Real-world patient characteristics, treatment patterns, and treatment outcomes of patients with diffuse large B-cell lymphoma by line of therapy.

BACKGROUND: Although initial treatment of diffuse large B-cell lymphoma (DLBCL) with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) can be effective, up to 50% of patients will develop refractory or relapsed (R/R) disease. This study aimed to provide contemporary data on characteristics, treatment patterns, and outcomes for R/R-DLBCL. METHODS: Patients with incident (January 2016 to March 2021) DLBCL age ≥18 years who initiated first-line (1L) therapy were identified from the COTA real-world database. Baseline characteristics, treatment patterns, and real-world outcomes, including time to next treatment (rwTTNT) and overall survival (rwOS), were assessed for the study population and by line of therapy (LOT). RESULTS: A total of 1347 eligible DLBCL patients were identified. Of these, 340 (25.2%) proceeded to receive 2L, of whom 141 (41.5%) proceeded to receive 3L, of whom 51 (36.2%) proceeded to receive 4L+. Most common treatments were R-CHOP in 1L (63.6%), stem cell transplant (SCT) in 2L (17.9%), polatuzumab vedotin, bendamustine, and rituximab (Pola-BR) in 3L (9.9%), and chimeric antigen receptor T-cell therapy (CAR-T) in 4L (11.8%). Treatment patterns were more variable in later LOTs. One- and 3-year rwOS from 1L initiation were 88.5% and 78.4%, respectively. Patients who received later LOTs experienced numerically lower 1- and 3-year rwOS (from 2L initiation: 62.4% and 46.4%, respectively). CONCLUSIONS: In this real-world analysis, 25.2% of patients experienced R/R-DLBCL after 1L with poor outcomes. Given the findings of this study, there is a high unmet need for novel, safe, and effective treatment options for patients with R/R DLBCL.

Unfavorable early-stage Hodgkin lymphoma: assessment of patient characteristics in a real-world setting.

Aim: Unfavorable prognostic factors among classical Hodgkin lymphoma (cHL) patients in the real-world setting have yet to be fully characterized. Methods: In this retrospective study using the ConcertAI Oncology Dataset, patient characteristics, unfavorable prognostic factors and treatment patterns were evaluated among patients diagnosed with cHL. Results: Among 324 adult cHL patients diagnosed 2016-2021, 16.1% were classified as early favorable, 32.7% early unfavorable and 51.2% advanced disease. Early unfavorable patients were younger and had a larger nodal mass. The prognostic factor B symptoms was most frequently documented in early unfavorable patients (59.4%), followed by bulky disease (46.2%), >3 involved lymph node regions (31.1%), and erythrocyte sedimentation rate ≥50 (25.5%). Conclusion: In this analysis of real-world data, we found that nearly a third of newly diagnosed cHL patients had early unfavorable disease. Our analysis also showed differences in the proportion of patients for each unfavorable factor among patients with early-stage unfavorable cHL.

What is this article about? Lymphoma is a type of blood cancer that develops when white blood cells grow out of control. This study looked at a certain type of lymphoma called classical Hodgkin lymphoma (cHL). Patients with cHL are put into groups based on risk factors. Risk factors mean the cancer had certain characteristics that make it more likely to spread to other body parts and more difficult to treat. These can be symptoms like drenching night sweats, unexplained fever, sudden weight loss, or large swellings of the infection fighting glands of the body.What did we do? We studied the risk factors of patients with cHL, using data from electronic medical records. What were the results? About a third of the patients in this study had early stage cHL with unfavorable risk factors, and over half of the patients had advanced stage cHL. The patients who had early stage cHL with unfavorable risk factors were younger and had a larger lump in a lymph node. More than half of the patients experienced drenching night sweats, unexplained fever, or weight loss of more than 10%. What do the results mean? We found that nearly a third of new cHL patients had early-stage cHL with unfavorable risk factors. We also showed differences in the number of patients with each unfavorable risk factor among patients with early-stage unfavorable cHL. This study can help doctors and researchers group patients and determine the best treatment or research study for patients who have cHL.

Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018.

