Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California.

PURPOSE: We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival. METHODS: This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model. RESULTS: 4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS. CONCLUSIONS: Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.

Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer.

BACKGROUND: National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance. OBJECTIVE: This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence. DESIGN: This was a retrospective study. SETTINGS: The study was conducted using the California Cancer Registry. PATIENTS: This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care. MAIN OUTCOME MEASURES: ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models. RESULTS: A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34). LIMITATIONS: Limitations included unmeasured confounders and the retrospective nature of the review. CONCLUSIONS: Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 . EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO: ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).

Hyperthermic intraperitoneal chemotherapy for epithelial ovarian cancer: A meta-analysis.

BACKGROUND: The value of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of cytoreductive surgery (CRS) for epithelial ovarian cancer (EOC) is controversial and its use remains experimental in most national and international guidelines. We wished to systematically evaluate all available evidence. METHODS: A comprehensive review of data from MEDLINE, EMBASE, and Cochrane Library databases was conducted from the first report on HIPEC in EOC till April 3, 2022. Progression-free survival (PFS) and overall survival (OS) were compared between the HIPEC and control groups. This meta-analysis was registered with PROSPERO (CRD42021265810). RESULTS: Fifteen studies (10 case-control studies and 5 randomized controlled trials [RCTs]) were included in the present meta-analysis. Based on the time interval between the last systemic chemotherapy exposure and timing of CRS +/- HIPEC, all studies and patients' cohorts we classified into recent (<6 months; n = 9 studies/patients cohorts) and non-recent (≥6 months, n = 8 studies/patients cohorts) chemotherapy exposure groups. In the recent chemotherapy exposure group, HIPEC was associated with improvement of both PFS (HR, 0.585; 95% CI, 0.422-0.811) and OS (HR, 0.519; 95% CI, 0.346-0.777). On the contrary, in the non-recent chemotherapy exposure group, HIPEC failed to significantly affect PFS (HR, 1.037; 95% CI, 0.684-1.571) or OS (HR, 0.932; 95% CI, 0.607-1.430). Consistent results were observed in subsequent sensitivity analyses. CONCLUSION: Our present meta-analysis demonstrates that the value of HIPEC at CRS for EOC appears to depend on the timing of the last systemic chemotherapy exposure. Future trials are awaited to define the role of HIPEC in EOC.

Racial-Ethnic and Socioeconomic Disparities in Guideline-Adherent Treatment for Endometrial Cancer.

OBJECTIVE: To evaluate the association of race-ethnicity and neighborhood socioeconomic status with adherence to National Comprehensive Cancer Network guidelines for endometrial carcinoma. METHODS: Data are from the SEER (Surveillance, Epidemiology, and End Results) cancer registry of women diagnosed with endometrial carcinoma for the years 2006-2015. The sample included 83,883 women after inclusion and exclusion criteria were applied. Descriptive statistics, bivariate analyses, univariate, and multivariate logistic regression models were performed to evaluate the association between race-ethnicity and neighborhood socioeconomic status with adherence to treatment guidelines. RESULTS: After controlling for demographic and clinical covariates, Black (odds ratio [OR] 0.89, P<.001), Latina (OR .92, P<.001), and American Indian or Alaska Native (OR 0.82, P=.034) women had lower odds of receiving adherent treatment and Asian (OR 1.14, P<.001) and Native Hawaiian or Pacific Islander (OR 1.19 P=.012) women had higher odds of receiving adherent treatment compared with White women. After controlling for covariates, there was a gradient by neighborhood socioeconomic status: women in the high-middle (OR 0.89, P<.001), middle (OR 0.84, P<.001), low-middle (OR 0.80, P<.001), and lowest (OR 0.73, P<.001) neighborhood socioeconomic status categories had lower odds of receiving adherent treatment than the those in the highest neighborhood socioeconomic status group. CONCLUSIONS: Findings from this study suggest there are racial-ethnic and neighborhood socioeconomic disparities in National Comprehensive Cancer Network treatment adherence for endometrial cancer. Standard treatment therapies should not differ based on sociodemographics. Interventions are needed to ensure that equitable cancer treatment practices are available for all individuals, regardless of racial-ethnic or socioeconomic background.

