Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer.

OBJECTIVE: The racial gap in surgical treatment for early-stage non-small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level. PATIENTS AND METHODS: We queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year. RESULTS: In total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings. CONCLUSIONS: Trends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.

Utilization of radiation therapy in multiple myeloma: trends and changes in practice.

Plasma cell disorders including plasmacytomas and multiple myeloma (MM) are exquisitely radiosensitive, and thus, radiation therapy (XRT) is used effectively in their management. The role of XRT in the setting of novel MM therapeutics has not been explored. The 2016 National Cancer Database (NCDB) for MM with patients diagnosed between 2004 and 2013 was studied. Association between utilization of XRT as part of initial therapy and patient, disease, or treating facility characteristics was studied. A total of 111,281 cases with 91.6% MM, 7% osseous plasmacytoma (PLA-O), and 1.4% extramedullary plasmacytoma (PLA-E) were identified. XRT was utilized as part of initial therapy in 25.4% cases, including 69.3% of PLA-O, 60% of PLA-E, and 21.5% of MM patients. Patients with PLA-E and MM were significantly less likely to receive XRT as compared to PLA-O (p < 0.001). A significantly decreased use of XRT was noted over time (p < 0.001), and for advancing patient age (p < 0.001), women (p < 0.001), and blacks (p < 0.001), and with increasing income (p = 0.015). Patients with Medicare were less likely to receive XRT (OR 0.86, 95% CI 0.78, 0.94) as compared to uninsured as were those with initial treatment at academic or high-volume facilities and facilities performing stem cell transplant. There was overall decreased utilization of XRT in recent years, possibly due to advent of efficacious systemic agents for MM therapy, with a higher XRT utilization for plasmacytomas. Patterns of XRT use need to be explored prospectively, so that uniform standards of healthcare delivery can be maintained and treatment heterogeneity can be minimized.

The importance of adjuvant treatment and primary anatomical site in head and neck basaloid squamous cell carcinoma survival: an analysis of the National Cancer Database.

PURPOSE: Basaloid squamous cell carcinoma (BSCC) of the head and neck is an aggressive and highly malignant variant of squamous cell carcinoma that accounts for 2% of head and neck cancers. Previous studies have not analyzed the significance of adjuvant chemoradiation and anatomical site within BSCC subtype and its impact on survival. METHODS: A cohort of 1999 patients with BSCC of the head and neck was formed from the National Cancer Database and analyzed with descriptive studies, median survival and 5- and 10-year survival. A multivariable Cox hazard regression was performed to determine the prognostic significance of anatomical site and adjuvant therapy. RESULTS: The most common primary anatomical site was the oropharynx (71.9%) followed by oral cavity (11.5%), larynx (10.1%), hypopharynx (3.5%), esophagus (1.9%), and nasopharynx (1.1%). The presence of metastasis increased the risk of mortality (HR = 2.14; 95% CI 1.40-3.26). Tumors localized to the oropharynx demonstrated better survival compared to all sites except nasopharynx, including the oral cavity (HR = 2.45; 95% CI 1.83-3.29), hypopharynx (HR = 2.58; 95% CI:1.64-4.05), and larynx (HR = 2.89; 95% CI:2.25-3.73). Adjuvant chemoradiation (HR = 0.36; 95% CI 0.23-0.58) and adjuvant radiation (HR = 0.38; 95% CI 0.23-0.64) had better survival outcomes compared to adjuvant chemotherapy. Patients with microscopic margins had better survival outcomes when compared to no surgery (HR = 0.38, 98% Cl 0.23-0.64) while there were no better survival outcomes of patients with macroscopic margins compared to no surgery. CONCLUSION: This study illustrated that tumors in the oropharynx, lower age, adjuvant chemoradiation and radiation, and microscopic margins were associated with greater survival.

Sinonasal mucoepidermoid carcinoma: a review of the National Cancer Database.