Importance: Black patients are less likely than White patients to receive guideline-concordant cancer care in the US. Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, tumors surrounded by sensitive tissues, and childhood cancers. Objective: To evaluate whether there are racial disparities in the receipt of PBT among Black and White individuals diagnosed with all PBT-eligible cancers in the US. Design, Setting, and Participants: This cross-sectional study evaluated Black and White individuals diagnosed with PBT-eligible cancers between January 1, 2004, and December 31, 2018, in the National Cancer Database, a nationwide hospital-based cancer registry that collects data on radiation treatment, even when it is received outside the reporting facility. American Society of Radiation Oncology model policies were used to classify patients into those for whom PBT is the recommended radiation therapy modality (group 1) and those for whom evidence of PBT efficacy is still under investigation (group 2). Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT according to the National Academy of Medicine's definition of disparities. Data analysis was performed from October 4, 2021, to February 22, 2022. Exposure: Patients' self-identified race was ascertained from medical records. Main Outcomes and Measures: The main outcome was receipt of PBT, with disparities in this therapy's use evaluated with logistic regression analysis. Results: Of the 5 225 929 patients who were eligible to receive PBT and included in the study, 13.6% were Black, 86.4% were White, and 54.3% were female. The mean (SD) age at diagnosis was 63.2 (12.4) years. Black patients were less likely to be treated with PBT than their White counterparts (0.3% vs 0.5%; odds ratio [OR], 0.67; 95% CI, 0.64-0.71). Racial disparities were greater for group 1 cancers (0.4% vs 0.8%; OR, 0.49; 95% CI, 0.44-0.55) than group 2 cancers (0.3% vs 0.4%; OR, 0.75; 95% CI, 0.70-0.80). Racial disparities in PBT receipt among group 1 cancers increased over time (annual percent change = 0.09, P < .001) and were greatest in 2018, the most recent year of available data. Conclusions and Relevance: In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities that provide PBT will be needed to eliminate disparities.

Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes.

Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.

State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States.

BACKGROUND: Annual lung cancer screening (LCS) with low-dose chest computed tomography in older current and former smokers (ie, eligible adults) has been recommended since 2013. Uptake has been slow and variable across the United States. We estimated the LCS rate and growth at the national and state level between 2016 and 2018. METHODS: The American College of Radiology's Lung Cancer Screening Registry was used to capture screening events. Population-based surveys, the US Census, and cancer registry data were used to estimate the number of eligible adults and lung cancer mortality (ie, burden). Lung cancer screening rates (SRs) in eligible adults and screening rate ratios with 95% confidence intervals (CI) were used to measure changes by state and year. RESULTS: Nationally, the SR was steady between 2016 (3.3%, 95% CI = 3.3% to 3.7%) and 2017 (3.4%, 95% CI = 3.4% to 3.9%), increasing to 5.0% (95% CI = 5.0% to 5.7%) in 2018 (2018 vs 2016 SR ratio = 1.52, 95% CI = 1.51 to 1.62). In 2018, several southern states with a high lung-cancer burden (eg, Mississippi, West Virginia, and Arkansas) had relatively low SRs (<4%) among eligible adults, whereas several northeastern states with lower lung cancer burden (eg, Massachusetts, Vermont, and New Hampshire) had the highest SRs (12.8%-15.2%). The exception was Kentucky, which had the nation's highest lung cancer mortality rate and one of the highest SRs (13.7%). CONCLUSIONS: Fewer than 1 in 20 eligible adults received LCS nationally, and uptake varied widely across states. LCS rates were not aligned with lung cancer burden across states, except for Kentucky, which has supported comprehensive efforts to implement LCS.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States.

BACKGROUND: Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC. RESEARCH QUESTION: How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival? STUDY DESIGN AND METHODS: We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact. RESULTS: Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities. INTERPRETATION: Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Early Postoperative Mortality Among Patients Aged 75 Years or Older With Stage II/III Rectal Cancer.