Guideline-adherent treatment, sociodemographic disparities, and cause-specific survival for endometrial carcinomas.

BACKGROUND: Adherence to National Comprehensive Cancer Network guidelines have been adopted as the standard of care for various cancers and have been cited to have survival benefits. Few studies have examined the association of adherent treatment and endometrial cancer survival among various racial/ethnic groups and socioeconomic statuses. METHODS: Between January 1, 2006 and December 31, 2015, 83,673 women diagnosed with endometrial carcinomas were identified from the Surveillance, Epidemiology, and End Results database. Descriptive statistics of demographic and clinical characteristics were performed. Cox-proportional hazards models were used to examine the effect on cause-specific survival for adherence to guidelines across racial/ethnic and socioeconomic groups. RESULTS: Within our sample, 59.5% were treated according to guidelines. Nonadherence to treatment guidelines was significantly associated with decreased survival compared with adherent care (adjusted hazard ratio [HR], 1.59; 95% CI, 1.52-1.67). Being of Black (adjusted HR, 1.41; 95% CI, 1.32-1.51) or Native Hawaiian/Pacific Islander (adjusted HR, 1.44; 95% CI, 1.19-1.73) race/ethnicity compared with White women was significantly associated with worse survival. Being of Asian race/ethnicity (adjusted HR, 0.86, 95% CI, 0.78-0.94) was significantly associated with improved survival compared with White women. Lower neighborhood socioeconomic status was associated with a negative effect on survival relative to women in the highest socioeconomic status category. CONCLUSIONS: Findings from this study suggest treatment adherence is an independent predictor of improved survival; however, improved survival was not observed equally among all racial/ethnic and socioeconomic status groups. LAY SUMMARY: The National Comprehensive Cancer Network (NCCN) has developed guidelines for physicians to follow in treating various cancers. Within this study of 83,673 women with endometrial cancer, 59.5% of women were treated according to the NCCN guidelines. The findings suggest following NCCN guidelines for treatment of endometrial cancer improves survival. Black or Native Hawaiian/Pacific Islander race and lower neighborhood socioeconomic status has worse survival rates compared with other groups, indicating the importance of exploring other factors that may shape treatment across racial/ethnic and socioeconomic status groups.

Ovarian cancer in California: Guideline adherence, survival, and the impact of geographic location, 1996-2014.

BACKGROUND: Evidence suggests that geographic location may independently contribute to ovarian cancer survival. We aimed to investigate how the association between residential location and ovarian cancer-specific survival in California varies by race/ethnicity and socioeconomic status. METHODS: Additive Cox proportional hazard models were used to predict hazard ratios (HRs) and 95% confidence intervals (CI) for the association between geographic location throughout California and survival among 29,844 women diagnosed with epithelial ovarian cancer between 1996 and 2014. We conducted permutation tests to determine a global P-value for significance of location. Adjusted analyses considered distance traveled for care, distance to closest high-quality-of-care hospital, and receipt of National Comprehensive Cancer Network guideline care. Models were also stratified by stage, race/ethnicity, and socioeconomic status. RESULTS: Location was significant in unadjusted models (P = 0.009 among all stages) but not in adjusted models (P = 0.20). HRs ranged from 0.81 (95% CI: 0.70, 0.93) in Southern Central Valley to 1.41 (95% CI: 1.15, 1.73) in Northern California but were attenuated after adjustment (maximum HR = 1.17, 95% CI: 1.08, 1.27). Better survival was generally observed for patients traveling longer distances for care. Associations between survival and proximity to closest high-quality-of-care hospitals were null except for women of lowest socioeconomic status living furthest away (HR = 1.22, 95% CI: 1.03, 1.43). CONCLUSIONS: Overall, geographic variations observed in ovarian cancer-specific survival were due to important predictors such as receiving guideline-adherent care. Improving access to expert care and ensuring receipt of guideline-adherent treatment should be priorities in optimizing ovarian cancer survival.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer.

OBJECTIVES/HYPOTHESIS: To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS: Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS: Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals. CONCLUSIONS: A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care. LEVEL OF EVIDENCE: NA Laryngoscope, 130:672-678, 2020.