BACKGROUND: Primary sinonasal mucoepidermoid carcinoma (SN-MEC) is a malignancy arising from seromucinous glands of the nasal cavity and paranasal sinuses. Given its rarity, few large-scale studies have been performed. In this study we describe the incidence and determinants of survival of patients with SN-MEC leveraging the National Cancer Database (NCDB). METHODS: This was a retrospective, population-based cohort study of patients diagnosed with SN-MEC between 2004 and 2012 within the NCDB. The main outcome measure was overall survival (OS). RESULTS: A total of 164 patients were identified. The cohort was composed of 47.6% males. Mean age at diagnosis was 59.7 years. The maxillary sinus was the most common primary site, accounting for 45.7% of cases. Eleven percent of patients presented with nodal disease, whereas 2.1% had distant metastases. Stage IV disease was seen in 30.4% of cases. A total of 79.8% of the patients underwent surgery, 61.0% received radiation therapy, and 15.1% had chemotherapy. OS at 1, 2, and 5 years was 83%, 77.0%, and 57%, respectively. On multivariate analysis, Medicaid insurance status (hazard ratio [HR], 7.29; 95% confidence interval [CI], 1.74-30.57), advanced tumor size (HR, 4.94; 95% CI, 1.19-20.5), and advanced nodal disease (N1: HR, 9.48; 95% CI, 1.66-54.23; N2B: HR, 19.3; 95% CI, 1.07-350.64) were associated with worse OS. CONCLUSION: Mucoepidermoid carcinoma is the most common salivary gland malignancy but a rare sinonasal malignancy, with 5-year survival for SN-MEC approximating 50%. A significant proportion of patients present with advanced disease. Both socioeconomic factors and tumor characteristics are associated with survival.

National patterns of care for early-stage penile cancers in the United States: How is radiation and brachytherapy utilized?

PURPOSE: Per American Brachytherapy Society guidelines, cT1-2N0 penile cancers <4 cm in diameter are excellent candidates for curative brachytherapy. Using that criterion, we evaluated national patterns of care and predictors of use of radiation techniques using the National Cancer Database. METHODS AND MATERIALS: The National Cancer Database was queried for men with cT1-2N0 penile cancers <4 cm in size. Comparative statistics for treatment modality were generated using bivariate logistic regression analysis. RESULTS: Among 1235 cases eligible for analysis, median age was 69 years. Median tumor size was 2.0 cm. 95.8% of men underwent surgery alone, with 91 (7.4%) undergoing radical penectomy, 673 (54.5%) partial penectomy, and 419 (33.9%) cosmesis-preserving surgical procedure. Only 4 (0.3%) men were treated with brachytherapy alone, 48 (3.9%) with external-beam radiation therapy (EBRT) alone, and 8 (0.6%) with EBRT after surgery. Surgical margins were positive in 118 (9.6%) patients, 14 of whom received adjuvant EBRT (11.9%) and two adjuvant brachytherapy (1.7%). There was no difference in demographic or clinical characteristics in groups treated with surgery vs. radiation (all p > 0.2). Age >70, lesions >2 cm, and T2 tumors were more likely to undergo non-organ-preserving therapy vs. radiation or a cosmesis-preserving procedure (all p < 0.05). The propensity-matched 5-year survival was not different between definitive radiation vs. surgery (61.6% vs. 62.2%, p = 0.70). CONCLUSIONS: Men with penile-preserving eligible lesions in the United States are overwhelmingly treated with surgery. Penile-preserving radiation techniques including brachytherapy and EBRT are underutilized and should be offered as curative interventions.

Adenoid cystic carcinoma of the sinonasal tract: a review of the national cancer database.

BACKGROUND: Sinonasal adenoid cystic carcinoma (SNACC) is a rare malignancy with a propensity for distant metastasis. In this study we describe the incidence and determinants of survival among patients with SNACC between the years 2004 and 2012 using the National Cancer Database (NCDB). METHODS: This was a retrospective, population-based cohort study performed at a tertiary academic medical center. All participants were diagnosed with SNACC between 2004 and 2012 within the NCDB. The main outcome was overall survival (OS). RESULTS: A total of 793 patients were identified. The cohort was composed of 46.9% males. Mean age at diagnosis was 59.6 years. The maxillary sinus was the most common primary site (49.7%). Nodal disease was seen in 3.6% of the patients, whereas 3.7% had distant metastases. Stage IV disease was seen in 49.1% of cases. In total, 77.4% of patients underwent surgery, 68.2% received radiation therapy, and 16.4% had chemotherapy. Median OS was 78.5 months; OS at 1, 2, and 5 years was 91%, 83%, and 61%, respectively. On multivariate analysis, advanced age (p = 0.001), frontal sinus primary site (p < 0.001), positive margins (p < 0.001), Charlson comorbidity index >0 (p = 0.01), residing in an urban setting (p = 0.04), poorly differentiated or undifferentiated tumor grade (p = 0.003), and advanced tumor stage (p = 0.01) were associated with worse OS, whereas surgery (p < 0.001), but not radiation therapy (p = 0.52) or chemotherapy (p = 0.57), predicted improved OS. CONCLUSION: Predictors of survival in SNACC include age, comorbidity status, grade, and stage. Surgery is associated with improved survival and remains the mainstay of therapy, whereas the roles of radiation therapy and chemotherapy require future investigation.

