Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB.

PURPOSE: Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET). METHODS: The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging. RESULTS: The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease. CONCLUSION: Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.

An implementation science approach to the systematic study of access to gynecologic cancer care.

INTRODUCTION: Barriers to access to cancer care are profoundly threatening to patients with gynecologic malignancies. Implementation science focuses on empirical investigation of factors influencing delivery of clinical best practices, as well as interventions designed to improve delivery of evidence-based care. We outline one prominent framework for conducting implementation research and discuss its application to improving access to gynecologic cancer care. METHODS: Literature on the use of the Consolidated Framework for Implementation Research (CFIR) was reviewed. Delivery of cytoreductive surgery for advanced ovarian carcinoma was selected as an illustrative case of an evidence-based intervention (EBI) in gynecologic oncology. CFIR domains were applied to the context of cytoreductive surgical care, highlighting examples of empirically-assessable determinants of care delivery. RESULTS: CFIR domains include Innovation, Inner Setting, Outer Setting, Individuals, and Implementation Process. "Innovation" relates to characteristics of the surgical intervention itself; "Inner Setting" relates to the environment in which surgery is delivered. "Outer Setting" refers to the broader care environment influencing the Inner Setting. "Individuals" highlights attributes of persons directly involved in care delivery, and "Implementation Process" focuses on integration of the Innovation within the Inner Setting. CONCLUSIONS: Prioritization of implementation science methods in the study of access to gynecologic cancer care will help ensure that patients are able to utilize interventions with the greatest prospect of benefiting them.

The Impact of Commission on Cancer Accreditation Status, Hospital Rurality and Hospital Size on Quality Measure Performance Rates.

BACKGROUND: Rural cancer patients receive lower-quality care and experience worse outcomes than urban patients. Commission on Cancer (CoC) accreditation requires hospitals to monitor performance on evidence-based quality measuresPlease confirm the list of authors is correc, but the impact of accreditation is not clear due to lack of data from non-accredited facilities and confounding between patient rurality and hospital accreditation, rurality, and size. METHODS: This retrospective, observational study assessed associations between rurality, accreditation, size, and performance rates for four CoC quality measures (breast radiation, breast chemotherapy, colon chemotherapy, colon nodal yield). Iowa Cancer Registry data were queried to identify all eligible patients diagnosed between 2011 and 2017. Cases were assigned to the surgery hospital to calculate performance rates. Univariate and multivariate regression models were fitted to identify patient- and hospital-level predictors and assess trends. RESULTS: The study cohort included 10,381 patients; 46% were rural. Compared with urban patients, rural patients more often received treatment at small, rural, and non-accredited facilities (p < 0.001 for all). Rural hospitals had fewer beds and were far less likely to be CoC-accredited than urban hospitals (p < 0.001 for all). On multivariate analysis, CoC accreditation was the strongest, independent predictor of higher hospital performance for all quality measures evaluated (p < 0.05 in each model). Performance rates significantly improved over time only for the colon nodal yield quality measure, and only in urban hospitals. CONCLUSIONS: CoC accreditation requires monitoring and evaluating performance on quality measures, which likely contributes to better performance on these measures. Efforts to support rural hospital accreditation may improve existing disparities in rural cancer treatment and outcomes.

Hospital and Surgeon Selection for Medicare Beneficiaries With Stage II/III Rectal Cancer: The Role of Rurality, Distance to Care, and Colonoscopy Provider.

OBJECTIVE: To determine factors associated with rectal cancer surgery performed at high-volume hospitals (HVHs) and by high-volume surgeons (HVSs), including the roles of rurality and diagnostic colonoscopy provider characteristics. SUMMARY OF BACKGROUND DATA: Although higher-volume hospitals/surgeons often achieve superior surgical outcomes, many rectal cancer resections are performed by lower-volume hospitals/surgeons, especially among rural populations. METHODS: Patients age 66+ diagnosed from 2007 to 2011 with stage II/III primary rectal adenocarcinoma were selected from surveillance, epidemiology, and end results-medicare data. Patient ZIP codes were used to classify rural status. Hierarchical logistic regression was used to determine factors associated with surgery by HVH and HVS. RESULTS: Of 1601 patients, 22% were rural and 78% were urban. Fewer rural patients received surgery at a HVH compared to urban patients (44% vs 65%; P < 0.0001). Compared to urban patients, rural patients more often had colonoscopies performed by general surgeons (and less often from gastroenterologists or colorectal surgeons), and lived substantially further from HVHs; these factors were both associated with lower odds of surgery at a HVH or by a HVS. In addition, whereas over half of both rural and urban patients received their colonoscopy and surgery at the same hospital, rural patients who stayed at the same hospital were significantly less likely to receive surgery at a HVH or by a HVS compared to urban patients. CONCLUSIONS: Rural rectal cancer patients are less likely to receive surgery from a HVH/HVS. The role of the colonoscopy provider has important implications for referral patterns and initiatives seeking to increase centralization.