It's time to warm up to hyperthermic intraperitoneal chemotherapy for patients with ovarian cancer.

The peritoneal spread of ovarian cancer makes it a potential target for hyperthermic intraperitoneal chemotherapy (HIPEC). Intraperitoneal delivery exposes the tumor to concentrations of cytotoxic drugs much greater than with intravenous delivery, and in vitro studies have also shown that combining hyperthermia and platinum leads to an additive cytotoxic effect. Pharmacokinetic analyses have confirmed very high concentrations of cytotoxic drugs in the peritoneal cavity, with minimal systemic exposure and toxicity. The majority of historical data evaluating HIPEC in ovarian cancer are based on retrospective research, which included heterogeneous groups of patients and drugs used for HIPEC. Recent publications on the findings of prospective studies, including the first randomized trial in which the only difference in intervention was the addition of HIPEC with cisplatin to interval debulking surgery in stage III patients, have shown a benefit in favor of HIPEC. Yet, a recent prospective study from Korea did not find a benefit. Opponents of HIPEC have cited higher rates of complications with this approach, yet most of the serious adverse events observed are likely related to the surgery itself, and are comparable to the rates reported in studies evaluating cytoreductive surgery without HIPEC. Findings from a recent randomized controlled trial showed no delays in initiation or completion of postoperative chemotherapy in patients treated with HIPEC. A growing body of evidence is indicating that it might be time to seriously consider HIPEC as a complementary treatment at the time of cytoreductive surgery for patients with advanced-stage ovarian cancer in the setting of an experienced center. Yet, more research is needed to identify the population of patients who gain the most benefit from this therapy.

Disparities in Adherence to National Comprehensive Cancer Network Treatment Guidelines and Survival for Stage IB-IIA Cervical Cancer in California.

OBJECTIVE: To evaluate the association of sociodemographic and hospital characteristics with adherence to National Comprehensive Cancer Network treatment guidelines for stage IB-IIA cervical cancer and to analyze the relationship between adherent care and survival. METHODS: This is a retrospective population-based cohort study of patients with stage IB-IIA invasive cervical cancer reported to the California Cancer Registry from January 1, 1995, through December 31, 2009. Adherence to National Comprehensive Cancer Network guideline care was defined by year- and stage-appropriate surgical procedures, radiation, and chemotherapy. Multivariate logistic regression, Kaplan-Meier estimate, and Cox proportional hazard models were used to examine associations between patient, tumor, and treatment characteristics and National Comprehensive Cancer Network guideline adherence and cervical cancer-specific 5-year survival. RESULTS: A total of 6,063 patients were identified. Forty-seven percent received National Comprehensive Cancer Network guideline-adherent care, and 18.8% were treated in high-volume centers (20 or more patients/year). On multivariate analysis, lowest socioeconomic status (adjusted odds ratio [OR] 0.69, 95% CI 0.57-0.84), low-middle socioeconomic status (adjusted OR 0.76, 95% CI 0.64-0.92), and Charlson-Deyo comorbidity score 1 or higher (adjusted OR 0.78, 95% CI 0.69-0.89) were patient characteristics associated with receipt of nonguideline care. Receiving adherent care was less common in low-volume centers (45.9%) than in high-volume centers (50.9%) (effect size 0.90, 95% CI 0.84-0.96). Death from cervical cancer was more common in the nonadherent group (13.3%) than in the adherent group (8.6%) (effect size 1.55, 95% CI 1.34-1.80). Black race (adjusted hazard ratio 1.56, 95% CI 1.08-2.27), Medicaid payer status (adjusted hazard ratio 1.47, 95% CI 1.15-1.87), and Charlson-Deyo comorbidity score 1 or higher (adjusted hazard ratio 2.07, 95% CI 1.68-2.56) were all associated with increased risk of dying from cervical cancer. CONCLUSION: Among patients with early-stage cervical cancer, National Comprehensive Cancer Network guideline-nonadherent care was independently associated with increased cervical cancer-specific mortality along with black race and Medicaid payer status. Nonadherence was more prevalent in patients with older age, lower socioeconomic status, and receipt of care in low-volume centers. Attention should be paid to increase guideline adherence.