Prostate brachytherapy, either alone or in combination with external beam radiation, is associated with longer overall survival in men with favorable pathologic Group 4 (Gleason score 8) prostate cancer.

PURPOSE: Conventional prostate cancer risk stratification results in considerable heterogeneity within each prognostic group. Men with pathologic grade Group 4 (Gleason score 8) but otherwise low-risk features have been identified as a favorable subset of high-risk prostate cancer. Given recent randomized data supporting improved cancer outcome with brachytherapy in intermediate- and high-risk prostate cancer, we sought to evaluate brachytherapy utilization and overall survival (OS) for these patients. METHODS AND MATERIALS: We queried the National Cancer Database for clinical T1c-T2a N0 M0 prostate cancer with prostate-specific antigen <10 ng/mL and Gleason score 8 adenocarcinoma on biopsy. All patients received androgen deprivation therapy and either external beam radiation therapy (EBRT) alone, brachytherapy alone, or a combination of EBRT with brachytherapy boost (brachytherapy + EBRT). Kaplan-Meier OS estimates as well as univariate and multivariate Cox proportional hazards regression analyses were performed. Propensity score-matched analyses were performed to further control for baseline confounders. RESULTS: Four thousand four hundred ninety-six patients were identified with a median followup of 62.5 months (range, 2.3-119.8). Median age was 72 years (range, 41-90+). Utilization of brachytherapy decreased from 2004 to 2009. The odds ratio for brachytherapy by year (continuous variable) was 0.86 (p < 0.001). Five-year OS was 84%, 88%, and 89% for the EBRT alone, brachytherapy alone, and brachytherapy + EBRT groups, respectively. On multivariate analysis, higher median income, low comorbidity score, and treatment with brachytherapy alone (hazard ratio, 0.66; p = 0.005) or brachytherapy + EBRT (hazard ratio, 0.70; p = 0.001) remained associated with longer OS. Propensity score matching confirmed longer OS associated with either brachytherapy regimen. CONCLUSIONS: Of those men with World Health Organization pathologic grade Group 4 (Gleason score 8) prostate cancer and otherwise favorable prognostic features treated with androgen deprivation therapy and radiation therapy, longer OS was achieved when prostate brachytherapy was included, whether used alone or in combination with supplemental EBRT. In spite of these excellent outcomes, prostate brachytherapy utilization is declining in the United States.

Brachytherapy boost for prostate cancer: Trends in care and survival outcomes.

PURPOSE: Androgen suppression combined with elective nodal and dose-escalated radiation therapy recently demonstrated an improved biochemical failure-free survival in men who received external beam radiation therapy (EBRT) plus a brachytherapy boost (BB) compared with dose-escalated external beam radiotherapy (DE-EBRT). We sought to analyze the factors predictive for use of EBRT + BB as compared with DE-EBRT and report resulting survival outcomes on a national level using a hospital-based registry. METHODS AND MATERIALS: We identified 113,719 men from the National Cancer Database from 2004 to 2013 with intermediate- or high-risk prostate cancer who were treated with EBRT + BB or DE-EBRT. We performed univariate and multivariate analyses of all available factors potentially predictive of receipt of treatment selection. Survival was evaluated in a multivariable model with propensity adjustment. RESULTS: For intermediate-risk patients, utilization of BB decreased from 33.1% (n = 1742) in 2004 to 12.5% (n = 766) in 2013 and for high-risk patients, utilization dropped from 27.6% (n = 879) to 10.8% (n = 479). Numerous factors predictive for use of BB were identified. Cox proportional hazards analysis was performed-adjusting for age, Charlson-Deyo comorbidity score, T stage, prostate-specific antigen, Gleason score, and sociodemographic factors-and demonstrated BB use was associated with a hazard ratio of 0.71 (95% confidence interval, 0.67-0.75; p < 0.0005) and 0.73 (95% confidence interval, 0.68-0.78; p < 0.0005) for intermediate- and high-risk patients, respectively. CONCLUSIONS: There has been a concerning decline in the utilization of BB for intermediate- and high-risk prostate cancer patients despite an association with improved on overall survival. Numerous factors predictive for use of BB have been identified.