Surgical Decision-Making Surrounding Contralateral Prophylactic Mastectomy: Comparison of Treatment Goals, Preferences, and Psychosocial Outcomes from a Multicenter Survey of Breast Cancer Patients.

BACKGROUND: Differences in patient characteristics and decision-making preferences have been described between those who elect breast-conserving surgery (BCS), unilateral mastectomy (UM), or contralateral prophylactic mastectomy (CPM) for breast cancer. However, it is not known whether preferred and actual decision-making roles differ across these surgery types, or whether surgery choice reflects a woman's goals or achieves desired outcomes. METHODS: Women diagnosed with stage 0-III unilateral breast cancer across eight large medical centers responded to a mailed questionnaire regarding treatment decision-making goals, roles, and outcomes. These data were linked to electronic medical records. Differences were assessed using descriptive analyses and logistic regression. RESULTS: There were 750 study participants: 60.1% BCS, 17.9% UM, and 22.0% CPM. On multivariate analysis, reducing worry about recurrence was a more important goal for surgery in the CPM group than the others. Although women's preferred role in the treatment decision did not differ by surgery, the CPM group was more likely to report taking a more-active-than-preferred role than the BCS group. On multivariate analysis that included receipt of additional surgery, posttreatment worry about both ipsilateral and contralateral recurrence was higher in the BCS group than the CPM group (both p < 0.001). The UM group was more worried than the CPM group about contralateral recurrence only (p < 0.001). CONCLUSIONS: Women with CPM were more likely to report being able to reduce worry about recurrence as a very important goal for surgery. They were also the least worried about ipsilateral breast recurrence and contralateral breast cancer almost two years postdiagnosis.

Improving the Quality of Cancer Care in Community Hospitals.

BACKGROUND: Cancer patients treated in community hospitals receive less guideline-recommended care and experience poorer outcomes than those treated in academic medical centers or National Cancer Institute-Designated Cancer Centers. The Markey Cancer Center Affiliate Network (MCCAN) was designed to address this issue in Kentucky, the state with the highest cancer incidence and mortality rates in the U.S. METHODS: Using data obtained from the Kentucky Cancer Registry, the study evaluated the impact of patients treated in MCCAN hospitals on four evidence-based Commission on Cancer (CoC) quality measures using a before-and-after matched-cohort study design. Each group included 13 hospitals matched for bed size, cancer patient volume, community population, and region (Appalachian vs. non-Appalachian). Compliance with quality measures was assessed for the 3 years before the hospital joined MCCAN (T1) and the 3 years afterward (T2). RESULTS: In T1, the control hospitals demonstrated greater compliance with two quality measures than the MCCAN hospitals. In T2, the MCCAN hospitals achieved greater compliance in three measures than the control hospitals. From T1 to T2, the MCCAN hospitals significantly increased compliance on three measures (vs. 1 measure for the control hospitals). Although most of the hospitals were not accredited by the CoC in T1, 92% of the MCCAN hospitals had achieved accreditation by the end of T2 compared with 23% of the control hospitals. CONCLUSION: After the MCCAN hospitals joined the Network, their compliance with quality measures and achievement of CoC accreditation increased significantly compared with the control hospitals. The unique academic/community-collaboration model provided by MCCAN was able to make a significant impact on improvement of cancer care. Future research is needed to adapt and evaluate similar interventions in other states and regions.

Early and Locally Advanced Metaplastic Breast Cancer: Presentation and Survival by Receptor Status in Surveillance, Epidemiology, and End Results (SEER) 2010-2014.