Factors Predicting Use of Neoadjuvant Chemotherapy Compared With Primary Debulking Surgery in Advanced Stage Ovarian Cancer-A National Cancer Database Study.

OBJECTIVES: We performed a patterns-of-care study to characterize the types of patients with epithelial ovarian cancer (EOC) who received neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) using the National Cancer Database (NCDB). METHODS: We identified patients with stages IIIC and IV EOC in the NCDB diagnosed from 2003 to 2011. Patients who received chemotherapy (CT) prior to surgery were classified as receiving NACT; if surgery preceded CT, then it was classified as PDS. Data collected from the NCDB included demographics, medical comorbidity index, cancer characteristics and treatment, and hospital characteristics. Univariate and multivariable analyses were performed using χ test, logistic regression, log-rank test, and Cox proportional hazards modeling as indicated. Statistical significance was set at P < 0.05. RESULTS: A total of 62,727 patients with stages IIIC and IV EOC were identified. The sequence of surgery and CT was identified, of which 6922 (11%) had NACT and 31,280 (50%) had PDS. Neoadjuvant CT was more frequently done in stage IV than stage IIIC (13% vs 9%), and its use markedly increased over time. Variables associated with increased likelihood of NACT use were as follows: age older than 50 years and those with higher comorbidities, stage IV, and higher-grade EOC. Neoadjuvant CT use was also associated with hospitals that were adherent to the National Comprehensive Cancer Network guidelines, high-volume facilities, those in the Midwest and West, and academic centers. CONCLUSIONS: Evidence suggests that patients with greater adverse risk factors are more likely to receive NACT instead of PDS. Use of NACT has significantly increased over the study period, especially in patients with stage IV ovarian cancer.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for ovarian cancer.

OBJECTIVE: To develop an observed-to-expected ratio (O/E) for adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines as a risk-adjusted hospital measure of quality care correlated with disease-specific survival. METHODS: Consecutive patients with stages I-IV epithelial ovarian cancer were identified from the California Cancer Registry (1/1/96-12/31/06). Using a fit logistic regression model, O/E for guideline adherence was calculated for each hospital and distributed into quartiles stratified by hospital annual case volume: lowest O/E quartile or annual hospital case volume <5, middle two O/E quartiles and volume ≥5, and highest O/E quartile and volume ≥5. A multivariable logistic regression model was used to characterize the independent effect of hospital O/E on ovarian cancer-specific survival. RESULTS: Overall, 18,491 patients were treated at 405 hospitals; 37.3% received guideline adherent care. Lowest O/E hospitals (n=285) treated 4661 patients (25.2%), mean O/E=0.77±0.55 and median survival 38.9months (95%CI=36.2-42.0months). Intermediate O/E hospitals (n=85) treated 8715 patients (47.1%), mean O/E=0.87±0.17 and median survival of 50.5months (95% CI=48.4-52.8months). Highest O/E hospitals (n=35) treated 5115 patients (27.7%), mean O/E=1.34±0.14 and median survival of 53.8months (95% CI=50.2-58.2months). After controlling for other variables, treatment at highest O/E hospitals was associated with independent and statistically significant improvement in ovarian cancer-specific survival compared to intermediate O/E (HR=1.06, 95% CI=1.01-1.11) and lowest O/E (1.16, 95% CI=1.10-1.23) hospitals. CONCLUSIONS: Calculation of hospital-specific O/E for NCCN treatment guideline adherence, combined with minimum case volume criterion, as a measure of ovarian cancer quality of care is feasible and is an independent predictor of survival.

Improving NCCN guideline-adherent care for ovarian cancer: Value of an intervention.

