Cardiovascular Mortality and Duration of Androgen Deprivation in Locally Advanced Prostate Cancer: Long-term Update of NRG/RTOG 9202.

BACKGROUND: Androgen deprivation therapy (ADT) has been associated with coronary heart disease and myocardial infarction (MI) in prostate cancer patients, but controversy persists regarding its effects on cardiovascular mortality (CVM). OBJECTIVE: We assessed the long-term relationship between ADT and CVM in a prostate cancer randomized trial (NRG Oncology/Radiation Therapy Oncology Group 9202). DESIGN, SETTING, AND PARTICIPANTS: From 1992 to 1995, 1554 men with locally advanced prostate cancer (T2c-T4, prostate-specific antigen <150 ng/ml) received radiotherapy with 4 mo (short-term [STADT]) versus 28 mo (longer-term [LTADT]) of ADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using the Fine-Gray and Cox regression models, the relationship between ADT and mortality was evaluated. RESULTS AND LIMITATIONS: With a median follow-up of 19.6 yr, LTADT was associated with improved overall survival (OS) versus STADT (adjusted hazard ratio [HR] 0.88; p = 0.03) and prostate cancer survival (subdistribution HR [sHR] 0.70, p = 0.003). Comparing LTADT with STADT, prostate cancer mortality improved by 6.0% (15.6% [95% confidence interval 13.0-18.3%] vs 21.6% [18.6-24.7%]) at 15 yr, while CVM increased by 2.2% (14.9% [12.4-17.6%] vs 12.7% [10.4-15.3%]). In multivariable analyses, LTADT was not associated with increased CVM versus STADT (sHR 1.22 [0.93-1.59]; p = 0.15). An association between LTADT and MI death was detected (sHR 1.58 [1.00-2.50]; p = 0.05), particularly in patients with prevalent cardiovascular disease (CVD; sHR 2.54 [1.16-5.58]; p = 0.02). CONCLUSIONS: With 19.6 yr of follow-up, LTADT was not significantly associated with increased CVM in men with locally advanced prostate cancer. Patients may have increased MI mortality with LTADT, particularly those with baseline CVD. Overall, there remained a prostate cancer mortality benefit and no OS detriment with LTADT. PATIENT SUMMARY: In a long-term analysis of a large randomized prostate cancer trial, radiation with 28 mo of hormone therapy did not increase the risk of cardiovascular death significantly versus 4 mo of hormone therapy. Future studies are needed for patients with pre-existing heart disease, who may have an increased risk of myocardial infarction death with longer hormone use.

Change in stage after neoadjuvant chemoradiation is associated with survival in patients with esophageal cancer.

BACKGROUND: The aim of this study was to determine if change in stage after neoadjuvant chemoradiation (CRT) was associated with improved survival in esophageal cancer using a national database. METHODS: Using the National Cancer Database, patients with non-metastatic, resectable esophageal cancer who received neoadjuvant CRT and surgery were identified. Comparing clinical to the pathologic stage, change in stage was classified as pathologic complete response (pCR), downstaged, same-staged, or upstaged. Univariable and multivariable Cox regression models were used to identify factors associated with survival. RESULTS: A total of 7745 patients were identified. The median overall survival (OS) was 34.9 months. Median OS was 60.3 months if pCR, 39.1 months if downstaged, 28.3 months if same-staged, and 23.4 months if upstaged (p < 0.0001). On multivariable analysis, pCR was associated with improved OS compared to the other groups (downstaged: hazard ratio [HR]: 1.32 [95% confidence interval [CI]: 1.18-1.46]; same-staged: HR: 1.89 [95% CI: 1.68-2.13]; upstaged: HR: 2.54 [95% CI: 2.25-2.86]; all p < 0.0001). CONCLUSIONS: In this large database study, change in stage after neoadjuvant CRT was strongly associated with survival for patients with non-metastatic, resectable esophageal cancer. There was a significant stepwise decline in survival, in descending order of pCR, downstaged tumor, same-staged tumor, and upstaged tumor.

Inequalities in Cancer Stage at Diagnosis Among Incarcerated Individuals Undergoing Radiation Therapy at a Large Safety-Net Hospital.