BACKGROUND: Elderly patients with rectal cancer have been excluded from randomized studies, thus little is known about their early postoperative mortality, which is critical for informed consent and treatment decisions. This study examined early mortality after surgery in elderly patients with locally advanced rectal cancer (LARC). METHODS: Using the National Cancer Database, we identified patients aged ≥75 years, diagnosed with clinical stage II/III rectal cancer who underwent surgery in 2004 through 2015. Descriptive analyses determined proportions and trends and multivariable logistic regression analyses were performed to determine factors associated with early mortality after rectal cancer surgery. RESULTS: Among 11,794 patients with rectal cancer aged ≥75 years, approximately 6% underwent local excision and 94% received radical resection. Overall 30-day, 90-day, and 6-month postoperative mortality rates were 4.2%, 7.8%, and 11.5%, respectively. Six-month mortality varied by age (8.4% in age 75-79 years to 18.3% in age ≥85 years), and comorbidity score (10.1% for comorbidity score 0 to 17.7% for comorbidity score ≥2). Six-month mortality declined from 12.3% in 2004 through 2007 to 10.2% in 2012 through 2015 (Ptrend=.0035). Older age, higher comorbidity score, and lower facility case volume were associated with higher 6-month mortality. Patients treated at NCI-designated centers had 30% lower odds of 6-month mortality compared with those treated at teaching/research centers. CONCLUSIONS: Six-month mortality rates after surgery among patients aged ≥75 years with LARC have declined steadily over the past decade in the United States. Older age, higher comorbidity score, and care at a low-case-volume facility were associated with higher 6-month mortality after surgery. This information is necessary for informed consent and decisions regarding optimal management of elderly patients with LARC.

Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma.

Importance: Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC). Objective: To determine the association of Medicaid expansions as part of the ACA with stage at diagnosis and TTI for patients with HNSCC. Design, Setting, and Participants: A retrospective cohort study was conducted at Commission on Cancer-accredited facilities among 90 789 patients identified from the National Cancer Database aged 18 to 64 years with HNSCC that was diagnosed during the period from January 1, 2010, to December 31, 2016. Statistical analysis was conducted from February 18 to November 8, 2019. Main Outcomes and Measures: Outcome measures included health insurance coverage, stage at diagnosis, and TTI. Absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis, and TTI before (2010-2013) and after (2014-2016) ACA implementation were calculated for Medicaid expansion and nonexpansion states. Results: Of the 90 789 nonelderly adults with newly diagnosed HNSCC (mean [SD] age, 54.7 [7.0] years), 70 907 (78.1%) were men, 72 911 (80.3%) were non-Hispanic white, 52 142 (57.4%) were between 55 and 64 years of age, and 54 940 (60.5%) resided in states with an ACA Medicaid expansion. Compared with nonexpansion states, the percentage of patients with HNSCC with Medicaid increased more in expansion states after the implementation of the ACA (adjusted DD, 4.6 percentage points [95% CI, 3.7-5.4 percentage points]). The percentage of patients with localized disease (American Joint Committee on Cancer stage I-II) at diagnosis increased in expansion states compared with nonexpansion states for the overall cohort (adjusted DD, 2.3 percentage points [95% CI, 1.1-3.5 percentage points]) and for the subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points [95% CI, 1.5-5.2 percentage points]). The mean TTI did not differ between expansion and nonexpansion states for the cohort (adjusted DD, -12.7 percentage points [95% CI, -27.4 to 4.2 percentage points]) but improved for patients with nonoropharyngeal HNSCC (adjusted DD, -26.5 percentage points [95% CI, -49.6 to -3.4 percentage points]). Conclusions and Relevance: This study suggests that Medicaid expansions were associated with a greater increase in the percentage of patients with HNSCC with Medicaid coverage, an increase in the percentage of patients with localized disease at diagnosis for the overall cohort of patients with HNSCC, and improved TTI for patients with nonoropharyngeal HNSCC.

Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments.

BACKGROUND: Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions. METHODS: We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided. RESULTS: Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured. CONCLUSIONS: Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments.

County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States.

BACKGROUND: Although counties are the smallest geographic level for comprehensive health-care delivery analysis, little is known about county-level variations in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States. METHODS: A total of 179,189 patients aged ≥ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the District of Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with ≥ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression. RESULTS: Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8% to 48.6% in the lowest decile of counties, to 74.3% to 91.7% in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25% absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status. CONCLUSIONS: Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors.

Prevalence and correlates of non-tissue prostate cancer diagnosis in the United States.