OBJECTIVE: To estimate the potential cost-effectiveness of an intervention to improve adherence to National Comprehensive Cancer Network (NCCN) guideline-based care for ovarian cancer. METHODS: A modified Markov model with a 5-year time horizon estimated the potential cost-effectiveness of an intervention (AD-INT) to improve NCCN-guideline adherence compared to status quo (SQ) levels of adherence. Data were obtained from a population-based analysis of National Cancer Data Base records for ovarian cancer diagnosed from 1998 to 2002 (N=47,160). Cohorts were defined by race and adherence to NCCN guideline-based care. Costs were estimated using 2014 Medicare reimbursements. Incremental cost-effectiveness ratios (ICERs) were calculated in 2014 US dollars per year of life saved (YLS) using the standard threshold of $50,000/YLS. We simulated an AD-INT that reduced non-adherence by 25% and cost at least $100 per patient. One-way sensitivity analyses were performed. RESULTS: Although the individual components of guideline-adherent care are more costly than non-adherent care, a reasonably effective AD-INT is also highly likely to be cost-effective. An AD-INT costing $100 per patient and reducing non-adherence by 25% is cost-effective with an ICER of $22/YLS compared with SQ, while interventions costing over $1000 remain cost-effective, up to a per-patient intervention cost of up to $8000 (targeting only blacks) or $4000 (targeting all patients). CONCLUSIONS: An ovarian cancer intervention that moderately decreases racial disparities in NCCN guideline adherent care or improves adherence for all is potentially cost-effective. Further research may determine which modifiable factors may be targeted to help reduce adherence disparities.

Socioeconomic status as a predictor of adherence to treatment guidelines for early-stage ovarian cancer.

OBJECTIVE: Investigate the impact of socioeconomic status and other demographic variables on adherence to the National Comprehensive Cancer Network ovarian cancer treatment guidelines among patients with stage I/II disease. METHODS: Patients diagnosed with stage I/II epithelial ovarian cancer between 1/1/96-12/31/06 were identified from the California Cancer Registry. Univariate analysis and multivariate logistic regression models were used to evaluate differences in surgical procedures, chemotherapy regimens, and overall adherence to the NCCN guidelines according to increasing SES quintiles (SES-1 to SES-5). RESULTS: A total of 5445 stage I and II patients were identified. The median age at diagnosis was 54.0years (range=18-99years); 72.5% of patients had stage I disease, while 27.5% had stage II disease. With a median follow-up time of 5years, the 5-year ovarian cancer-specific survival for all patients was 82.7% (SE=0.6%). Overall, 23.7% of patients received care that was adherent to the NCCN guidelines. Compared to patients in the highest SES quintile (SES-5), patients in the lowest SES quintile (SES-1) were significantly less likely to receive proper surgery (27.3% vs 47.9%, p<0.001) or chemotherapy (42.4% vs 53.6%, p<0.001). There were statistically significant trends between increasing SES and the likelihood of overall treatment plan adherence to the NCCN guidelines: SES-1=16.4%, SES-2=19.0%, SES-3=22.4%, SES-4=24.2% and SES-5=31.6% (p<0.001). Multivariate logistic regression analysis revealed that compared to SES-5, decreasing SES was independently predictive of a higher risk of non-standard overall care. CONCLUSIONS: For patients with early-stage ovarian cancer, low SES is a significant and independent predictor of deviation from the NCCN guidelines for surgery, chemotherapy, and overall treatment.

Impact of National Cancer Institute Comprehensive Cancer Centers on ovarian cancer treatment and survival.

