Radiotherapy Deserts: The Impact of Race, Poverty, and the Rural-Urban Continuum on Density of Providers and the Use of Radiation Therapy in the US.

PURPOSE: Prior efforts to characterize disparities in radiation therapy access and receipt have not comprehensively investigated interplay between race, socioeconomic status, and geography relative to oncologic outcomes. This study sought to define these complex relationships at the US county level for prostate cancer (PC) and invasive breast (BC) cancer to build a tool that facilitates identification of "radiotherapy deserts"-regions with mismatch between radiation therapy resources and oncologic need. METHODS AND MATERIALS: An ecologic study model was constructed using national databases to evaluate 3,141 US counties. Radiation therapy resources and use densities were operationalized as physicians to persons at risk (PPR) and use to persons at risk (UPR): the number of attending radiation oncologists and Medicare beneficiaries per 100,000 persons at risk, respectively. Oncologic need was defined by "hot zone" counties with ≥2 standard deviations (SDs) above mean incidence and death rates. Univariable and multivariable logistic regressions examined links between PPR and UPR densities, epidemiologic variables, and hot zones for oncologic outcomes. Statistics are reported at a significance level of P < .05. RESULTS: The mean (SD) PPR and UPR densities were 2.1 (5.9) and 192.6 (557.6) for PC and 1.9 (5.3) and 174.4 (501.0) for BC, respectively. Counties with high PPR and UPR densities were predominately metropolitan (odds ratio [OR], 2.9-4.4), generally with a higher percentage of Black non-Hispanic constituents (OR, 1.5-2.3). Incidence and death rate hot zones were largely nonmetropolitan (OR, 0.3-0.6), generally with a higher percentage of Black non-Hispanic constituents (OR, 3.2-6.3). Lower PPR density was associated with death rate hot zones for both types of cancer (OR, 0.8-0.9); UPR density was generally not linked to oncologic outcomes on multivariable analysis. CONCLUSIONS: The study found that mismatch between oncologic need with PPR and UPR disproportionately affects nonmetropolitan communities with a higher percentage of Black non-Hispanic constituents. An interactive web platform (bit.ly/densitymaps) was developed to visualize "radiotherapy deserts" and drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.

Treatment patterns and economic burden among newly diagnosed cervical and endometrial cancer patients.

Aim: This study evaluated treatment patterns, healthcare resource use and healthcare costs among newly diagnosed US patients with cervical or endometrial cancer. Materials & methods: The authors identified patients diagnosed between 2015 and 2018, described them by line of therapy (LOT), then summarized all-cause per patient per month healthcare resource use and healthcare costs per LOT. Results: Among 1004 patients with cervical cancer and 2006 patients with endometrial cancer, 65.2 and 71.4%, respectively, received at least LOT1. Common treatment modalities in LOT1 were surgery (cervical, 58.0%; endometrial, 92.6%), radiation therapy (cervical, 49.8%; 24.7%) and systemic therapy (cervical, 53.3%; endometrial, 26.1%). Mean per patient per month costs per LOT were pre-treatment (cervical, US$17,210; endometrial, US$14,601), LOT1 (cervical, US$10,929; endometrial, US$6859), LOT2 (cervical, US$15,183; endometrial, US$10,649) and LOT3+ (cervical, US$19,681; endometrial, US$9206). Conclusion: Overall, newly diagnosed patients with cervical or endometrial cancer received guideline-recommended treatment. Outpatient visits mainly drove healthcare costs across LOTs.

Estimativa da necessidade de radioterapia externa no Brasil baseada em critérios epidemiológicos / Optimal utilization of radiotherapy in Brazil according to local epidemiological data