INTRODUCTION: There is a dearth of data on cancer care in the incarcerated population, despite being the leading cause of illness-related death in United states' prisons. We retrospectively reviewed the demographic and clinicopathologic characteristics of incarcerated individuals who received radiation therapy at a large safety-net hospital. METHODS: Following IRB approval, we identified 80 incarcerated patients who presented for radiation therapy between January 2003 and May 2019. Descriptive statistics on the patients, tumor types and stage, treatment factors, and follow-up rates were analyzed. RESULTS: 80 individuals with 82 cancer diagnoses presented for radiation oncology consultation over the study period. The median age was 54 years (range, 46-64). Patients of White, Black, and "other" races comprised 61.3% (n=49), 28.8% (n=23), and 10% (n=8), respectively. Most patients were male (n=75, 93.8%) and English speakers (n=76, 95%). Moreover, 50% (n=40) had a substance use disorder history and 75% (n=60) had a smoking history. The three most common cancer types were prostate (n=12, 14.6%), gastrointestinal (n=14, 17.1%), thoracic (n=17, 20.7%), and head and neck (n=21, 25.6%). The distribution of tumor stage (AJCC) was I (n=12, 14.6%), II (n=12, 14.6%), III (n=14, 17.1%), IV (n=38, 46.3%), and unknown/unavailable (n=6, 7.3%). Of the cohort, 65 patients with 66 cancers (80.5%) received radiation. Among them, the 6-month, 1-year, and 5-year follow-up rates were 41.5%, 27.7%, and 3.1%, respectively. Subset analysis limited to stage I-III patients (n=30) revealed 6-month, 1-year and 5-year follow-up rates of 41.9%, 22.6%, and 3.2%, respectively. CONCLUSIONS: This study highlights inequalities in cancer stage at diagnosis among a vulnerable patient population that is largely excluded from clinical research. Majority of the incarcerated patients presented with stage III & IV cancers and have poor follow up rates even among those with early-stage disease. Efforts to understand and mitigate persistent health inequalities among incarcerated patients are warranted.

Association between hospital safety-net burden and receipt of trimodality therapy and survival for patients with esophageal cancer.

BACKGROUND: To examine the relationship between hospital safety-net burden and (1) receipt of surgery after chemoradiation (trimodality therapy) and (2) survival in esophageal cancer patients. METHODS: The National Cancer Database was queried to identify 22,842 clinical stage II to IVa esophageal cancer patients diagnosed in 2004 to 2015. The treatment facilities were categorized by proportion of uninsured/Medicaid-insured patients into percentiles. No safety-net burden hospitals (0-37th percentile) treated no uninsured/Medicaid-insured patients, whereas low (38-75th percentile) and high (76-100th percentile) safety-net burden hospitals treated a median (range) of 8.8% (0.87%-16.7%) and 23.6% (16.8%-100%), respectively. Adjusted odds ratios and hazard ratios with 95% confidence intervals were computed, adjusting for patient, tumor, and treatment characteristics. RESULTS: Compared to no safety-net burden hospital patients, high safety-net burden hospital patients were significantly more likely to be young, Black, and low-income. Age, female sex, Black race, Hispanic ethnicity, nonprivate insurance, lower income, higher comorbidity score, upper esophageal location, squamous cell histology, higher stage, time to treatment, and treatment at a community program or a low-volume facility were associated with lower odds of receiving trimodality therapy. Adjusting for these factors, high safety-net burden hospital patients were less likely to receive surgery after chemoradiation versus no safety-net burden hospital patients (adjusted odds ratio 0.77 [95% confidence interval 0.68-0.86], P < .0001); no difference was detected comparing low safety-net burden hospitals versus no safety-net burden hospitals (adjusted odds ratio 1.01 [0.92-1.11], P = .874). No significant survival difference was noted by safety-net burden (low safety-net burden hospitals versus no safety-net burden hospitals: adjusted hazard ratio 1.01 [0.96-1.06], P = .704; high safety-net burden hospital versus no safety-net burden hospitals: adjusted hazard ratio 0.99 [0.93-1.06], P = .859). CONCLUSION: Adjusting for patient, tumor, and treatment factors, high safety-net burden hospital patients were less likely to undergo surgery after chemoradiation but without significant survival differences.