BACKGROUND: Metaplastic breast cancer (MBC) is a rare disease subtype characterized by an aggressive clinical course. MBC is commonly triple negative (TN), although hormone receptor (HR) positive and human epidermal growth receptor 2 (HER2) positive cases do occur. Previous studies have reported similar outcomes for MBC with regard to HR status. Less is known about outcomes for HER2 positive MBC. MATERIALS AND METHODS: Surveillance, Epidemiology, and End Results Program data were used to identify women diagnosed 2010-2014 with MBC or invasive ductal carcinoma (IDC). Kaplan-Meier curves estimated overall survival (OS) and multivariate Cox models were fitted. For survival analyses, only first cancers were included, and 2014 diagnoses were excluded to allow for sufficient follow-up. RESULTS: Our MBC sample included 1,516 women. Relative to women with IDC, women with MBC were more likely to be older (63 vs. 61 years), black (16.0% vs. 11.1%), and present with stage III disease (15.6% vs. 10.8%). HER2 positive and HER2 negative/HR positive MBC tumors represented 5.2% and 23.0% of cases. For MBC overall, 3-year OS was greatest for women with HER2 positive MBC (91.8%), relative to women with TN (75.4%) and HER2 negative/HR positive MBC (77.1%). This difference was more pronounced for stage III MBC, for which 3-year OS was 92.9%, 47.1%, and 42.2% for women with HER2 positive, TN, and HER2 negative/HR positive MBC, respectively. A multivariate Cox model of MBC demonstrated that HER2 positive tumors (relative to TN) were associated with improved survival (hazard ratio = 0.32, 95% confidence interval [CI] 0.13-0.79). In a second Cox model of exclusively HER2 positive tumors, OS did not differ between MBC and IDC disease subtypes (hazard ratio = 1.16, 95% CI 0.48-2.81). CONCLUSION: In this contemporary, population-based study of women with MBC, HER2 but not HR status was associated with improved survival. Survival was similar between HER2 positive MBC and HER2 positive IDC. This suggests HER2 positive MBC is responsive to HER2-directed therapy, a finding that may offer insights for additional therapeutic approaches to MBC. IMPLICATIONS FOR PRACTICE: This population-based study reports recent outcomes, by receptor status, for women with metaplastic breast cancer. Survival in metaplastic breast cancer is not impacted by hormone receptor status. To the authors' knowledge, this is the first report indicating that women with human epidermal growth receptor 2 (HER2) positive metaplastic breast cancer have survival superior to women with HER2 negative metaplastic breast cancer and survival similar to women with HER2 positive invasive ductal carcinoma. This information can be used for counseling patients diagnosed with metaplastic breast cancer. Further understanding of HER2 positive metaplastic breast cancer could offer insights for the development of therapeutic approaches to metaplastic breast cancer more broadly.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment.

BACKGROUND: High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients. METHODS: Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared. RESULTS: NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients. CONCLUSIONS: Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

Impact of vitamin D on pathological complete response and survival following neoadjuvant chemotherapy for breast cancer: a retrospective study.

BACKGROUND: There has been interest in the potential benefit of vitamin D (VD) to improve breast cancer outcomes. Pre-clinical studies suggest VD enhances chemotherapy-induced cell death. Vitamin D deficiency was associated with not attaining a pathologic complete response (pCR) following neoadjuvant chemotherapy (NAC) for operable breast cancer. We report the impact of VD on pCR and survival in an expanded cohort. METHODS: Patients from Iowa and Montpellier registries who had serum VD level measured before or during NAC were included. Vitamin D deficiency was defined as < 20 ng/mL. Pathological complete response was defined as no residual invasive disease in the breast and lymph nodes. Survival was defined from the date of diagnosis to the date of relapse (PFS) or date of death (OS). RESULTS: The study included 327 women. Vitamin D deficiency was associated with the odds of not attaining pCR (p = 0.04). Fifty-four patients relapsed and 52 patients died. In multivariate analysis, stage III disease, triple-negative (TN) subtype and the inability to achieve pCR were independently associated with inferior survival. Vitamin D deficiency was not significantly associated with survival in the overall sample; however a trend was seen in the TN (5-years PFS 60.4% vs. 72.3%, p = 0.3), and in the hormone receptor positive /human epidermal growth factor receptor 2 negative (HER2-) subgroups (5-years PFS 89% vs 78%, p = 0.056). CONCLUSION: Vitamin D deficiency is associated with the inability to reach pCR in breast cancer patients undergoing NAC.

Male Breast Cancer as a Second Primary Cancer: Increased Risk Following Lymphoma.