Esta tese teve como objetivo estimar a necessidade de radioterapia no Brasil a partir de dados epidemiológicos locais. O estudo foi desenvolvido em duas etapas que consistiram na estimativa de casos incidentes e, posteriormente, na classificação dos casos registrados nos Registros Hospitalares de Câncer (RHC) para integrar as árvores de decisão para o emprego do tratamento radioterápico conforme evidências e diretrizes clínicas de tratamento. As estimativas de casos incidentes em 2018 foram calculadas a partir de dados de Registros de Câncer de Base Populacional (RCBP) selecionados de acordo com critérios internacionais de qualidade e de dados corrigidos para causas mal definidas e não específicas na causa básica dos óbitos registrados no Sistema de Informação de Mortalidade (SIM) no período de 2007 a 2016. Foram calculadas razões de incidência/mortalidade (I/M) anuais para cada topografia, estratificadas por sexo e faixa etária nos RCBP selecionados. As razões I/M para 2018 foram estimadas para as regiões brasileiras a partir de modelos multiníveis de Poisson a partir de uma abordagem longitudinal com efeito aleatório no RCBP. As razões estimadas foram aplicadas ao número de óbitos ocorridos em 2018 por tipo de câncer, também corrigido para causas mal definidas e não específicas na causa básica, registrados no SIM. As distribuições dos dados por estadiamento obtidas a partir do RHC foram combinadas às frequências relativas por tipo de câncer incidente e aos dados das árvores de decisão do projeto Collaboration for Cancer Outcomes Research and Evaluation (CCORE) para uso da radioterapia. As estimativas de necessidade foram calculadas por tipo de câncer e para o conjunto das neoplasias, exceto pele não melanoma. Foram realizadas análises de sensibilidade para avaliar a relevância dos dados locais na estimativa de necessidade. O número necessário de equipamentos de radioterapia para atender os casos que se beneficiariam do tratamento em algum momento no curso da doença foi calculado e a análise da cobertura da oferta foi realizada. Para o Brasil, em 2018, foram estimados 506.462 casos novos de câncer, exceto pele não melanoma. Diferenças regionais nas razões I/M e no padrão de casos incidentes foram identificadas, podendo estar relacionadas a fatores socioeconômicos. Foi estimado que 53,55% dos casos novos no Brasil teriam necessidade de tratamento radioterápico. A maior necessidade de radioterapia foi identificada para o Norte: 55,32%, com um peso expressivo do câncer do colo do útero, tanto pela incidência como pelo número de casos em estágios avançados, para os quais a radioterapia é considerada tratamento de escolha. Para atender aos casos com necessidade de radioterapia no Brasil, foram estimados 497 equipamentos de radioterapia externa, sendo o déficit estimado em 114 para 2018 no país. Os maiores déficits foram observados para o Norte e para a rede assistencial do SUS. Em conclusão, o emprego de parâmetros internacionais não se mostrou adequado para a realidade brasileira. O planejamento de recursos para a assistência oncológica no Brasil demanda estimativas confiáveis baseadas nas necessidades locais para que as inequidades não sejam ainda mais agravadas.

This thesis aimed to estimate the need for radiotherapy in Brazil based on local epidemiological data. The study was developed in two stages which consisted of estimating incident cases and, later, classifying the cases registered in the Hospital Cancer Registries (RHC) to integrate decision trees for the use of radiotherapy according to evidence and clinical treatment guidelines. The estimates of incident cases in 2018 were calculated based on data from Population-Based Cancer Registries (RCBP) selected according to international quality criteria and from data corrected for ill-defined and non-specific causes in the underlying cause of deaths recorded in the System of Mortality Information (SIM) from 2007 to 2016. Annual incidence/mortality ratios (I/M) were calculated for each topography, stratified by sex and age group in the selected RCBP. The I/M ratios for 2018 were estimated for Brazilian regions using multilevel Poisson models from a longitudinal approach with random effect on the RCBP. The estimated reasons were applied to the number of deaths that occurred in 2018 by type of cancer, also corrected for ill-defined and non-specific causes in the underlying cause, recorded in the SIM. The staging data distributions obtained from the RHC were combined with the relative frequencies by type of incident cancer and data from the Collaboration for Cancer Outcomes Research and Evaluation (CCORE) project decision trees for radiotherapy use. Optimal utilization rates were estimated by type of cancer and for the set of tumors, except for non-melanoma skin. Sensitivity analyzes were performed to assess the relevance of local data in estimating the need. The number of radiotherapy equipment needed to attend to cases that would benefit from treatment at some point in the course of the disease was calculated and the analysis of the offer coverage was performed. For Brazil, in 2018, 506,462 new cases of cancer were estimated, except for non-melanoma skin. Regional differences in I/M ratios and in the pattern of incident cases were identified, which may be related to socioeconomic factors. It was estimated that 53.55% of new cases in Brazil would need radiotherapy. The greatest need for radiotherapy was identified for the North: 55.32%, with an expressive weight of cervical cancer, both in terms of incidence and the number of cases in advanced stages, for which radiotherapy is considered the treatment of choice. To meet the need for radiotherapy in Brazil, 497 external radiotherapy equipment were estimated, with an estimated deficit of 114 for 2018 in the country. The greatest deficits were observed for the North and for the SUS care network. In conclusion, the use of international parameters was not adequate for the Brazilian reality. The planning of resources for cancer care in Brazil requires reliable estimates based on local needs so that inequities are not further aggravated.

Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs.

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

National variation in the delivery of radiation oncology procedures in the non-facility-based setting.

PURPOSE: Though utilization of medical procedures has been shown to vary considerably across the United States, similar efforts to characterize variation in the delivery of radiation therapy (RT) procedures have not been forthcoming. Our aim was to characterize variation in the delivery of common RT procedures in the Medicare population. We hypothesized that delivery would vary significantly based on provider characteristics. METHODS: The Centers for Medicare and Medicaid Services (CMS) Physician and Other Supplier Public Use File was linked to the CMS Physician Compare (PC) database by physician NPI to identify and sum all treatment delivery charges submitted by individual radiation oncologists in the non-facility-based (NFB) setting in 2016. Multivariable logistic regression analysis was carried out to determine provider characteristics (gender, practice rurality, practice region, and years since graduation) that predicted for the delivery of 3D conformal RT (3DCRT), intensity modulated RT (IMRT), stereotactic body RT (SBRT), stereotactic radiosurgery (SRS), low dose rate (LDR) brachytherapy, and high dose rate (HDR) brachytherapy delivery in the Medicare patient population. The overall significance of categorical variables in the multivariable logistic regression model was assessed by the likelihood ratio test (LRT). RESULTS: In total, 1,802 physicians from the NFB practice setting were analyzed. Male gender predicted for greater LDR brachytherapy delivery (OR 8.19, 95% CI 2.58-26.05, p < 0.001), but not greater delivery of other technologies. Metropolitan practice was the only predictor for greater HDR brachytherapy utilization (OR 12.95, 95% CI 1.81-92.60, p = 0.01). Practice region was predictive of the delivery of 3DCRT, SRS and SBRT (p < 0.01, p < 0.001, and p < 0.001, respectively). With the Northeast as the reference region, 3DCRT was more likely to be delivered by providers in the South (OR 1.33, 95% CI 1.09-1.62, p < 0.01) and the West (OR 1.38, 95% CI 1.11-1.71, p < 0.01). At the same time, SRS use was less likely in the Midwest (OR 0.71, 95% CI 0.55-0.91, p < 0.01), South (OR 0.49, 95% CI 0.40-0.61, p < 0.001), and West (OR 0.43, 95% CI 0.34-0.55, p < 0.001). SBRT, on the other hand, was more commonly utilized in the Midwest (OR 2.63, 95% CI 1.13-6.13, p = 0.03), South (OR 3.44, 95% CI 1.58-7.49, p < 0.01), and West (OR 4.87, 95% CI 2.21-10.72, p < 0.001). HDR brachytherapy use was also more likely in the Midwest (OR 1.97, 95% CI 1.11-3.49, p = 0.02) and West (OR 1.87, 95% CI 1.08-3.24, p = 0.03). While the degree held by the billing physician did not predict for delivery of a given procedure, greater years since graduation was related to decreased likelihood of SBRT use (OR 0.98, 95% CI 0.96-0.99, p < 0.001) and increased likelihood of LDR brachytherapy use (OR 1.02, 95% CI 1.00-1.04, p = 0.02). CONCLUSIONS: Substantial geographic variation in the use of specific RT technologies was identified. The degree to which this variation reflects effective care, preference-sensitive care, or supply-sensitive care warrants further investigation.

The Association between Income Status and Treatment Selection for Prostate Cancer in a Universal Health Care System: A Population-Based Analysis.