BACKGROUND: The regional impact of care at a National Cancer Institute Comprehensive Cancer Center (NCI-CCC) on adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines and survival is unclear. STUDY DESIGN: We performed a retrospective population-based study of consecutive patients diagnosed with epithelial ovarian cancer between January 1, 1996 and December 31, 2006 in southern California. Patients were stratified according to care at an NCI-CCC (n = 5), non-NCI high-volume hospital (≥ 10 cases/year, HVH, n = 29), or low-volume hospital (<10 cases/year, LVH, n = 158). Multivariable logistic regression and Cox-proportional hazards models were used to examine the effect of NCI-CCC status on treatment guideline adherence and ovarian cancer-specific survival. RESULTS: A total of 9,933 patients were identified (stage I, 22.8%; stage II, 7.9%; stage III, 45.1%; stage IV, 24.2%), and 8.1% of patients were treated at NCI-CCCs. Overall, 35.7% of patients received NCCN guideline adherent care, and NCI-CCC status (odds ratio [OR] 1.00) was an independent predictor of adherence to treatment guidelines compared with HVHs (OR 0.83, 95% CI 0.70 to 0.99) and LVHs (OR 0.56, 95% CI 0.47 to 0.67). The median ovarian cancer-specific survivals according to hospital type were: NCI-CCC 77.9 (95% CI 61.4 to 92.9) months, HVH 51.9 (95% CI 49.2 to 55.7) months, and LVH 43.4 (95% CI 39.9 to 47.2) months (p < 0.0001). National Cancer Institute Comprehensive Cancer Center status (hazard ratio [HR] 1.00) was a statistically significant and independent predictor of improved survival compared with HVH (HR 1.18, 95% CI 1.04 to 1.33) and LVH (HR 1.30, 95% CI 1.15 to 1.47). CONCLUSIONS: National Cancer Institute Comprehensive Cancer Center status is an independent predictor of adherence to ovarian cancer treatment guidelines and improved ovarian cancer-specific survival. These data validate NCI-CCC status as a structural health care characteristic correlated with superior ovarian cancer quality measure performance. Increased access to NCI-CCCs through regional concentration of care may be a mechanism to improve clinical outcomes.

Sociodemographic disparities in advanced ovarian cancer survival and adherence to treatment guidelines.

OBJECTIVE: To estimate whether race or ethnic and socioeconomic strata are independently associated with advanced-stage ovarian cancer-specific survival after adjusting for adherence to National Comprehensive Cancer Network treatment guidelines. METHODS: The design was a retrospective population-based cohort study of patients with stage IIIC-IV epithelial ovarian cancer identified from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2009). Quartile of census tract median household income was used as the measure of socioeconomic status (quartiles 1-4). A multivariable logistic regression model was used to identify characteristics predictive of adherence to National Comprehensive Cancer Network guidelines for surgery and chemotherapy. Cox proportional hazards models and propensity score matching were used for survival analyses. RESULTS: A total of 10,296 patients were identified, and 30.2% received National Comprehensive Cancer Network guideline-adherent care. Among demographic variables, black race (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.22-1.92) and low socioeconomic status (quartile 1, adjusted OR 1.32, 95% CI 1.14-1.52) were independently associated with nonguideline care. Stratified multivariate survival analysis using the propensity score-matched sample (n=5,124) revealed that deviation from treatment guidelines was associated with a comparable risk of disease-related death across race-ethnicity: whites (adjusted hazard ratio [HR] 1.59, 95% CI 1.48-1.71), blacks (adjusted HR 1.66, 95% CI 1.19-2.30), Asian or Pacific Islanders (adjusted HR 1.52, 95% CI 0.99-1.92), and Hispanics (adjusted HR 1.91, 95% CI 0.98-3.72). Across socioeconomic status, deviation from treatment guidelines was also associated with a comparable risk of ovarian cancer mortality for quartile 1 (adjusted HR 1.69, 95% CI 1.47-1.95), quartile 2 (adjusted HR 1.63, 95% CI 1.42-1.87), quartile 3 (adjusted HR 1.51, 95% CI 1.32-1.73), and quartile 4 (adjusted HR 1.57, 95% CI 1.38-1.79). CONCLUSION: Adherence to treatment guidelines for advanced-stage ovarian cancer is associated with equivalent survival benefit across racial or ethnic and socioeconomic strata. Ensuring equal access to standard treatment is a viable strategic approach to reduce survival disparities.

Spatial analysis of advanced-stage ovarian cancer mortality in California.