Frailty Index is Associated with Treatment Decisions for Stage I Non-Small Cell Lung Cancer at a High-Burden Safety-Net Hospital.

BACKGROUND: Lobectomy remains the cornerstone of care for stage I NSCLC while sublobar resection and stereotactic body radiation therapy (SBRT) are reserved for patients with smaller tumors and/or poor operative risk. Herein, we investigate the effect of patient frailty on treatment modality for stage I NSCLC at a safety-net hospital. PATIENTS AND METHODS: A retrospective chart review was performed of stage I NSCLC patients between 2006 and 2015. Demographics, patient characteristics, and treatment rates were compared to a National Cancer Database cohort of stage 1 NSCLC patients. Patient frailty was assessed using the MSK-FI. RESULTS: In our cohort of 304 patients, significantly fewer patient were treated via lobectomy compared to national rates (P < .001). Advanced age (P = .02), lower FEV1 (P < .001) and DLCO (P < .001), not socioeconomic factors, were associated with higher utilization of non-lobectomy (sublobar resection or SBRT). Patients with lower MSK-FI were more likely to receive any surgical treatment (P = .01) and lobectomy (P = .03). Lower MSK-FI was an independent predictor for use of lobectomy over other modalities (OR 0.75, P = .04). MSK-FI (OR 0.64, P = .02), and FEV1 (OR 1.03, P < .001) were independently associated with use of SBRT over any surgery. CONCLUSION: Our safety-net hospital performed fewer lobectomies and lung resections compared to national rates. Patient frailty and clinical factors were associated with use of SBRT or sublobar resection suggesting that the increased illness burden of a safety-net population may drive the lower use of lobectomy. The MSK-FI may help physicians stratify patient risk to guide stage I NSCLC management.

Longitudinal Outcomes of Medical Student Research Mentorship: a 15-Year Analysis of the Radiation Oncology Mentorship Initiative.

At our institution, students can be mentored by radiation oncology faculty through structured research programs, such as the Medical Student Summer Research Program (MSSRP). The purpose of this study is to report the research productivity of students who engaged in radiation oncology research mentorship, whether through the MSSRP or other avenues of research mentorship. We compiled a database of abstracts and manuscripts co-authored by 58 students who conducted research with radiation oncology faculty from 2005 to 2020. The means, medians, ranges, and interquartile ranges (IQR) of co-authorships and first authorships were calculated for the overall cohort and compared for MSSRP and non-MSSRP students, who matched into radiation oncology and those who did not, and male versus female students. Among all 58 students, 106 abstracts and 70 manuscripts were identified. Of those students, 54 (93.1%) published at least one abstract or manuscript. The mean number of abstract co-authorships per student was 3.07 (median 2, range 0-25, IQR 0-4), and the mean number of manuscript co-authorships per student was 2.22 (median 1, range 0-18, IQR 1-3). There were no significant differences in research output between MSSRP and non-MSSRP students or male and female students. However, the students who matched into radiation oncology published more co-author (3.67 vs. 1.63, p = 0.01) and first-author (1.62 vs. 0.53, p = 0.006) manuscripts than those who did not. Further research is warranted to assess whether skills gained from student-directed research translate into residency and beyond.

Black Race Remains Associated with Lower Eligibility for Screening Using 2021 US Preventive Services Task Force Recommendations Among Lung Cancer Patients at an Urban Safety Net Hospital.