PURPOSE: Treatment selection for localized prostate cancer is guided by risk stratification and patient preferences. While socioeconomic status (SES) disparities exist for access to care, less is known about the effect of SES on treatment decision-making. We sought to evaluate whether income status was associated with the treatment selected (radical prostatectomy [RP] vs radiation therapy [RT]) for nonmetastatic prostate cancer in a universal health care system. MATERIALS AND METHODS: All men from Manitoba, Canada who were diagnosed with nonmetastatic prostate cancer between 2005 and 2016 and subsequently treated with RP or RT were identified using a provincial cancer database. SES was defined as neighborhood income by postal code and divided into income quintiles (Q1-Q5, with Q1 the lowest quintile and Q5 the highest). Multivariable logistic regression nested models were used to compare whether SES was associated with treatment type received. RESULTS: We identified 3,966 individuals who were diagnosed with nonmetastatic prostate cancer and were treated with RP (2,354) or RT (1,612). After adjusting for demographic and clinicopathological characteristics, as income quintile increased, men were incrementally more likely to undergo RP than RT (range Q2 vs Q1: adjusted OR 1.40, 95% CI 1.01-1.93; Q5 vs Q1: adjusted OR 2.30, 95% CI 1.70-3.12). CONCLUSIONS: As income levels increased there was a stepwise incremental increase in the odds of receiving RP over RT for localized prostate cancer. These results may inform initiatives to better understand the values, priorities and barriers that patients experience when making treatment decisions in a universal health care system.

Determinants of delay and association with outcome in head and neck cancer: A systematic review.

INTRODUCTION: Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview of factors contributing to delay can provide critical insights on necessary adjustments to optimize care pathways. This systematic review aims to identify factors associated with delay and summarize the effect of delay on oncological outcome measures. METHODS: A search strategy was conducted according to PRISMA guidelines to search electronic databases for studies assessing the carepathway interval (days between first visit in head and neck oncology center and treatment initiation) and/or time-to-treatment-initiation interval (days between histological diagnosis and treatment initiation) and 1) determinants of delay and/or 2) effect of delay on outcome within these timeframes. Due to heterogeneity between included studies, a meta-analysis was not possible. RESULTS: Fifty-two studies were eligible for quantitative analysis. Non-Caucasian race, academic setting, Medicaid/no insurance and radiotherapy as primary treatment were associated with delay. Advanced tumour stage was related to increased time-to-treatment initiation in the four common sites combined (oral cavity, oropharynx, hypopharynx, larynx). Separate determinants for delay in different tumour locations were identified. In laryngeal, oral cavity cancer and the four common HNC sites combined, delay in start of treatment is associated with decreased overall survival, although no cut-off time point could be determined. CONCLUSION: Race, facility type, type of insurance and radiotherapy as primary treatment were associated with delay and subsequent inferior survival in the four common sites combined.

Influence of Sociodemographic Factors on Definitive Intervention Among Low-risk Active Surveillance Patients.

OBJECTIVES: To investigate sociodemographic factors influencing decision of initially active surveillance (AS) prostate cancer (CaP) patients to opt for definitive therapy, and, specifically, choice of radical prostatectomy (RP) versus radiation therapy (XRT). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify AS patients diagnosed with NCCN low-risk CaP between 2010 and 2015. We sought to determine predictors of treatment type using multivariable logistic regression analyses. RESULTS: Out of 32,874 men included, 21,255 (64.7%) underwent delayed treatment, with 3,751 (17.6%) and 17,463 (82.2%) opting for RP and XRT, respectively. Patients who were married (Odds Ratio [OR]: 1.18, P <.001), insured (OR 2.94, P <.001), of higher socioeconomic status (OR 1.67 for highest vs lowest, P <.01), and residing in a Southeastern or Midwestern region (ORs 1.26 and 1.22 vs Northeast, respectively, P <.01) were significantly more likely to undergo definitive intervention. A significant interaction between patient race and marital/socioeconomic statuses on the decision-making process was identified. Decision for XRT (vs RP) was more likely in older (OR 11.6 for 70-79 vs 50-59 years, P <.01), unmarried (OR 1.89, P <.01), African American (OR 1.41, P .018), and higher socioeconomic status (OR 1.54 for highest versus lowest quartile, P <.01) patients. CONCLUSION: The majority of patients initially treated with AS underwent delayed treatment. After accounting for pathologic characteristics, the interaction of sociodemographic factors including race, socioeconomic status, marital status, insurance status, and region of residence are significantly associated with the likelihood of undergoing definitive therapy.

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study.

BACKGROUND: There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England. METHODS: Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated. FINDINGS: As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53-71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89-95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020. INTERPRETATION: The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England. FUNDING: Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

Active Surveillance for Men with Intermediate Risk Prostate Cancer.

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.

Location as Destiny: Identifying Geospatial Disparities in Radiation Treatment Interruption by Neighborhood, Race, and Insurance.