OBJECTIVE: We sought to determine the impact of geographic location on advanced-stage ovarian cancer mortality in relation to adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and hospital case volume. STUDY DESIGN: This was a retrospective observational cohort study of patients diagnosed with stage IIIC/IV epithelial ovarian cancer (Jan. 1, 1996, through Dec. 31, 2006) identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, demographic characteristics, disease-related variables, adherence to NCCN guidelines, and hospital case volume, with simultaneous smoothing of geographic location and adjustment for confounding variables. RESULTS: A total of 11,765 patients were identified. Twelve of the 378 hospitals (3.2%) were high-volume hospitals (HVH) (≥20 cases/y) and cared for 2112 patients (17.9%). For all patients, the median distance to an HVH was 22.7 km/14.1 miles and 80% were located within 79.6 km/49.5 miles of an HVH. Overall, 45.4% of patients were treated according to NCCN guidelines. The global test for location revealed that geographic position within the state was significantly correlated with ovarian cancer mortality after adjusting for other variables (P < .001). Distance to receive care ≥32 km/20 miles was protective against mortality (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.79-0.93), while distance from an HVH ≥80 km/50 miles was associated with an increased risk of death (HR, 1.13; 95% CI, 1.03-1.23). The effects of geographic predictors were attenuated when nonadherence to NCCN guidelines (HR, 1.25; 95% CI, 1.18-1.32) and care at an HVH (HR, 0.87; 95% CI, 0.81-0.93) were introduced into the model. CONCLUSION: Geographic location is a significant predictor of advanced-stage ovarian cancer mortality and the effect is primarily related to the likelihood of receiving NCCN guideline adherent care and treatment at an HVH.

Impact of race, socioeconomic status, and the health care system on the treatment of advanced-stage ovarian cancer in California.

OBJECTIVE: We sought to investigate the impact of race, socioeconomic status (SES), and health care system characteristics on receipt of specific components of National Comprehensive Cancer Network guideline care for stage IIIC/IV ovarian cancer. STUDY DESIGN: Patients diagnosed with stage IIIC/IV epithelial ovarian cancer between Jan. 1, 1996, through Dec. 31, 2006, were identified from the California Cancer Registry. Multivariate logistic regression analyses evaluated differences in surgery, chemotherapy, and treatment sequence according to race, increasing SES (SES-1 to SES-5), and provider annual case volume. RESULTS: A total of 11,865 patients were identified. Median age at diagnosis was 65.0 years. The overall median cancer-specific survival was 28.2 months. African American race (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.45-2.87) and care by a low-volume physician (OR, 19.72; 95% CI, 11.87-32.77) predicted an increased risk of not undergoing surgery. Patients with SES-1 (OR, 0.71; 95% CI, 0.60-0.85) and those treated at low-volume hospitals (OR, 0.88; 95% CI, 0.77-0.99) or by low-volume physicians (OR, 0.80; 95% CI, 0.70-0.92) were less likely to undergo debulking surgery. African American race (OR, 1.55; 95% CI, 1.24-1.93) and SES-1 (OR, 1.80; 95% CI, 1.35-2.39) were both significant predictors of not receiving chemotherapy. African American patients were also more likely than whites to receive no treatment (OR, 2.08; 95% CI, 1.45-2.99) or only chemotherapy (OR, 1.55; 95% CI, 1.10-2.18). Patients with low SES were more likely to receive no treatment (OR, 1.95; 95% CI, 1.44-2.64) or surgery without chemotherapy (OR, 1.67; 95% CI, 1.38-2.03). CONCLUSION: Among patients with advanced-stage ovarian cancer, African American race, low SES, and treatment by low-volume providers are significant and independent predictors of receiving no surgery, no debulking surgery, no chemotherapy, and nonstandard treatment sequences.

Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status.

OBJECTIVE: To determine the impact of geographic location on advanced-stage ovarian cancer care adherence to the National Comprehensive Cancer Network (NCCN) guidelines in relation to race and socioeconomic status (SES). METHODS: Patients diagnosed with stage IIIC/IV epithelial ovarian cancer (1/1/96-12/31/06) were identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, proximity to a high-volume hospital (≥20 cases/year), distance traveled to receive care, race, and SES on adherence to NCCN guidelines, with simultaneous smoothing of geographic location and adjustment for confounding variables. Disparities in geographic predictors of treatment adherence were analyzed with the x(2) test for equality of proportions. RESULTS: Of the 11,770 patients identified, 45.4% were treated according to NCCN guidelines. Black race (OR=1.49, 95%CI=1.21-1.83), low-SES (OR=1.46, 95%CI=1.24-1.72), and geographic location ≥80 km/50 mi from a high-volume hospital (OR=1.88, 95%CI=1.61-2.19) were independently associated with an increased risk of non-adherent care, while high-volume hospital treatment (OR=0.59, 95%CI=0.53-0.66) and travel distance to receive care ≥32 km/20 mi (OR=0.80, 95%CI=0.69-0.92) were independently protective. SES was inversely associated with location ≥80 km/50 mi from a high-volume hospital, ranging from 6.3% (high-SES) to 33.0% (low-SES) (p<0.0001). White patients were significantly more likely to travel ≥32 km/20 mi to receive care (21.8%) compared to Blacks (14.4%), Hispanics (15.9%), and Asian/Pacific Islanders (15.5%) (p<0.0001). CONCLUSION: Geographic proximity to a high-volume hospital and travel distance to receive treatment are independently associated with NCCN guideline adherent care for advanced-stage ovarian cancer. Geographic barriers to standard ovarian cancer treatment disproportionately affect racial minorities and women of low-SES.