OBJECTIVE: To evaluate whether the revised US Preventive Services Task Force (USPSTF) criteria reduced inequities in lung cancer screening (LCS) eligibility among a racially diverse sample of patients with lung cancer. METHODS: This is a retrospective analysis of adults diagnosed with primary lung malignancies at an urban safety net hospital. For all patients and exclusively ever-smokers, χ2 tests were used to evaluate differences in LCS eligibility among socio-demographic variables using the 2013 and 2021 USPSTF criteria. Patients who were ineligible for LCS were categorized by reason for exclusion. RESULTS: Among 678 lung cancer patients (46% female, mean age 66 ± 10 years), 51% were White, and 39% were Black. Using the 2013 guidelines, White patients (57%) would have been more likely to be eligible than Black (37%) and other-race patients (35%) (P < 0.0001) at time of cancer diagnosis. Under the 2021 guidelines, White patients (68%) remained more likely to be eligible for LCS than Black (54%) and other-race patients (48%) (P = 0.0002). Among exclusively ever-smoking patients, we did not observe a significant difference in eligibility by race under the 2021 USPSTF guidelines (White [73%], Black [65%], and other-race [65%]; [P = 0.48]). Sex, ethnicity, education level, and insurance type were not associated with differential screening eligibility under either the 2013 or 2021 guidelines. CONCLUSION: The revised 2021 USPSTF LCS guidelines may not be sufficient to eliminate racial inequities in LCS eligibility among patients who go on to be diagnosed with primary lung cancer. Differential rates of lung cancer among never-smokers may contribute to this inequity.

Small cell lung cancer in young patients: trends in sociodemographic factors, diagnosis, treatment, and survival.

Background: Small cell lung cancer (SCLC) in patients <50 years old has unique socioeconomic and clinical implications. We aimed to examine the demographics, treatment patterns, and survival of young patients with SCLC and compared them to older adults. Methods: The National Cancer Database (NCDB) was queried to identify SCLC cases diagnosed from 2004 to 2016. Patients were divided into three age groups: ≥18-<50, ≥50-<70, and ≥70 years. Patient characteristics were evaluated for survival within each age group. Kaplan-Meier and Cox regression analyses were used to assess survival. Results: Of the 172,453 evaluated SCLC patients (median age 66 years), 8,792 were ≥18-<50 years old. Compared to the older groups, patients under 50 were more likely to be Black, uninsured or on Medicaid, have household income <$30,000, and present with stage III or IV disease (P<0.0001 for all). While young patients were more likely to receive guideline-concordant care (GCC), the hazard of death increased to 1.96 (95% CI: 1.80-2.14; P<0.0001) with receipt of nonstandard therapy. Private insurance, female gender, non-White race, Hispanic ethnicity, and higher income were associated with better survival. The youngest cohort had significantly better survival overall when compared to the older patients (P<0.0001), but the survival advantage was reduced with the advancing stage. Conclusions: SCLC patients under 50 years old represent a socioeconomically disadvantaged group with advanced disease at presentation. Despite having fewer comorbidities and being offered guideline-concordant treatment, younger patients with SCLC have only marginally better survival than older patients in advanced stages.

Racial disparities in non-recommendation of adjuvant chemotherapy in stage II-III ovarian cancer.

OBJECTIVES: To identify patient factors associated with not receiving a recommendation for adjuvant chemotherapy after primary surgery for ovarian cancer. METHODS: This retrospective cohort study used the National Cancer Database (NCDB) data from 2004 to 2015 to identify patients with stage II-III ovarian cancer who underwent primary surgery. Multivariate logistic regression analyses evaluated factors associated with notation in the NCDB that "chemotherapy was not recommended/administered because it was contraindicated due to patient risk factors (i.e., comorbid conditions, advanced age)." Survival data were assessed via Kaplan-Meier analyses. RESULTS: Of the 48,245 patients who met the inclusion criteria, 522 (1.08%) did not receive adjuvant chemotherapy because it was determined to be contraindicated. In multivariate analyses, independent predictors for not receiving a recommendation for adjuvant chemotherapy were age ≥ 70 years old (adjusted odds ratio, aOR = 2.43, p < 0.0001), non-zero Charlson-Deyo comorbidity scores (score 1, aOR = 1.41, p = 0.002; score ≥ 2, aOR = 2.57, p < 0.0001), and Black race (aOR = 2.12, p < 0.0001). For Black patients, recommendation against adjuvant chemotherapy occurred at a younger median age (64.5 years vs. 72 years) and was associated with lower 5-year survival (25.9% vs. 40.3%, p < 0.0001). CONCLUSIONS: Patients with ovarian cancer who underwent surgery but did not receive chemotherapy "because it was contraindicated due to patient risk factors" were older and had higher comorbidity scores. Even after controlling for these differences, Black patients were disproportionately not recommended for chemotherapy, which was associated with worse survival. Determining eligibility for adjuvant chemotherapy requires an individualized approach, and the possible influence of racial bias on risk estimation should be further investigated.