PURPOSE: Radiation therapy interruption (RTI) worsens cancer outcomes. Our purpose was to benchmark and map RTI across a region in the United States with known cancer outcome disparities. METHODS AND MATERIALS: All radiation therapy (RT) treatments at our academic center were cataloged. Major RTI was defined as ≥5 unplanned RT appointment cancellations. Univariate and multivariable logistic and linear regression analyses identified associated factors. Major RTI was mapped by patient residence. A 2-sided P value <.0001 was considered statistically significant. RESULTS: Between 2015 and 2017, a total of 3754 patients received RT, of whom 3744 were eligible for analysis: 962 patients (25.8%) had ≥2 RT interruptions and 337 patients (9%) had major RTI. Disparities in major RTI were seen across Medicaid versus commercial/Medicare insurance (22.5% vs 7.2%; P < .0001), low versus high predicted income (13.0% vs 5.9%; P < .0001), Black versus White race (12.0% vs 6.6%; P < .0001), and urban versus suburban treatment location (12.0% vs 6.3%; P < .0001). On multivariable analysis, increased odds of major RTI were seen for Medicaid patients (odds ratio [OR], 3.35; 95% confidence interval [CI], 2.25-5.00; P < .0001) versus those with commercial/Medicare insurance and for head and neck (OR, 3.74; 95% CI, 2.56-5.46; P < .0001), gynecologic (OR, 3.28; 95% CI, 2.09-5.15; P < .0001), and lung cancers (OR, 3.12; 95% CI, 1.96-4.97; P < .0001) compared with breast cancer. Major RTI was mapped to urban, majority Black, low-income neighborhoods and to rural, majority White, low-income regions. CONCLUSIONS: Radiation treatment interruption disproportionately affects financially and socially vulnerable patient populations and maps to high-poverty neighborhoods. Geospatial mapping affords an opportunity to correlate RT access on a neighborhood level to inform potential intervention strategies.

Estimated Costs Associated With Radiation Therapy for Positive Surgical Margins During Radical Prostatectomy.

Importance: Prostate cancer is the most common malignant neoplasm among men and is the one with the highest positive surgical margin (PSM) rate. This high rate is due to the difficulty in balancing the risk of extraprostatic disease and excising periprostatic structures, which ultimately affects patients' quality of life. In the case of a PSM, the appropriateness of adjuvant radiation therapy (aRT) should be discussed. The financial burden of PSMs on health systems has not been investigated. Objective: To estimate the financial costs associated with a PSM during radical prostatectomy on the basis of the odds of undergoing aRT. Design, Setting, and Participants: This cohort study used data on men with prostate cancer from the US National Cancer Database (January 1, 2010, through December 31, 2015). Data were requested in March 2019, accessed in April 2019, and analyzed in August 2019. Exposure: Treatment with radical prostatectomy followed by aRT, if indicated. Main Outcomes and Measures: The attributable risk fraction of PSMs on undergoing aRT was estimated from a logistic regression with aRT administration as the outcome. The analysis was adjusted for patients' socioeconomic and demographic characteristics and tumor characteristics. The aRT cost for the year 2019 was calculated using the Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System. The fraction of this cost attributable to a PSM was estimated according to its attributable risk fraction. Results: In total, 230 175 men were identified (median [interquartile range] age at diagnosis, 62.0 [56.0-67.0] years). Overall, 22.8% of the patients had a PSM. Patients with PSMs were more likely than those without PSMs to be older (median [interquartile range] age, 62.0 [56.0-66.0] years vs 62.0 [57.0-67.0] years) and nonwhite (9320 patients [17.8%] vs 29 872 patients [16.8%]), to have higher comorbidity scores (1604 patients [3.1%] vs 4884 patients [2.7%] with a Charlson-Deyo Comorbidity Index score ≥2) and worse tumor characteristics (category T3 and T4 disease, 26 394 patients [50.3%] vs 36 040 patients [20.3%]), and to have lower socioeconomic indicators (median annual income <$30 000, 5708 patients [10.9%] vs 17 874 patients [10.1%]; proportion of individuals without a high school degree in the area ≥29%, 6925 patients [13.2%] vs 22 648 patients [12.7%]). In addition, PSMs were documented more frequently at nonacademic institutions than academic ones (31 702 patients [60.5%] vs 20 714 patients [39.5%]). A total of 11 585 patients (5.0%) underwent aRT, and 7698 of them (3.3%) had a PSM at the final pathology examination. When controlling for patients' socioeconomic and demographic characteristics and tumor characteristics, men with PSMs were more likely than those with negative margins to undergo aRT, with an odds ratio of 3.79 (95% CI, 3.63-3.96; P < .001). The attributable risk fraction of the presence of a PSM on aRT was 44% (95% CI, 42%-45%). The attributable cost of a PSM was calculated as $17 356 (95% CI, $16 567-$17 751). Assuming 60 000 prostatectomies in 2019 and similar trends of PSM and aRT, the overall health burden attributable to PSMs was calculated to be $52 068 000 (95% CI, $49 701 000-$53 253 000). Conclusions and Relevance: The estimated aRT cost attributable to the presence of a PSM was $17 356, resulting in $52 068 000 in spending on aRT in 2019. Strategies to reduce PSMs could be associated with a reduction in the overall health costs of surgically treated PCa.