BACKGROUND: Given the potential complications of prostate biopsies, it is sometimes reasonable in selected patients to make a non-tissue diagnosis of prostate cancer. Little is known about prevalence and factors associated with non-tissue prostate cancer diagnoses in the United States. METHODS: We identified 40 to 99-year-old prostate cancer patients with prostate specific antigen (PSA) ≥20 ng/ml from the 2010-2015 National Cancer Database. Associations were examined between non-tissue prostate cancer diagnosis and age, race, clinical T (cT) and M (cM) categories, PSA, and Charlson-Deyo Comorbidity Index (CCI) with multivariable analyses. RESULTS: Among 62,635 patients, 6.2% had a non-tissue diagnosis. The proportion of patients with non-tissue diagnoses increased with advanced age (from 0.9% in ages 40-49 to 44.0% in ages 90-99) and disease stage (cT and cM) and higher CCI and PSA level. Demographic and clinical characteristics statistically significantly associated (all P < .001) with non-tissue diagnosis in adjusted analyses were older age (OR = 24.24, 90 to 99 vs. 60 to 69 years), and higher cT (OR = 4.83; T4 vs. T1), cM (OR = 5.25, M1C vs. M0), CCI (OR = 2.07; 3+ vs. 0), and PSA levels (OR = 3.19, >97.9 ng/ml vs.20 to 39 ng/ml), as well as hormonal therapy (OR = 0.51, with vs. without). CONCLUSIONS: Non-tissue diagnosis of prostate cancer, while rare, is not outside normal clinical practice and is strongly associated with advanced patient age, higher clinical stage, multiple comorbidities, and very high PSA levels.

Treatment Patterns Among De Novo Metastatic Cancer Patients Who Died Within 1 Month of Diagnosis.

BACKGROUND: Little is known about patterns of and factors associated with treatment for de novo metastatic cancer patients who die soon after diagnosis. In this study, we examine treatment patterns for patients newly diagnosed with metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis. METHODS: We identified 100 848 adult patients in the National Cancer Database with de novo metastatic lung, colorectal, breast, and pancreatic cancer, diagnosed between 2004 and 2014 and who died within 1 month. We performed descriptive and multivariable logistic regression analyses to examine receipt of surgery, chemotherapy, radiation, and hormonal therapy by cancer type, adjusting for sociodemographic and clinical variables. RESULTS: Treatment substantially varied by cancer type, over time, age, insurance, and facility type. Surgery ranged from 0.4% in pancreatic to 28.3% in colorectal cancer (CRC) patients, chemotherapy from 5.8% among CRC to 11% in lung and breast cancer patients, and radiotherapy from 1.3% in pancreatic to 18.7% in lung cancer patients. Use of some treatments (eg, surgery for CRC and breast cancer) progressively declined between 2004 and 2014. Compared with lung cancer patients treated at National Cancer Institute-designated cancer centers, those treated at community cancer centers had 48% lower odds of radiation. CONCLUSIONS: Treatment of patients diagnosed with imminently fatal de novo metastatic cancer varied markedly by cancer type and patient/facility characteristics. These variations warrant more research to better identify patients with imminently fatal de novo metastatic cancer who may not benefit from aggressive and expensive therapies.

The impact of dependent coverage expansion under the Affordable Care Act on time to breast cancer treatment among young women.

INTRODUCTION: Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer. METHODS: A total of 7,176 patients diagnosed with early stage breast cancer in 2007-2009 (pre-ACA) and 2011-2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19-25 (targeted by the policy) considered as the intervention group, and patients aged 26-34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation. RESULTS: Compared with the control group of patients aged 26-34, young patients aged 19-25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort. CONCLUSIONS AND RELEVANCE: No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.

Patterns of axillary evaluation in older patients with breast cancer and associations with adjuvant therapy receipt.