The Impact of Residential Racial Segregation on Non-Small Cell Lung Cancer Treatment and Outcomes.

BACKGROUND: Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, affecting health care access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality. METHODS: Patient data were obtained from Surveillance, Epidemiology, and End Results Program database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest: stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality. RESULTS: Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients, with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white patients. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival. CONCLUSIONS: Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage disease, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.

Racial and Other Healthcare Disparities in Patients With Extensive-Stage SCLC.

INTRODUCTION: Systemic treatment with chemotherapy is warranted for patients with extensive-stage SCLC (ES-SCLC). The objective of this study was to determine whether racial and other healthcare disparities exist in receipt of chemotherapy for ES-SCLC. METHODS: Utilizing the National Cancer Database, 148,961 patients diagnosed to have stage IV SCLC from 2004 to 2016 were identified. Adjusted ORs with 95% confidence intervals (95% CIs) were computed for receipt of chemotherapy using multivariate logistic regression modeling. Cox regression modeling was used to perform overall survival analysis, and adjusted hazard ratios were calculated. RESULTS: A total of 82,592 patients were included, among which chemotherapy was not administered to 6557 (7.9%). Higher education, recent year of diagnosis, and treatment at more than one facility were associated with increased odds of receiving chemotherapy. Factors associated with a decreased likelihood of receiving chemotherapy were increasing age, race, nonprivate insurance, and comorbidities. On multivariate analysis, black patients had lower odds of receiving chemotherapy compared with white patients (adjusted OR, 0.85; 95% CI: 0.77-0.93, p = 0.0004). Furthermore, black patients had better survival compared with white patients (adjusted hazard ratio, 0.91; 95% CI: 0.89-0.94, p = 0.91). The 1-year survival (median survival) for black and white patients was 31.7% (8.3 mo) and 28.6% (8 mo), respectively. CONCLUSIONS: Black patients with ES-SCLC were less likely to receive chemotherapy, as were elderly, uninsured, and those with nonprivate insurance. Further studies are required to address underlying reasons for lack of chemotherapy receipt in black patients with ES-SCLC and guide appropriate interventions to mitigate disparities.

Racial and socioeconomic disparities in the use of stereotactic body radiotherapy for treating non-small cell lung cancer: a narrative review.

In the past two decades, there has been a steady increase in the use of stereotactic body radiotherapy (SBRT) as an alternative to surgical intervention for early-stage non-small cell lung cancer (NSCLC) patients; however, not much is known about the impact of race and socioeconomic status (SES) on the delivery of SBRT. Here, we conduct a narrative review to examine potential disparities in the use of SBRT. Keyword searches of MEDLINE/PubMed, Web of Science, Embase, and Google Scholar databases were performed for studies focused on race, SES, and the use of SBRT published between 2000 and 2020. Six studies were identified, and showed that minority patients, especially Blacks, were less likely to receive SBRT and had a significantly longer median time between diagnosis to SBRT treatment. Patients with lower income or lower education, as well as those from lower socioeconomic regions were less likely to receive SBRT; they were more likely to receive conventionally fractionated external beam radiation (CFRT) or no treatment. These racial and socioeconomic factors were associated with worse survival in other general early-stage NSCLC studies. In conclusion, the limited number of published studies suggest significant disparities in the treatment of early-stage NSCLC with SBRT. These factors potentially lead to worse survival outcomes among vulnerable patient populations. Equal access to SBRT should be a focus of healthcare delivery systems, to ensure optimal clinical outcomes for patients with early-stage NSCLC.

Disparities in Laryngeal Cancer Treatment and Outcomes: An Analysis by Hospital Safety-Net Burden.