Comorbidity in lung cancer patients and its association with medical service cost and treatment choice in China.

BACKGROUND: It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China. METHODS: We used claims data from China Urban Employees' Basic Medical Insurance (UEBMI) and Urban Residents' Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively. RESULTS: Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941.9), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI:1.012-1.441) and chemotherapy (1.363, 1.196-1.554), and decreased possibility of choosing surgery (0.850, 0.730-0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions. CONCLUSION: Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016.

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non-small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients' demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1-Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5-year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87-0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA-IV; odds ratio [OR], 1.24; 95% CI, 1.16-1.32; P < .0001), lung resection (IA-IIIA; OR, 1.58; 95% CI, 1.43-1.74; P < .0001), platinum-based vinorelbine adjuvant chemotherapy (IB-IIIA; OR, 1.63; 95% CI, 1.39-1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05-1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32-1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA-IIIB; OR, 0.86; 95% CI, 0.79-0.94; P = .0003). Across 2007-2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

Assessing Cancer Treatment Information Using Medicare and Hospital Discharge Data among Women with Non-Hodgkin Lymphoma in a Los Angeles County Case-Control Study.

BACKGROUND: We assessed the ability to supplement existing epidemiologic/etiologic studies with data on treatment and clinical outcomes by linking to publicly available cancer registry and administrative databases. METHODS: Medical records were retrieved and abstracted for cases enrolled in a Los Angeles County case-control study of non-Hodgkin lymphoma (NHL). Cases were linked to the Los Angeles County cancer registry (CSP), the California state hospitalization discharge database (OSHPD), and the SEER-Medicare database. We assessed sensitivity, specificity, and positive predictive value (PPV) of cancer treatment in linked databases, compared with medical record abstraction. RESULTS: We successfully retrieved medical records for 918 of 1,004 participating NHL cases and abstracted treatment for 698. We linked 59% of cases (96% of cases >65 years old) to SEER-Medicare and 96% to OSHPD. Chemotherapy was the most common treatment and best captured, with the highest sensitivity in SEER-Medicare (80%) and CSP (74%); combining all three data sources together increased sensitivity (92%), at reduced specificity (56%). Sensitivity for radiotherapy was moderate: 77% with aggregated data. Sensitivity of BMT was low in the CSP (42%), but high for the administrative databases, especially OSHPD (98%). Sensitivity for surgery reached 83% when considering all three datasets in aggregate, but PPV was 60%. In general, sensitivity and PPV for chronic lymphocytic leukemia/small lymphocytic lymphoma were low. CONCLUSIONS: Chemotherapy was accurately captured by all data sources. Hospitalization data yielded the highest performance values for BMTs. Performance measures for radiotherapy and surgery were moderate. IMPACT: Various administrative databases can supplement epidemiologic studies, depending on treatment type and NHL subtype of interest.

Impact of Hospice on Spending and Utilization Among Patients With Lung Cancer in Medicare.