PURPOSE: Although axillary lymph node status has traditionally been a key factor in informing adjuvant breast cancer therapy recommendations, this information may be less relevant as our focus shifts more towards tumor biology, particularly in older patients where comorbidity influences treatment decisions and nodal staging and/or surgery may not improve outcomes. We examined patterns of axillary surgery and associations between axillary surgery and receipt of adjuvant treatment in older breast cancer patients. METHODS: Women aged ≥ 65 years with clinically node-negative, stage I-II breast cancer treated between 2012 and 2013 were identified using the National Cancer Data Base. Using multivariable logistic regression, we examined associations between axillary surgery and age, adjusting for patient, clinical, and facility factors. We also examined receipt of adjuvant treatment by nodal surgery. RESULTS: Among 68,205 women, 40.1% were aged 65-70, 24.5% were 71-75, 17.4% were 76-80, and 18.0% were > 80. Overall, 91.2% had axillary surgery (67.8% sentinel lymph node biopsy, 11.7% axillary lymph node dissection, 11.7% unspecified/unknown axillary surgery); 88.0% of those aged ≥ 70 with lower risk, hormone receptor-positive tumors underwent axillary surgery. In adjusted analyses, compared to patients aged 65-70, increasing age was associated with lower odds of any axillary surgery (ages 71-75: OR 0.64, 95% CI 0.57-0.71; ages 76-80: OR 0.33, 95% CI 0.30-0.37; age > 80: OR 0.08, 95% CI 0.07-0.08). Axillary surgery was associated with higher odds of receipt of radiation after breast conservation and receipt of chemotherapy in human epidermal growth factor 2-positive disease. CONCLUSIONS: In a large nationwide dataset, the vast majority of older women with clinically node-negative breast cancer underwent axillary staging despite uncertainty about its impact on survival, particularly for those with lower-risk disease. Further study on how to tailor node assessment in older patients is warranted.

Treatment Patterns Among Women Diagnosed With Stage I-III Triple-negative Breast Cancer.

OBJECTIVE: To examine contemporary treatment patterns for women diagnosed with stage I-III triple-negative breast cancer (TNBC) in the United States. METHODS: We identified 48,961 patients diagnosed with stage I-III TNBC from 2010 to 2013 in the National Cancer Data Base and created 3 treatment subcohorts (definitive locoregional therapy [appropriate local therapy, including surgery/radiation], adjuvant chemotherapy [stage II-III disease or stage I tumors with tumor size ≥1 cm], and adjuvant chemotherapy for small tumors [stage I tumors with tumor size <1 cm and node negative]). We performed descriptive analyses, calculated percentages for treatment receipt, and used multivariable modified Poisson regression models to estimate risk ratios (RRs) with 95% confidence intervals (CIs) predicting receipt of treatments. RESULTS: Older age, larger tumor size, positive nodal status, and Southern/Pacific US regions, but not race/ethnicity, were strongly associated with a lower probability of receiving definitive locoregional therapy. Older age was also strongly associated with lower likelihood of adjuvant chemotherapy receipt, as were grade, negative nodal status, and higher comorbidity. For example, compared with women aged 18 to 39 years, those aged 75 to 90 years were 17% less likely to receive definitive locoregional therapy (RR, 0.83; 95% CI, 0.73-0.88), and 62% less likely to receive adjuvant chemotherapy (RR, 0.38; 95% CI, 0.35-0.41). Age, tumor grade, tumor size, and comorbidity score were also independently associated with receipt of chemotherapy for women with small TNBC. CONCLUSIONS: Advancing age but not race/ethnicity was associated with lower likelihood of recommended treatment receipt among women with TNBC. Although omission of therapy among older patients with breast cancer may be appropriate in the case of smaller and lower risk TNBC, some were likely undertreated.

Factors That Contribute to Differences in Survival of Black vs White Patients With Colorectal Cancer.