OBJECTIVES/HYPOTHESIS: To analyze the impact of hospital safety-net burden on survival outcomes for laryngeal squamous cell carcinoma (LSCC) patients. STUDY DESIGN: Retrospective cohort study. METHODS: From 2004 to 2015, 59,733 LSCC patients treated with curative intent were identified using the National Cancer Database. Low (LBH) <25th, medium (MBH) 25th-75th, and high (HBH) >75th safety-net burden hospitals were defined by the percentage quartiles (%) of uninsured/Medicaid-insured patients treated. Social and clinicopathologic characteristics and overall survival (using Kaplan-Meier survival analysis) were evaluated. Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling. RESULTS: There were 324, 647, and 323 hospitals that met the criteria as LBH, MBH, and HBH, respectively. The median follow-up was 38.6 months. A total of 27,629 deaths were reported, with a median survival of 75.8 months (a 5-year survival rate of 56.6%). Median survival was 83.2, 77.8, and 69.3 months for patients from LBH, MBH, and HBH, respectively (P < .0001). The median % of uninsured/Medicaid-insured patients treated among LBH, MBH, and HBH were 3.6%, 14.0%, and 27.0%, respectively. Patients treated at HBH were significantly more likely to be young, Black, Hispanic, of low income, and present with more advanced disease compared to LBH and MBH. Survival was comparable for LBH and MBH (HR = 1.02; 95% CI = 0.97-1.07, P = .408) on multivariate analysis. HBH, compared to LBH patients, had inferior survival (HR = 1.07; 95% CI = 1.01-1.13, P = .023). CONCLUSIONS: High burden safety-net hospitals receive disproportionately more patients with advanced-stage and low socioeconomic status, yielding inferior survival compared to low burden hospitals. LEVEL OF EVIDENCE: 3 (individual cohort study) Laryngoscope, 131:E1987-E1997, 2021.

Optimal Radiotherapy Dose in Anal Cancer: Trends in Prescription Dose and Association with Survival.

PURPOSE: Definitive chemoradiotherapy represents a standard of care treatment for localized anal cancer. National Comprehensive Cancer Network guidelines recommend radiotherapy (RT) doses of ≥ 45 Gy and escalation to 50.4-59 Gy for advanced disease. Per RTOG 0529, 50.4 Gy was prescribed for early-stage disease (cT1-2N0), and 54 Gy for locally advanced cancers (cT3-T4 and/or node positive). We assessed patterns of care and overall survival (OS) with respect to the RT dose. METHODS: The National Cancer Database identified patients with non-metastatic anal squamous cell carcinoma from 2004 to 2015 treated with chemoradiotherapy. Patients were stratified by RT dose: 40-< 45, 45-< 50, 50-54, and > 54-60 Gy. Crude and adjusted hazard ratios (HR) were computed using Cox regression modeling. RESULTS: A total of 10,524 patients were identified with a median follow-up of 40.7 months. The most commonly prescribed RT dose was 54 Gy. On multivariate analysis, RT doses of 40-< 45 Gy were associated with worse OS vs. 50-54 Gy (HR 1.68 [1.40-2.03], P < 0.0001). There was no significant difference in OS for patients who received 45-< 50 or > 54-60 Gy compared with 50-54 Gy. For early-stage disease, there was no significant association between RT dose and OS. For locally advanced disease, 45-< 54 Gy was associated with worse survival vs. 54 Gy (HR 1.18 [1.04-1.34], P = 0.009), but no significant difference was detected comparing > 54-60 Gy vs. 54 Gy (HR 1.08 [0.97-1.22], P = 0.166). CONCLUSIONS: For patients with localized anal cancer, RT doses of ≥ 45 Gy were associated with improved OS. For locally advanced disease, 54 Gy but not > 54 Gy was associated with improved OS.

Placard in Hand: A Simple, Inexpensive Intervention to Improve On-Treatment Visit Compliance in a Safety Net Radiation Oncology Patient Population.