OBJECTIVES: To compare patterns and understand drivers of spending and utilization by month in the last 6 months of life between patients with lung cancer who used hospice versus those who did not. STUDY DESIGN: Retrospective cohort analysis using 2009 to 2013 Medicare claims. METHODS: We used a 10% random sample of Medicare fee-for-service beneficiaries with lung cancer who died between 2010 and 2013 (43 789 beneficiaries). Patients were assigned to 2 groups depending on whether they used hospice care in the last 6 months of life. The following outcomes were constructed by month: (1) all-cause Medicare spending, (2) indicator of hospitalization, (3) indicator of emergency department (ED) visit, (4) number of part B chemotherapy claims, and (5) number of radiation therapy sessions. We used a combination of propensity score matching and regression analysis to compare outcomes between the 2 groups. RESULTS: Patients who used hospice had significantly lower spending in the last month of life compared to nonusers (US$16 907 vs US$26 906, P < .00). The spending differences in the last month of life between the 2 groups were largely driven by lower likelihood of hospitalization (54% vs 80%, P < .01) and ED visits (15% vs 22%, P < .01) and fewer chemotherapy (0.12 vs 0.32, P < .01) and radiation therapy sessions (0.80 vs 1.26, P < .01). During the other months in the 6-month period, spending was similar between the 2 groups. CONCLUSIONS: Timely hospice enrollment of patients with lung cancer-the group suffering from high morbidity and mortality among patients with cancer-may lead to significant cost savings.

Racial Differences in Treatment and Survival among Veterans and Non-Veterans with Stage I NSCLC: An Evaluation of Veterans Affairs and SEER-Medicare Populations.

BACKGROUND: Surgery is the preferred treatment for stage I non-small cell lung cancer (NSCLC), with radiation reserved for those not receiving surgery. Previous studies have shown lower rates of surgery among Blacks with stage I NSCLC than among Whites. METHODS: Black and White men ages ≥65 years with stage I NSCLC diagnosed between 2001 and 2009 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and Veterans Affairs (VA) cancer registry. Logistic regression and Cox proportional hazards models were used to examine associations between race, treatment, and survival. RESULTS: Among the patients in the VA (n = 7,895) and SEER (n = 8,744), the proportion of Blacks was 13% and 7%, respectively. Overall, 16.2% of SEER patients (15.4% of Whites, 26.0% of Blacks) and 24.5% of VA patients received no treatment (23.4% of Whites, 31.4% of Blacks). In both cohorts, Blacks were less likely to receive any treatment compared with Whites [ORadj = 0.57; 95% confidence interval (CI), 0.47-0.69 for SEER-Medicare; ORadj = 0.68; 95% CI, 0.58-0.79 for VA]. Among treated patients, Blacks were less likely than Whites to receive surgery only (ORadj = 0.57; 95% CI, 0.47-0.70 for SEER-Medicare; ORadj = 0.73; 95% CI, 0.62-0.86 for VA), but more likely to receive chemotherapy only and radiation only. There were no racial differences in survival. CONCLUSIONS: Among VA and SEER-Medicare patients, Blacks were less likely to get surgical treatment. Blacks and Whites had similar survival outcomes when accounting for treatment. IMPACT: This supports the hypothesis that equal treatment correlates with equal outcomes and emphasizes the need to understand multilevel predictors of lung cancer treatment disparities.

Is economic status the main determinant of radiation therapy availability? The Arab world as an example of developing countries.

BACKGROUND AND PURPOSE: Arab countries share a common location, history, language and culture with different economic characteristics. In this study, we analyze the availability and factors influencing radiotherapy services and cancer mortality incidence ratio (MIR) in Arabic countries. MATERIALS AND METHODS: Data were collected from GLOBOCAN report, World Health Organization, World Bank, United Nation and Directory of Radiotherapy Centre databases. RESULTS: The average number of megavoltage machines (MVM) in Arab countries is 0.84 machine per 1000 cancer patients. The number of MVM per 1000 cancer patients was found to be significantly correlated with gross domestic product (GDP) per capita (r = 0.583, P = 0.006). In addition, it was found to be significantly more in politically stable countries compared to unstable ones (P = 0.004) and more in high and upper-middle income countries (median 0.94 ±â€¯1.0) compared to lower-middle and low income countries (median 0.3 ±â€¯0.51) (P = 0.013). MIR was found to be significantly correlated with GDP per capita, physicians per 1000 population, MVM per 1000 cancer patients and absolute MVM deficit (r = -0.555, -0.625, -0.42, -0.436 and P = 0.009, 0.006, 0.047, 0.043, respectively). On multivariate regression analysis, the number of physicians per 1000 population had the strongest prediction of MIR in Arabic countries (P = 0.01). CONCLUSION: Although the economic status is of paramount importance, it is not the only factor determining the quantity and quality of radiotherapy services in the Arab world. More efforts are urgently needed to improve the status of radiation oncology and fill its gap in the Arab countries.