BACKGROUND & AIMS: Previous studies reported that black vs white disparities in survival among elderly patients with colorectal cancer (CRC) were because of differences in tumor characteristics (tumor stage, grade, nodal status, and comorbidity) rather than differences in treatment. We sought to determine the contribution of differences in insurance, comorbidities, tumor characteristics, and treatment receipt to disparities in black vs white patients with CRC 18-64 years old. METHODS: We used data from the National Cancer Database, a hospital-based cancer registry database sponsored by the American College of Surgeons and the American Cancer Society, on non-Hispanic black (black) and non-Hispanic white (white) patients, 18-64 years old, diagnosed from 2004 through 2012 with single or first primary invasive stage I-IV CRC. Each black patient was matched, based on demographic, insurance, comorbidity, tumor, and treatment features, with 5 white patients, from partially overlapping subgroups, using propensity score and greedy matching algorithms. We used the Kaplan-Meier method to estimate 5-year survival and Cox proportional hazards models to generate hazard ratios. RESULTS: The absolute 5-year survival difference between black and white unmatched patients with CRC was 9.2% (57.3% for black patients vs 66.5% for white patients; P < .0001). The absolute difference in survival did not change after patient groups were matched for demographics, but decreased to 4.9% (47% relative decrease [4.3% of 9.2%]) when they were matched for insurance and to 2.3% when they were matched for tumor characteristics (26% relative decrease [2.4% of 9.2%]). Further matching by treatment did not reduce the difference in 5-year survival between black and white patients. In proportional hazards model, insurance and tumor characteristics matching accounted for the 54% and 27% excess risk of death in black patients, respectively. CONCLUSIONS: In an analysis of data from the National Cancer Database, we found that insurance coverage differences accounted for approximately one half of the disparity in survival rate of black vs white patients with CRC, 18-64 years old; tumor characteristics accounted for a quarter of the disparity. Affordable health insurance coverage for all populations could substantially reduce differences in survival times of black vs white patients with CRC.

Use of Next-Generation Sequencing Tests to Guide Cancer Treatment: Results From a Nationally Representative Survey of Oncologists in the United States.

Purpose: There are no nationally representative data on oncologists' use of next-generation sequencing (NGS) testing in practice. The purpose of this study was to investigate how oncologists in the United States use NGS tests to evaluate patients with cancer and to inform treatment recommendations. Methods: The study used data from the National Survey of Precision Medicine in Cancer Treatment, which was mailed to a nationally representative sample of oncologists in 2017 (N = 1,281; cooperation rate = 38%). Weighted percentages were calculated to describe NGS test use. Multivariable modeling was conducted to assess the association of test use with oncologist practice characteristics. Results: Overall, 75.6% of oncologists reported using NGS tests to guide treatment decisions. Of these oncologists, 34.0% used them often to guide treatment decisions for patients with advanced refractory disease, 29.1% to determine eligibility for clinical trials, and 17.5% to decide on off-label use of Food and Drug Administration-approved drugs. NGS test results informed treatment recommendations often for 26.8%, sometimes for 52.4%, and never or rarely for 20.8% of oncologists. Oncologists younger than 50 years of age, holding a faculty appointment, having genomics training, seeing more than 50 unique patients per month, and having access to a molecular tumor board were more likely to use NGS tests. Conclusion: In 2017, most oncologists in the United States were using NGS tests to guide treatment decisions for their patients. More research is needed to establish the clinical usefulness of these tests, to develop evidence-based clinical guidelines for their use in practice, and to ensure that patients who can benefit from these new technologies receive appropriate testing and treatment.

Limited Use of Adjuvant Therapy in Patients With Resected Gallbladder Cancer Despite a Strong Association With Survival.

Background: There are no randomized data to guide clinicians treating patients with gallbladder cancer (GBC). Several retrospective studies reported the survival benefits of adjuvant radiotherapy (RT) and chemoradiation (CRT). In this paper, we examine whether these publications have impacted the utilization of adjuvant therapies and whether their survival benefits are evident in a contemporary cohort of patients. Methods: Using the National Cancer Data Base, we identified 5029 patients diagnosed with T1-3N0-1 GBC and treated with surgical resection from 2005 to 2013. We described trends in receipt of adjuvant treatments for three time periods (2005-2007, 2008-2010, 2011-2013) and calculated three-year overall survival (OS) probabilities for 2989 patients treated in 2005-2010. All statistical tests were two-sided. Results: The percentage of patients who received no adjuvant treatments was unchanged from 2005 to 2013. Adjuvant RT decreased from 4.2% to 1.7% ( P < .001), adjuvant chemotherapy increased from 8.3% to 13.8% ( P < .001), and adjuvant CRT remained stable at 15.9% ( P = .98). Adjuvant treatments were associated with improved three-year OS, with adjusted hazard ratio of 0.47 (95% confidence interval [CI] = 0.39 to 0.58) for CRT, 0.77 (95% CI = 0.61 to 0.97) for chemotherapy, and 0.63 (95% CI = 0.44 to 0.92) for RT. Adjuvant CRT was associated with improved survival in all categories, except T1N0, and in patients with negative and positive margins. Conclusion: Over the past decade there was no increase in the utilization of adjuvant therapies in the United States for patients with resected GBC. Adjuvant therapy is associated with statistically significantly improved three-year OS. This analysis should form the basis for current clinical recommendations and support future prospective trials.