PURPOSE: On-treatment visits (OTVs) for patients undergoing radiotherapy (RT) should occur every five fractions. Compliance with OTVs was identified as a potential issue in a safety-net patient population. This study determined if brightly colored placards given to patients improved OTV compliance. MATERIALS AND METHODS: A retrospective analysis of all patients with lung cancer receiving RT from October 1, 2015 to September 30, 2017 evaluated OTV compliance before (No Placard) and after (Placard) the placard was introduced in the clinic. Analysis of variance, χ2 tests, and Fisher's exact tests were performed to assess differences in continuous and categorical patient and treatment variables, respectively. RESULTS: The No Placard group included 48 patients who were scheduled for 151 OTVs. The Placard group included 50 patients who were scheduled for 187 OTVs. The percentage of missed OTVs in the No Placard group was 9.3% (14/151), versus 2.1% (4/187) in the Placard group (P = .004). Patients in the No Placard group were more likely to speak English (97.9% v 86.0%; P = .060), were less likely to have stage I-III disease (75% v 88%; P = .097), and received lower mean RT doses (48.2 Gy v 55.6 Gy; P = .007). On multivariate analysis adjusting for language, stage, and RT dose, the adjusted mean rate of missed OTVs in the No Placard group was 7.1%, versus 1.4% in the Placard group (P = .019). CONCLUSION: A significant increase in compliance of OTVs was observed with the introduction of brightly colored placards. This represents a simple, inexpensive method to improve OTV compliance in a safety-net setting and may be applicable to other patient populations.

Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital.

Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.

Stereotactic body radiation therapy with higher biologically effective dose is associated with improved survival in stage II non-small cell lung cancer.

OBJECTIVES: The role of stereotactic body radiation therapy (SBRT) in treating stage II non-small cell lung cancer (NSCLC) remains unclear. This study evaluates SBRT dose prescription patterns and survival outcomes in Stage II NSCLC using the National Cancer Database (NCDB). MATERIALS AND METHODS: Patients diagnosed with Stage II NSCLC and treated with SBRT between 2004-2013 were identified in NCDB. The biologically effective dose with α/ß = 10 Gy (BED10) was calculated. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox regression models. RESULTS: Of 56,543 patients with Stage II NSCLC, 451 (0.8%) received SBRT. There were 360 patients (79.8%) with node-negative and 91 patients (20.2%) with node-positive disease. The most common prescriptions were 10 Gy x 5 (35.9%) and 12 Gy x 4 (19.3%). The mean and median BED10 were 114.9 Gy and 105.6 Gy, respectively. With median follow-up of 19.3 months, overall median survival was 23.7 months. Median survival was 22.4 months for those treated with BED10 < 114.9 Gy versus 31.5 months for BED10 ≥ 114.9 Gy (p = 0.036). On multivariate analysis, BED10 as a continuous variable (hazard ratio [HR] 0.991, p = 0.009) and ≥ 114.9 Gy (HR 0.63, p = 0.015) were associated with improved survival in node-negative patients. BED10 as a continuous variable (HR 0.997, p = 0.465) and ≥ 114.9 Gy (HR 0.81, p = 0.546) were not significant factors for predicting survival in node-positive patients. CONCLUSION: SBRT is infrequently utilized to treat Stage II NSCLC in the United States. Treatment with higher BED10 was associated with improved survival, and the benefit was limited to patients with node-negative disease.

Esophageal Cancer Presentation, Treatment, and Outcomes Vary With Hospital Safety-Net Burden.

BACKGROUND: Social determinants of health affect diagnosis and delivery of care to patients with esophageal cancer. This study hypothesized that hospital safety-net burden affects presentation, treatment, and outcomes in patients with esophageal cancer. METHODS: The National Cancer Database was queried for patients with esophageal cancer (2004 to 2013). Treating facilities were categorized according to their relative burden of uninsured or Medicaid-insured patients. Hospitals with low (LBH), medium (MBH), and high (HBH) safety-net burden were compared with respect to patient demographics, disease and treatment characteristics, and survival using χ2 analysis, Kaplan-Meier survival analysis, and multivariable modeling. RESULTS: There were 56,115 patients from 1,215 facilities. HBH treated a greater proportion of racial and ethnic minorities and patients with lower socioeconomic status. Patients at HBH presented at later stages and received primary surgical therapy less often than at MBH and LBH. Survival for patients with esophageal adenocarcinoma did not differ significantly between HBH and LBH after adjusting for age, sex, race, ethnicity, income, comorbidity, stage, histologic type, tumor location, facility type, insurance status, and treatment modality (hazard ratio, 1.06; 95% confidence interval, 0.99 to 1.14; p = 0.093). HBH were associated with a higher mortality risk than LBH for patients with squamous cell carcinoma (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.20; p = 0.014). CONCLUSIONS: There is a mortality risk for patients with squamous cell carcinoma, but not for adenocarcinoma at HBH compared with LBH. Further analysis of unadjusted variables such as performance status, completion of therapy, and continuity of care, and others should be undertaken among safety-net hospitals with the goal of creating appropriate clinical pathways for care of esophageal cancer in vulnerable populations.