[Analytical study of the breast cancer patient flow network in Brazil from 2014 to 2016]. / Estudo de análise de rede do fluxo de pacientes de câncer de mama no Brasil entre 2014 e 2016.

This study aims to analyze the flow of breast cancer patients treated outside of their municipality of residence, based on hospital admissions and chemotherapy and radiotherapy in the Brazilian Unified National Health System (SUS) from 2014 to 2016. Network analysis was used, considering the municipality of residence and of treatment as nodes in a graph, thus consisting of a "health system organizational network study". In addition, highway distances and travel time were estimated via the best feasible route according to the Open Street Maps highway project. According to the results, 51.34% of breast cancer patients in Brazil were treated outside their municipality of residence, following regionalized flows that respect state borders, generally towards the state capital or other large cities. The results also point to specific exceptions, where some municipalities occupy outstanding positions that extrapolate state borders. Median travel time from the municipality of residence to the municipality of care was nearly 3 hours, and 75% of trips totaled 324km for chemotherapy, 287km for radiotherapy, and 282km for hospitalizations. These results are indicative of the difficulties in access to oncology services, potentially aggravating the illness experience with cancer in terms of impact on the individuals and their families.

Este estudo busca analisar o fluxo de pacientes oncológicos de mama que são atendidos fora de seu domicílio de residência. Foram considerados as internações hospitalares e os tratamentos por quimioterapia e radioterapia para neoplasias malignas na mama, no âmbito do Sistema Único de Saúde, entre os anos de 2014 e 2016. Foi empregado o método de análise de redes, considerando o município de residência e de tratamento como nós de um grafo, que consiste em um "estudo de redes organizacionais de sistemas de saúde". Além disso, distância e tempo de deslocamento foram estimados por meio da melhor rota viável, segundo a malha rodoviária do projeto Open Street Maps. Os resultados apontam que 51,34% dos pacientes de câncer de mama no Brasil foram atendidos fora de seu município de residência, seguindo fluxos que são regionalizados e que preservam fronteiras estaduais, em geral, em direção a capitais ou a cidades de grande porte. Por outro lado, os resultados também apontam exceções específicas, visto que alguns municípios detêm um grau de proeminência que supera os limites estaduais. O tempo de deslocamento entre município de residência e município de atendimento apresentou medianas próximas a três horas, e 75% dos deslocamentos se dão em até 324km para tratamento por quimioterapia, 287km para tratamento por radioterapia e 282km para internações. Esses resultados são indicativos das dificuldades de acesso aos serviços de oncologia, o que potencialmente agrava a experiência do adoecimento oncológico em termos de impacto no indivíduo e em sua família.

El objetivo de este estudio fue analizar el flujo de pacientes oncológicos con cáncer de mama que son atendidos fuera de su domicilio de residencia. Se consideraron internamientos hospitalarios, tratamientos por quimioterapia y radioterapia para neoplasias malignas de mama, dentro del ámbito del Sistema Único de Salud brasileño, entre los años de 2014 a 2016. Se empleó el método de análisis de redes, considerando como nudos de un grafo el municipio de residencia y el del tratamiento, formándose de esta forma un "estudio de redes organizativas de sistemas de salud". Asimismo, se estimaron las distancias viales y el tiempo de desplazamiento, a través de la mejor ruta de carreteras, según la red de carreteras del proyecto Open Street Maps. Los resultados apuntan que un 51,34% de los pacientes con cáncer de mama en Brasil fueron atendidos fuera de su municipio de residencia, siguiendo flujos regionalizados y dentro de sus fronteras estatales, en general, en dirección a las capitales de las mismas o grandes ciudades. Por otro lado, los resultados también muestran excepciones específicas, donde algunos municipios detentan un grado de relevancia superando las fronteras estatales. El tiempo de desplazamiento entre el municipio de residencia y el municipio de atención presentó unas medias cercanas a las 3 horas, y en un 75% de los desplazamientos se recorrieron hasta 324km para recibir tratamiento de quimioterapia, 287km para el tratamiento de radioterapia y 282km para internamientos. Estos resultados son indicativos de las dificultades de acceso a los servicios de oncología, lo que agrava potencialmente la experiencia de la enfermedad oncológica en términos de impacto en el individuo y su familia.