Contemporary Patterns and Survival Outcome of Adjuvant Systemic Therapy for Localized Gastrointestinal Stromal Tumors.

OBJECTIVES: To describe contemporary patterns of and factors associated with adjuvant therapy use and survival outcome after resection of localized gastrointestinal stromal tumors (GISTs) using a large contemporary clinical database. METHODS: We queried the National Cancer Data Base to identify localized GIST cases diagnosed from 2004 to 2011, and used descriptive and logistic regression analyses to determine patterns of and factors associated with adjuvant therapy. Kaplan-Meier and Cox proportional-hazard model were utilized to generate survival probabilities and hazard ratios (HRs). RESULTS: Of 4694 patients, 73.5% received surgery alone, and 26.5% received adjuvant therapy during 2004 to 2011. Receipt of adjuvant therapy more than doubled between 2006 (13.2%) and 2007 (30.5%), peaked to 37.9% in 2009, and then decreased to 25.6% in 2011 (P for trend<0.0001). Receipt of adjuvant therapy monotonically decreased with older age (P for trend<0.0001), and was higher in patients with larger tumor size (>10 cm) than those with smaller tumor size (≤5 cm) (44.1% vs. 15.8%; P<0.0001). Patients who received adjuvant therapy had 46% lower risk of death than those who received surgery alone (HR=0.55; 95% confidence interval, 0.37-0.79; P<0.001); survival benefit was statistically significant for GISTs with >10 cm tumor size (HR=0.42; 95% confidence interval, 0.20-0.89; P=0.02). CONCLUSIONS: In a large nationwide dataset, we showed that the use of adjuvant therapy for localized GISTs has significantly increased over time and patients treated with adjuvant therapy have better survival than patients treated with surgery alone.

Changes in treatment patterns for patients with locally advanced rectal cancer in the United States over the past decade: An analysis from the National Cancer Data Base.

BACKGROUND: In the United States, neoadjuvant chemoradiotherapy (NACRT) is widely accepted as the standard of care in the treatment of patients with locally advanced rectal cancer. In the current study, the authors attempted to examine patterns of treatment in the United States over the past decade. METHODS: Using the National Cancer Data Base, a total of 66,197 patients who were diagnosed with American Joint Committee on Cancer stage II to III rectal adenocarcinoma and treated between 2004 and 2012 were identified. The authors described trends in the receipt of treatment for 3 time periods (2004-2006, 2007-2009, and 2010-2012) and analyzed 5-year overall survival probabilities for 28,550 patients treated between 2004 and 2007. RESULTS: Receipt of NACRT increased significantly from 42.9% between 2004 and 2006 to 50.0% between 2007 and 2009, and to 55.0% between 2010 and 2012 (P < .0001). In contrast, the use of adjuvant chemoradiotherapy (CRT) decreased from 16.7% between 2004 and 2006 to 10.5% between 2007 and 2009, and to 6.7% between 2010 and 2012 (P < .0001). Similarly, the use of surgery alone decreased from 13.1% between 2004 and 2006 to 8.7% between 2010 and 2012 (P < .0001). Older age, the presence of comorbidities, larger primary tumor size, lymph node involvement, not being of non-Hispanic white race/ethnicity, lack of private insurance, and treatment at a facility that did not have a high case volume were associated with a significantly lower possibility of receiving NACRT. The 5-year overall survival rates for patients treated with NACRT, surgery and adjuvant CRT, surgery alone, and definitive CRT were 72.4%, 70.9%, 44.9%, and 48.8%, respectively. CONCLUSIONS: The use of NACRT before surgery in US patients with rectal cancer has substantially increased over the past decade. However, only approximately one-half of patients currently receive this standard therapy, which could be explained in part by socioeconomic factors. Trimodality therapy is associated with the best outcomes for these patients. Cancer 2016;122:1996-2003. © 2016 American Cancer Society.