BACKGROUND: Male breast cancer (MBC) as a second primary cancer (SPC) has a known association with prior MBC. However, its association with non-breast index malignancies, relative to population risk, has not been previously reported. MATERIALS AND METHODS: Using Surveillance, Epidemiology, and End Results program (9 catchment area) data, we identified MBCs diagnosed from 1973-2012 as their SPC. Information regarding the index malignancy was also obtained. Standardized incidence ratios (SIR) of MBC as SPC were estimated, along with incidence rates and trends. Kaplan-Meier curves were used to estimate survival. RESULTS: Over a 38-year period, 464 MBCs were identified as SPC. The most common index malignancies were breast (SIR 30.86, 95% confidence interval [CI] 21.50-42.92, p < .001), lymphoma (SIR 1.58, 95% CI 1.08-2.22, p = .014), melanoma (SIR 1.26, 95% CI 0.80-1.89), urinary (SIR 1.05, 95% CI 0.74-1.43), colorectal (SIR 0.94, 95% CI 0.69-1.24), and prostate (SIR 0.93 95% CI 0.81-1.07). Apart from the known association with prior breast cancer, the only significant association was with lymphoma as an index cancer, although not significant with a Bonferroni correction. From 1975-2012, incidence of breast cancer as a first cancer increased at an annual percentage change of 1.3% while breast cancer as a SPC increased at 4.7% (both p values < .001). CONCLUSION: Male breast cancer as a SPC has increased markedly over 4 decades. Men with a history of lymphoma may experience higher-than-expected rates of breast SPC. These observations warrant further research, and suggest possible etiologic connections with disease biology, prior therapy, or genetics. IMPLICATIONS FOR PRACTICE: This study reports that men are presenting more frequently to the clinic with breast cancer, both as an initial cancer and as a second cancer following an earlier malignancy. We also report the novel observation that men who survive lymphoma are at increased risk of developing a subsequent breast cancer. Further work is needed to better understand possible treatment or biologic causes of this association. More immediately, these findings suggest the need for heightened vigilance for male breast cancer overall and, in particular, for male lymphoma survivors.

Variation in geographic access to chemotherapy by definitions of providers and service locations: a population-based observational study.

BACKGROUND: An aging population, with its associated rise in cancer incidence and strain on the oncology workforce, will continue to motivate patients, healthcare providers and policy makers to better understand the existing and growing challenges of access to chemotherapy. Administrative data, and SEER-Medicare data in particular, have been used to assess patterns of healthcare utilization because of its rich information regarding patients, their treatments, and their providers. To create measures of geographic access to chemotherapy, patients and oncologists must first be identified. Others have noted that identifying chemotherapy providers from Medicare claims is not always straightforward, as providers may report multiple or incorrect specialties and/or practice in multiple locations. Although previous studies have found that specialty codes alone fail to identify all oncologists, none have assessed whether various methods of identifying chemotherapy providers and their locations affect estimates of geographic access to care. METHODS: SEER-Medicare data was used to identify patients, physicians, and chemotherapy use in this population-based observational study. We compared two measures of geographic access to chemotherapy, local area density and distance to nearest provider, across two definitions of chemotherapy provider (identified by specialty codes or billing codes) and two definitions of chemotherapy service location (where chemotherapy services were proven to be or possibly available) using descriptive statistics. Access measures were mapped for three representative registries. RESULTS: In our sample, 57.2 % of physicians who submitted chemotherapy claims reported a specialty of hematology/oncology or medical oncology. These physicians were associated with 91.0 % of the chemotherapy claims. When providers were identified through billing codes instead of specialty codes, an additional 50.0 % of beneficiaries (from 23.8 % to 35.7 %) resided in the same ZIP code as a chemotherapy provider. Beneficiaries were also 1.3 times closer to a provider, in terms of driving time. Our access measures did not differ significantly across definitions of service location. CONCLUSIONS: Measures of geographic access to care were sensitive to definitions of chemotherapy providers; far more providers were identified through billing codes than specialty codes. They were not sensitive to definitions of service locations, as providers, regardless of how they are identified, generally provided chemotherapy at each of their practice locations.

Surgical Management of Breast Cancer in 2010-2011 SEER Registries by Hormone and HER2 Receptor Status.