Intraperitoneal chemotherapy from Armstrong to HIPEC: challenges and promise.

OPINION: The treatment of advanced stage ovarian, primary peritoneal and fallopian tube cancer represents a therapeutic challenge as evidenced by the 70 %-80 % recurrence rate. Our understanding of the synergy between surgical cytoreduction and effective systemic chemotherapy continues to evolve, with research supporting maximal cytoreductive effort followed by intraperitoneal chemotherapy. Specifically, analysis of phase III clinical trials has shown a median survival of 110 months in those treated with intraperitoneal chemotherapy, when surgery results in no visible residual disease. Additionally, incorporation of hyperthermic intraperitoneal chemotherapy at the time of surgical resection has gained attention as an alternate therapeutic option, in an attempt to obviate toxicities encountered with repetitive cycles of intraperitoneal chemotherapy. Currently, surgical cytoreduction in the hands of an experienced gynecologic oncologist, followed by intraperitoneal chemotherapy is thought to portend the greatest survival benefit in patients with advanced stage ovarian cancer spectrum cancers. Additional investigation regarding the oncologic outcomes and morbidity of hyperthermic intraperitoneal chemotherapy is warranted.

Adherence to treatment guidelines for ovarian cancer as a measure of quality care.

OBJECTIVES: To validate National Comprehensive Cancer Network ovarian cancer guideline adherence as a quality process measure associated with improved survival, and to identify structural health care characteristics predictive of adherence to National Comprehensive Cancer Network guideline care. METHODS: Consecutive patients with epithelial ovarian cancer diagnosed between 1 January 1999 and 31 December 2006 were identified from the California Cancer Registry. Adherence to National Comprehensive Cancer Network guideline care was defined by stage-appropriate surgical procedures and recommended chemotherapy. Multivariable logistic regression models were used to identify characteristics predictive of National Comprehensive Cancer Network guideline adherence and ovarian cancer-specific survival. RESULTS: A total of 13,321 patients were identified. Overall, 37.2% of patients received National Comprehensive Cancer Network guideline-adherent care. Guideline-adherent care was associated with high-volume hospitals (20 or more cases per year; 50.8% compared with 34.1%; P<.001) and high-volume physicians (10 or more cases per year; 47.6% compared with 34.5%; P<.001). After controlling for other factors, both low-volume hospitals (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.66-2.01) and low-volume physicians (OR 1.19, 95% CI 1.07-1.32) were independently associated with deviation from National Comprehensive Cancer Network guidelines. On multivariable survival analysis, nonadherence to National Comprehensive Cancer Network guideline care was associated with decreased disease-specific survival (hazard ratio [HR] 1.33, 95% CI 1.26-1.41). Both low-volume hospitals (HR 1.08, 95% CI 1.01-1.16) and low-volume physicians (HR 1.18, 95% CI 1.09-1.28) were associated with decreased disease-specific survival after adjusting for National Comprehensive Cancer Network guideline-adherent care. CONCLUSIONS: Adherence to National Comprehensive Cancer Network guidelines for treatment of ovarian cancer is correlated with improved survival and may be a useful process measure of quality cancer care. Ovarian cancer case volume correlates with a higher likelihood of recommended care and improved survival and may be a useful structural quality measure. Increased efforts to concentrate ovarian cancer care are warranted.