Definitive treatment patterns and survival in stage II non-small cell lung cancer.

OBJECTIVES: This study delineated definitive treatment patterns for Stage II non-small cell lung cancer (NSCLC) in the United States and evaluated survival by treatment approach. MATERIALS AND METHODS: Patients with clinically-staged Stage II NSCLC treated with surgery-based therapy, chemoradiation, conventionally-fractionated radiation (CFR), or stereotactic body radiotherapy (SBRT) were identified using the National Cancer Database (NCDB). Median survival was estimated using Kaplan-Meier analysis. Crude and adjusted hazard ratios (HR) and 95% confidence intervals were computed using Cox regression modeling. RESULTS: Between 2004-2012, 19,749 patients met study criteria: 13,382 (67.8%) underwent surgery-based treatment, 4,310 (21.8%) received chemoradiation, 1,606 (8.1%) received CFR, and 451 (2.3%) received SBRT. Surgery and SBRT utilization increased over time while CFR and chemoradiation decreased (all p ≤ 0.002). Patients receiving radiation-based treatments were older, with more comorbidities, and higher T/N stage (all p < 0.0001). With median follow-up of 25.2 months, median survival was 51.6, 23.3, 15.4, and 23.7 months for surgery-based treatment, chemoradiation, CFR, and SBRT, respectively (p < 0.0001). On multivariate analysis, chemoradiation (HR 1.67 [1.59-1.75], p < 0.0001), CFR (HR 2.38 [2.22-2.55], p < 0.0001), and SBRT (HR 1.76 [1.53-2.01], p < 0.0001) were associated with decreased survival versus surgery-based treatment. CFR was associated with decreased survival versus chemoradiation (HR 1.52 [1.41-1.63], p < 0.0001) and SBRT (HR 1.39 [1.19-1.61], p < 0.0001). SBRT was associated with similar survival versus chemoradiation (HR 1.10 [0.95-1.27], p = 0.212). CONCLUSION: NCDB data demonstrate increasing use of surgery-based treatments and SBRT for Stage II NSCLC over time. Radiation-based therapies were associated with decreased survival compared to surgery. CFR was associated with decreased survival compared to chemoradiation and SBRT.

Adjuvant chemoradiation does not improve survival in elderly patients with high-risk resected head and neck cancer.

OBJECTIVES/HYPOTHESIS: Randomized trials have demonstrated that adjuvant chemoradiotherapy (CRT) confers an overall survival (OS) benefit over adjuvant radiation therapy (RT) alone in patients with resected head and neck squamous cell carcinoma (HNSCC) with adverse pathologic features (positive surgical margins [SM+] and/or extracapsular extension [ECE]). Whether this OS benefit exists in an elderly population remains unknown. STUDY DESIGN: Retrospective database study. METHODS: Using the National Cancer Database, we identified 1,686 elderly patients (age ≥70 years) with resected HNSCC with SM+ and/or ECE, who received adjuvant CRT (491 patients, 29%) or adjuvant RT alone (1,195 patients, 71%) between 1998 and 2011. Three-year survival rates were estimated using the Kaplan-Meier method both before and after propensity score matching (PSM). Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling. RESULTS: Median follow-up was 23.5 and 42.8 months for all and surviving patients, respectively. Three-year OS was 50.7% and 44.4% among patients receiving adjuvant CRT and RT alone, respectively (P = .002). On multivariate analysis, there was no significant improvement in OS with adjuvant CRT relative to adjuvant RT alone (HR: 0.88, 95% CI: 0.73-1.06). Similarly, a PSM cohort showed no significant difference in the 3-year OS for patients receiving adjuvant CRT versus adjuvant RT alone (48.8% and 50.9%, respectively; P = .839). CONCLUSIONS: Although the addition of chemotherapy to adjuvant RT has been proven effective in randomized trials of patients with resected HNSCC with SM+ or ECE, it may be less efficacious in an elderly patient population treated outside of a controlled trial setting. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:831-840, 2018.