BACKGROUND: Although locoregional recurrence is known to affect overall survival for operable breast cancer, the impact of receptor status on locoregional control is debated. Currently, hormone receptor (HR) and human epidermal growth factor receptor-2 (HER2) status are generally not considered relevant to surgical choice. This study examines recent population-level surgical trends with regard to receptor status. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) data to identify stage I-III female breast cancers diagnosed from 2010 to 2011. Patients were categorized by HR and HER2 receptor status. Univariate and multivariate logistic regressions were used to assess factors associated with undergoing mastectomy and the choice of contralateral prophylactic mastectomy (CPM). RESULTS: The overall mastectomy rate for the 87,504 women diagnosed in 2010-2011 was 43.4 %. On multivariate analysis, the odds of receiving mastectomy was greater for HER2-positive disease with either HR-negative or HR-positive status, than for women with HER2-negative/HR-positive disease (odds ratio 1.73 and 1. 31, respectively; all p values <0.001). Age, stage, marital status, race, and year of diagnosis also correlated with mastectomy. Triple-negative breast cancer (TNBC) was associated with CPM, while HER2 status was not. The mastectomy rate, which increased overall from 2006 to 2010, has continued to increase for stage III disease but has decreased for stage I disease. Mastectomy rates overall were lower in 2011 than 2010 (p = 0.012). CONCLUSIONS: HER2-positive disease and TNBC were independent predictors of more extensive surgery in this large, recent, population-based cohort. Although mastectomy rates have continued to increase for stage III disease, mastectomy rates overall were lower in 2011 than in previous years.

Statin use after acute myocardial infarction by patient complexity: are the rates right?

BACKGROUND: Guidelines suggest statin use after acute myocardial infarction (AMI) should be close to universal in patients without safety concerns yet rates are much lower than recommended, decline with patient complexity, and display substantial geographic variation. Trial exclusions have resulted in little evidence to guide statin prescribing for complex patients. OBJECTIVE: To assess the benefits and risks associated with higher rates of statin use after AMI by baseline patient complexity. RESEARCH DESIGN: Sample includes Medicare fee-for-service patients with AMIs in 2008-2009. Instrumental variable estimators using variation in local area prescribing patterns by statin intensity as instruments were used to assess the association of higher statin prescribing rates by statin intensity on 1-year survival, adverse events, and cost by patient complexity. RESULTS: Providers seem to have individualized statin use across patients based on potential risks. Higher statin rates for noncomplex AMI patients were associated with increased survival rates with little added adverse event risk. Higher statin rates for complex AMI patients were associated with tradeoffs between higher survival rates and higher rates of adverse events. CONCLUSIONS: Higher rates of statin use for noncomplex AMI patients are associated with outcome rate changes similar to existing evidence. For the complex patients in our study, who were least represented in existing trials, higher statin-use rates were associated with survival gains and higher adverse event risks not previously documented. Policy interventions promoting higher statin-use rates for complex patients may need to be reevaluated taking careful consideration of these tradeoffs.

Rate of contralateral prophylactic mastectomy is influenced by preoperative MRI recommendations.

BACKGROUND: Women with breast cancer increasingly undergo contralateral prophylactic mastectomy (CPM). We evaluated the relationship between preoperative magnetic resonance imaging (MRI) findings and CPM. Other clinicopathologic variables associated with CPM choice and the pathology found in the contralateral breast are also reported. METHODS: Newly diagnosed breast cancer patients were prospectively enrolled in the University of Iowa Breast Molecular Epidemiology Resource. Patients with stages 0-III breast cancer who underwent mastectomy for the index cancer were eligible for this analysis. Univariate logistic regression and a multivariate model were used to identify factors predictive of CPM. RESULTS: Among 134 patients (mean age 54.9 years), 53 (39.6 %) chose CPM. On univariate analysis, patients undergoing CPM were more likely to have a preoperative breast MRI (64.2 vs. 39.5 %, p = 0.006) and to have follow-up testing recommended for the contralateral breast (28.3 vs. 4.9 %, p = 0.001). Univariate analysis also associated CPM with younger age (p < 0.0001), BRCA testing (p < 0.0001), BRCA mutation (p = 0.034) and reconstruction performed (p = 0.001). Median age of youngest child at diagnosis varied significantly between the CPM (15.9 years) and non-CPM (24.3 years) groups (p = 0.0018). On multivariate analysis, MRI follow-up recommendation, young age, reconstruction and human epidermal growth factor receptor 2 (HER2) positivity of the index cancer were significantly associated with CPM. Of the CPM specimens, one (1.8 %) had ductal carcinoma-in situ, which had not been identified on MRI. CONCLUSIONS: Abnormal findings in the contralateral breast on preoperative MRI, as well as young age, reconstruction and HER2-positive status correlated with CPM choice in this cohort. Occult malignancy was rare.