Patient characterization and usage trends of proton beam therapy for localized prostate cancer in the United States: A study of the National Cancer Database.

PURPOSE: To evaluate usage trends and identify factors associated with proton beam therapy (PBT) compared to alternative forms of external beam radiation therapy (RT) (EBRT) for localized prostate cancer. PATIENTS AND METHODS: The National Cancer Database was queried for men with localized (N0, M0) prostate cancer diagnosed between 2004 and 2013, treated with EBRT, with available data on EBRT modality (photon vs. PBT). Binary multiple logistic regression identified variables associated with EBRT modality. RESULTS: In total, 143,702 patients were evaluated with relatively few men receiving PBT (5,709 [4.0%]). Significant differences in patient and clinical characteristics were identified between those men treated with PBT compared to those treated with photon (odds ratio [OR]; 95% CI). Patients treated with PBT were generally younger (OR = 0.73; CI: 0.67-0.82), National Comprehensive Cancer Network low-risk compared to intermediate (0.71; 0.65-0.78) or high (0.44; 0.38-0.5) risk, white vs. black race (0.66; 0.58-0.77), with less comorbidity (Charlson-Deyo 0 vs. 2+; 0.70; 0.50-0.98), live in higher income counties (1.55; 1.36-1.78), and live in metropolitan areas compared to urban (0.21; 0.18-0.23) or rural (0.14; 0.10-0.19) areas. Most patients treated with PBT travelled more than 100 miles to the treatment facility. Annual PBT utilization significantly increased in both total number and percentage of EBRT over time (2.7%-5.6%; P<0.001). PBT utilization increased mostly in men classified as National Comprehensive Cancer Network low-risk (4%-10.2%). CONCLUSION: PBT for men with localized prostate cancer significantly increased in the United States from 2004 to 2013. Significant demographic and prognostic differences between those men treated with photons and protons were identified.

Primary radiotherapy for nonsurgically managed Stage I endometrial cancer: Utilization and impact of brachytherapy.

PURPOSE: The National Cancer Data Base (NCDB) was analyzed to evaluate practice patterns and the impact of radiotherapy modalities for endometrial cancer treated with primary radiotherapy. METHODS AND MATERIALS: The NCDB was queried for Stage I endometrioid adenocarcinoma patients treated with primary radiotherapy without surgery from 1998 to 2006. Brachytherapy (BT) utilization factors were established using multivariable logistic regression. Log-rank and Cox proportional hazards modeling were used to assess variables impacting survival. RESULTS: A total of 853 patients were analyzed: 23.7%, 31.3%, and 45.0% received BT alone, external beam radiotherapy (EBRT) and BT, or EBRT alone. The BT utilization ranged from 40.5% to 51.9% over time (p=0.70). Lower utilization was associated with advanced age (≥80 years: odds ratio [OR] 0.43, 95% confidence interval [CI] 0.28-0.65, p<0.01) and facilities with volume in the bottom quartile (OR 0.44, 95% CI 0.30-0.66, p<0.01). Utilization was higher among patients living more than 30 miles from the facilities (OR 2.14, 95%CI 1.35-3.42, p<0.01). With 36-month median followup, unadjusted median survivals for EBRT dose of 30Gy or lower, EBRT dose higher than 30Gy, BT, and EBRT+BT were 12.6, 31.1, 44.6, and 57.1 months (p<0.01). After correcting for other factors, higher risk of mortality was seen with EBRT dose of 30Gy or lower (hazard ratio [HR]2.75, 95% CI 1.66-4.55, p<0.01) and EBRT dose higher than 30Gy (HR 1.43, 95% CI 1.07-1.91, p=0.02) compared with EBRT+BT. No difference was seen using BT alone (HR 1.29, 95% CI 0.92-1.79, p=0.14). CONCLUSION: BT utilization for nonsurgically managed endometrial cancer remains low with most patients receiving EBRT alone. Despite concerns of overtreatment in a population with competing causes of death, BT appears to improve survival.