tumor- and management-related variables such as stage, tumor location, and receipt of neoadjuvant therapy. Hospital performance was examined as top 10%, middle 10% to 90%, and lowest 10% as ranked using risk-adjusted odds of mortality. There was moderate correlation between ranking based on 30- and 90-day mortality [weighted κ = 0.45 (95% confidence interval, 0.39-0.52)]. Compared with 30-day mortality rankings, nearly 20% of hospitals changed their ranking category when 90-day mortality rankings were used. CONCLUSIONS: Examination of 90-day mortality after esophagectomy reflects cancer patient management decisions and may provide actionable targets for quality improvement.

National Evaluation of Hospital Performance on the New Commission on Cancer Melanoma Quality Measures.

INTRODUCTION: To increase adherence to cancer management guidelines, the Commission on Cancer (CoC) developed and approved five melanoma quality measures in 2015. Our objectives were to evaluate formally the national performance of these melanoma measures and to examine patient, tumor, and hospital characteristics associated with adherence. METHODS: From the National Cancer Data Base (2012), patients with invasive, nonmetastatic melanoma were identified. Inclusion and exclusion criteria were based on the CoC definition for each measure. Patient-level and hospital-level adherence rates were calculated for the five measures. A hospital was deemed "compliant" if it met the CoC standard, which requires 80 % of patients to receive the measure-specific recommended care. Patient, tumor, and hospital characteristics potentially associated with higher likelihood of adherence at the patient-level were estimated using hierarchical random-effects logistic regression models. RESULTS: A total of 31,598 patients from 1343 hospitals were examined. Patient-level adherence rates varied from 31.6 % (Measure 5: ≥10 axillary lymph nodes removed/examined) to 72.6 % (Measure 1: sentinel lymph node biopsy (SLNB) appropriateness measure). Hospital-level adherence rates, ranged from 19.3 % of hospitals (N = 538 hospitals for Measure 5) to 44.8 % of hospitals (N = 1090 hospitals for Measure 3: completion lymph node dissection after positive SLNB). No hospital-level factors (e.g., teaching status) were consistently associated with better adherence. CONCLUSIONS: National adherence rates to the five new CoC melanoma quality metrics are low, and most hospitals would not meet the CoC requirement of 80 % adherence. Feedback for performance of these measures to hospitals, decisions support tools, and educational initiatives are needed to improve guideline adherence.

Utility of Clinical Breast Examinations in Detecting Local-Regional Breast Events After Breast-Conservation in Women with a Personal History of High-Risk Breast Cancer.

BACKGROUND: Although breast cancer follow-up guidelines emphasize the importance of clinical examinations, prior studies suggest a small fraction of local-regional events occurring after breast conservation are detected by examination alone. Our objective was to examine how local-regional events are detected in a contemporary, national cohort of high-risk breast cancer survivors. METHODS: A stage-stratified sample of stage II/III breast cancer patients diagnosed in 2006-2007 (n = 11,099) were identified from 1217 facilities within the National Cancer Data Base. Additional data on local-regional and distant breast events, method of event detection, imaging received, and mortality were collected. We further limited the cohort to patients with breast conservation (n = 4854). Summary statistics describe local-regional event rates and detection method. RESULTS: Local-regional events were detected in 5.5 % (n = 265) of patients. Eighty-three percent were ipsilateral or contralateral in-breast events, and 17 % occurred within ipsilateral lymph nodes. Forty-eight percent of local-regional events were detected on asymptomatic breast imaging, 29 % by patients, and 10 % on clinical examination. Overall, 0.5 % of the 4854 patients had a local-regional event detected on examination. Examinations detected a higher proportion of lymph node events (8/45) compared with in-breast events (18/220). No factors were associated with method of event detection. DISCUSSION: Clinical examinations, as an adjunct to screening mammography, have a modest effect on local-regional event detection. This contradicts current belief that examinations are a critical adjunct to mammographic screening. These findings can help to streamline follow-up care, potentially improving follow-up efficiency and quality.

National Evaluation of the New Commission on Cancer Quality Measure for Postmastectomy Radiation Treatment for Breast Cancer.

BACKGROUND: Current guidelines recommend postmastectomy radiotherapy (PMRT) for patients with ≥4 positive lymph nodes and suggest strong consideration of PMRT in those with 1-3 positive nodes. These recommendations were incorporated into a Commission on Cancer quality measure in 2014. However, national adherence with these recommendations is unknown. Our objectives were to describe PMRT use in the United States in patients with stage I to III invasive breast cancer and to examine possible factors associated with the omission of PMRT. METHODS: From the National Cancer Data Base, 753,536 mastectomies at 1123 hospitals were identified from 1998 to 2011. PMRT use over time was examined using random effects logistic regression analyses, adjusting for patient, tumor, and hospital characteristics. Analyses were stratified by nodal status (≥4 nodes positive, 1-3 nodes positive, node negative). RESULTS: The proportion of patients receiving PMRT increased from 1998 to 2011 (>4 positive nodes: 56.2 to 66.6 %; 1-3 positive nodes: 28.0 to 39.1 %; node-negative: 8.3 to 10.0 %, p < 0.001 for all). In adjusted analyses, patients with ≥4 positive nodes were more likely to have PMRT omitted if they had smaller tumors. Patients with 1-3 positive nodes were more likely to have PMRT omitted if they had lower grade or smaller tumors. Irrespective of patients' nodal status, PMRT utilization rates decreased as age increased. CONCLUSIONS: Though PMRT rates increased over time in patients with ≥4 and 1-3 positive nodes, PMRT in patients with ≥4 positive nodes remains underutilized. Feedback to hospitals using the new Commission on Cancer PMRT measure may help to improve adherence rates.

Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States.

PURPOSE: In October 2011 the USPSTF (U.S. Preventive Services Task Force) issued a draft guideline discouraging prostate specific antigen based screening for prostate cancer (grade D recommendation). We evaluated the effect of the USPSTF guideline on the number and distribution of new prostate cancer diagnoses in the United States. MATERIALS AND METHODS: We identified incident cancers diagnosed between January 2010 and December 2012 in NCDB (National Cancer Database). We performed an interrupted time series to evaluate the trend of new prostate cancers diagnosed each month before and after the draft guideline with colon cancer as a comparator. RESULTS: Incident monthly prostate cancer diagnoses decreased by -1,363 cases (12.2%, p<0.01) in the month after the USPSTF draft guideline and continued to decrease by 164 cases per month relative to baseline (-1.8%, p<0.01). In contrast monthly colon cancer diagnoses remained stable. Diagnoses of low, intermediate and high risk prostate cancers decreased significantly but new diagnoses of nonlocalized disease did not change. Subgroups of age, comorbidity, race, income and insurance showed comparable decreases in incident prostate cancer following the draft guideline. CONCLUSIONS: There was a 28% decrease in incident diagnoses of prostate cancer in the year after the USPSTF draft recommendation against prostate specific antigen screening. This study helps quantify the potential benefits (reduced harms of over diagnosis and overtreatment of low risk disease and disease found in elderly men) and potential harms (missed opportunities to diagnose important cancers in men who may benefit from treatment) of this guideline.

Use of Postmastectomy Radiotherapy and Survival Rates for Breast Cancer Patients with T1-T2 and One to Three Positive Lymph Nodes.

BACKGROUND: The effectiveness of postmastectomy radiotherapy (PMRT) in terms of survival for breast cancer patients with American Joint Committee on Cancer (AJCC) pT1-2 and one to three tumor positive lymph nodes is controversial, especially in this era of more effective systemic treatment. METHODS: Using data from the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) program between 1998 and 2008, this study respectively identified 93,793 and 36,299 women with AJCC pT1-2pN1 breast cancer who underwent mastectomy. The association of PMRT use with overall and cause-specific survival was examined using multivariable Cox models in subgroups defined by tumor stage. RESULTS: In the NCDB cohort, 21.5 % of the patients (n = 20,236) received PMRT, and a very similar percentage (21.9 %, n = 7939) received PMRT in the SEER cohort. In the NCDB cohort, PMRT was associated with a 14 % relative risk reduction in all-cause mortality among the patients with two positive lymph nodes and tumors 2-5 cm in size or three positive nodes [hazard ratio (HR), 0.86; 95 % confidence interval (CI), 0.81-0.91; p < 0.0001], but PMRT had no beneficial effect for the patients with one positive node or two positive nodes and tumors 2 cm in size or smaller. Analysis of the SEER cohort confirmed this heterogeneous effect, showing PMRT to be associated with a 14 % relative risk reduction in breast cancer cause-specific mortality among the patients with two positive nodes and tumors 2-5 cm in size or three positive nodes (HR 0.86; 95 % CI 0.77-0.96; p = 0.007) but not in the other subgroup. CONCLUSION: The effectiveness of radiotherapy depends on the combination comprising the number of positive lymph nodes and tumor size, which may enable more precise patient selection for PMRT.

Parathyroid Carcinoma: An Update on Treatment Outcomes and Prognostic Factors from the National Cancer Data Base (NCDB).

BACKGROUND: Parathyroid carcinoma is a rare disease. Conflicting results on prognostic factors and extent of surgical resection for patients with parathyroid carcinoma have been made based on small sample sizes. A large, robust dataset is needed to help address some of the controversies. METHODS: A retrospective review of patients with parathyroid carcinoma in the National Cancer Data Base from 1985 to 2006 was performed. Characteristics of the cohort and type of treatment were evaluated. Prognostic factors were assessed with Cox proportional hazards regression models and 5- and 10-year OS rates were determined. RESULTS: There were 733 evaluable patients with a mean age of 56.1 ± 15.3 years (median 57, range 15-89) and mean tumor size of 29.6 ± 18.4 mm (median 25.0 mm, range 10.0-150.0). Tumor size, age at diagnosis, male sex, positive nodal status, and complete tumor resection had hazard ratios for death of 1.02 (1.01-1.02, p < 0.0001), 1.06 (1.05-1.07, p < 0.0001), 1.67 (1.24-2.25, p = 0.0008), 1.25 (0.57-2.76, p = 0.6), and 0.42 (0.22-0.81, p = 0.01), respectively, on multivariable analysis. Patients who had removal of the parathyroid tumor with concomitant resection of adjacent organs had HR for death of 0.70 (0.35-1.41, p = 0.3). The 5- and 10-year OS rates were 82.3 and 66 % respectively. CONCLUSIONS: Patient age, tumor size, and sex have modest effects on survival in patients with parathyroid carcinoma. A staging system with prognostic value for parathyroid carcinoma should include at least these pertinent prognostic factors.