Adherence to Annual Lung Cancer Screening in a Centralized Academic Program.

BACKGROUND: Adherence to lung cancer screening (LCS) protocols is critical for achieving mortality reductions. However, adherence rates, particularly for recommended annual screening among patients with low-risk findings, are often sub-optimal. We evaluated annual LCS adherence for patients with low-risk findings participating in a centralized screening program at a tertiary academic center. PATIENTS AND METHODS: We conducted a retrospective, observational cohort study of a centralized lung cancer screening program launched in July 2018. We performed electronic medical review of 337 patients who underwent low-dose CT (LDCT) screening before February 1, 2021 (to ensure ≥ 15 months follow up) and had a low-risk Lung-RADS score of 1 or 2. Captured data included patient characteristics (smoking history, Fagerstrom score, environmental exposures, lung cancer risk score), LDCT imaging dates, and Lung-RADS results. The primary outcome measure was adherence to annual screening. We used multivariable logistic regression models to identify factors associated with adherence. RESULTS: Overall, 337 patients had an initial Lung-RADS result of 1 (n = 189) or 2 (n = 148). Among this cohort, 139 (73.5%) of Lung-RADS 1 and 111 (75.0%) of Lung-RADS 2 patients completed the annual repeat LDCT within 15 months, respectively. The only patient characteristic associated with adherence was having Medicaid coverage; compared to having private insurance, Medicaid patients were less adherent (adjusted OR = 0.37, 95% CI = 0.15-0.92). No other patient characteristic was associated with adherence. CONCLUSION: Our centralized screening program achieved a high initial annual adherence rate. Although LCS has first-dollar insurance coverage, other socioeconomic concerns may present barriers to annual screening for Medicaid recipients.

Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States.

PURPOSE: The Commission on Cancer (CoC) establishes standards to support multidisciplinary, comprehensive cancer care. CoC-accredited cancer programs diagnose and/or treat 73% of patients in the United States. However, rural patients may experience diminished access to CoC-accredited cancer programs. Our study evaluated distance to hospitals by CoC accreditation status, rurality, and Census Division. METHODS: All US hospitals were identified from public-use Homeland Infrastructure Foundation-Level Data, then merged with CoC-accreditation data. Rural-Urban Continuum Codes (RUCC) were used to categorize counties as metro (RUCC 1-3), large rural (RUCC 4-6), or small rural (RUCC 7-9). Distance from each county centroid to the nearest CoC and non-CoC hospital was calculated using the Great Circle Distance method in ArcGIS. FINDINGS: Of 1,382 CoC-accredited hospitals, 89% were in metro counties. Small rural counties contained a total of 30 CoC and 794 non-CoC hospitals. CoC hospitals were located 4.0, 10.1, and 11.5 times farther away than non-CoC hospitals for residents of metro, large rural, and small rural counties, respectively, while the average distance to non-CoC hospitals was similar across groups (9.4-13.6 miles). Distance to CoC-accredited facilities was greatest west of the Mississippi River, in particular the Mountain Division (99.2 miles). CONCLUSIONS: Despite similar proximity to non-CoC hospitals across groups, CoC hospitals are located farther from large and small rural counties than metro counties, suggesting rural patients have diminished access to multidisciplinary, comprehensive cancer care afforded by CoC-accredited hospitals. Addressing distance-based access barriers to high-quality, comprehensive cancer treatment in rural US communities will require a multisectoral approach.

Rural comprehensive cancer care: Qualitative analysis of current challenges and opportunities.

PURPOSE: While limited resources can make high-quality, comprehensive, coordinated cancer care provision challenging in rural settings, rural cancer patients often rely on local hospitals for care. To develop resources and strategies to support high-quality local cancer care, it is critical to understand the current experiences of rural cancer care physicians, including perceived strengths and challenges of providing cancer care in rural areas.  METHODS: Semi-structured interviews were conducted with 13 cancer providers associated with all 12 non-metropolitan/rural Iowa hospitals that diagnose or treat >100 cancer patients annually. Iterative thematic analysis was conducted to develop domains. FINDINGS: Participants identified geographic proximity and sense of community as strengths of local care. They described decision-making processes and challenges related to referring patients to larger centers for complex procedures, including a lack of dedicated navigators to facilitate and track transfers between institutions and occasional lack of respect from academic physicians. Participants reported a desire for strengthening collaborations with larger urban/academic cancer centers, including access to educational opportunities, shared resources and strategies to collect and monitor data on quality, and clinical trials. CONCLUSIONS: Rural cancer care providers are dedicated to providing high-quality care close to home for their patients and would welcome opportunities to increase collaboration with larger centers to improve coordination and comprehensiveness of care, collect and monitor data on quality of care, and access continuing education opportunities. Further research is needed to develop implementation approaches that will extend resources, services, and expertise to rural providers to facilitate high-quality cancer care for all cancer patients.

Association of aphthous ulcers with self-reported symptoms of depression in a sample of smartphone users.

BACKGROUND: Our goal is to examine the association of recurrent aphthous stomatitis (RAS) with symptoms of depression using a smartphone-based questionnaire survey. METHODS: An electronic survey was administered through a smartphone app asking respondents about current depressive symptoms using the Quick Inventory of Depressive Symptoms (QIDS), and asking whether they had ever or recently experienced RAS. Multivariate logistic regression analysis was used to determine associations. RESULTS: A total of 478 individuals completed the survey, with 64% reporting a lifetime prevalence of RAS, and 21% experiencing an aphthous ulcer within the last month. RAS was significantly associated with increased sleep, decreased appetite, low energy, and feeling sluggish. RAS was not associated with overall depression severity as measured by total QIDS score, or with cardinal features of depression such as sadness, insomnia, impaired concentration, self-blame, thoughts of death, or anhedonia. Prevalence of RAS did not differ by age, sex, or smoking status, but was less likely in blacks and Asians compared with whites. CONCLUSIONS: RAS was a common phenomenon in this sample of mostly depressed individuals, and was associated with some neurovegetative symptoms of depression, but not depression severity.

Improving cancer care locally: Study of a hospital affiliate network model.

PURPOSE: The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) increased access to high-quality cancer care for patients treated in community hospitals across the state by leveraging the American College of Surgeons Commission on Cancer (CoC) standards to improve quality among its member sites. This study describes the network activities and services identified as most helpful or effective to its members, as well as the perceived value of joining MCCAN or pursing accreditation. METHODS: An independent research team conducted in-depth, semistructured interviews with 18 administrators and clinicians from 10 MCCAN hospitals in 2019. Interviews were transcribed and a thematic analysis was conducted. FINDINGS: Network affiliation and CoC accreditation were perceived as helpful to improving quality of care. Having both clinician and administrative champions were key facilitators to achieving CoC standards and made mentoring of member sites a critical activity of the Network. Other components identified as valuable and/or key to the Network's success included providing access to specific CoC-required clinical services (eg, genetic counseling); offering regular performance monitoring and individualized feedback; establishing a culture of quality improvement; and fostering trust within the Network with patient referrals (ie, sending patients back to their local hospital for ongoing care). CONCLUSIONS: Quality improvement in community cancer programs is challenging but several strategies were identified by members as valuable and effective. Efforts to disseminate the MCCAN model should focus on identifying the needs of community hospitals, implementing a quality monitoring system, and fostering site-level champions who can be influential drivers of change.

Generating Practice-Based Evidence in the Use of Guideline-Recommended Combination Therapy for Secondary Prevention of Acute Myocardial Infarction.

Background: Clinical guidelines recommend beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, and statins for the secondary prevention of acute myocardial infarction (AMI). It is not clear whether variation in real-world practice reflects poor quality-of-care or a balance of outcome tradeoffs across patients. Methods: The study cohort included Medicare fee-for-service beneficiaries hospitalized 2007-2008 for AMI. Treatment within 30-days post-discharge was grouped into one of eight possible combinations for the three drug classes. Outcomes included one-year overall survival, one-year cardiovascular-event-free survival, and 90-day adverse events. Treatment effects were estimated using an Instrumental Variables (IV) approach with instruments based on measures of local-area practice style. Pre-specified data elements were abstracted from hospital medical records for a stratified, random sample to create "unmeasured confounders" (per claims data) and assess model assumptions. Results: Each drug combination was observed in the final sample (N = 124,695), with 35.7% having all three, and 13.5% having none. Higher rates of guideline-recommended treatment were associated with both better survival and more adverse events. Unmeasured confounders were not associated with instrumental variable values. Conclusions: The results from this study suggest that providers consider both treatment benefits and harms in patients with AMIs. The investigation of estimator assumptions support the validity of the estimates.