Daniel P. McKellar

Using the National Cancer Database for Outcomes Research: A Review

Importance The National Cancer Database (NCDB), a joint quality improvement initiative of the American College of Surgeons Commission on Cancer and the American Cancer Society, has created a shared research file that has changed the study of cancer care in the United States. A thorough understanding of the nuances, strengths, and limitations of the database by both readers and investigators is of critical importance. This review describes the use of the NCDB to study cancer care, with a focus on the advantages of using the database and important considerations that affect the interpretation of NCDB studies. Observations The NCDB is one of the largest cancer registries in the world and has rapidly become one of the most commonly used data resources to study the care of cancer in the United States. The NCDB paints a comprehensive picture of cancer care, including a number of less commonly available details that enable subtle nuances of treatment to be studied. On the other hand, several potentially important patient and treatment attributes are not collected in the NCDB, which may affect the extent to which comparisons can be adjusted. Finally, the NCDB has undergone several significant changes during the past decade that may affect its completeness and the types of available data. Conclusions and Relevance The NCDB offers a critically important perspective on cancer care in the United States. To capitalize on its strengths and adjust for its limitations, investigators and their audiences should familiarize themselves with the advantages and shortcomings of the NCDB, as well as its evolution over time.

Treatment Summaries and Survivorship Care Plans: The Approach by the Commission on Cancer to Increase Use

The implementation of CoC standard 3.3 represents a paradigm shift in the care of cancer survivors, with a statement that treatment summaries and survivorship care plans are important documents for patient care and should be required.

Building Data Infrastructure to Evaluate and Improve Quality: The National Cancer Data Base and the Commission on Cancer's Quality Improvement Programs

It is only in the last decade that the quality of cancer care delivery has begun to be seriously measured. The authors focus on efforts by the Commission on Cancer to develop the oncology quality agenda using the National Cancer Data Base.

The role of the American College of Surgeons' cancer program accreditation in influencing oncologic outcomes

The multidisciplinary Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC), administered by the American College of Surgeons (ACoS), defines evidence and consensus‐based standards, require an operational infrastructure, collect high quality cancer data, and validate compliance with standards through external peer review. A survey of our constituents confirms a high level of agreement that accreditation is regarded as important in improving oncologic outcomes through compliance with standards that include continuous quality improvement. J. Surg. Oncol. 2014 110:611–615.

Survival As a Quality Metric of Cancer Care: Use of the National Cancer Data Base to Assess Hospital Performance

PURPOSE Survival is considered an important indicator of the quality of cancer care, but the validity of different methodologies to measure comparative survival rates is less well understood. We explored whether the National Cancer Data Base (NCDB) could serve as a source of unadjusted and risk-adjusted cancer survival data and whether these data could be used as quality indicators for individual hospitals or in the aggregate by hospital type. METHODS The NCDB, an aggregate of > 1,500 hospital cancer registries, was queried to analyze unadjusted and risk-adjusted hazards of death for patients with stage III breast cancer (n = 116,787) and stage IIIB or IV non-small-cell lung cancer (n = 252,392). Data were analyzed at the individual hospital level and by hospital type. RESULTS At the hospital level, after risk adjustment, few hospitals had comparative risk-adjusted survival rates that were statistically better or worse. By hospital type, National Cancer Institute-designated comprehensive cancer centers had risk-adjusted survival ratios that were statistically significantly better than those of academic cancer centers and community hospitals. CONCLUSION Using the NCDB as the data source, survival rates for patients with stage III breast cancer and stage IIIB or IV non-small-cell lung cancer were statistically better at National Cancer Institute-designated comprehensive cancer centers when compared with other hospital types. Compared with academic hospitals, risk-adjusted survival was lower in community hospitals. At the individual hospital level, after risk adjustment, few hospitals were shown to have statistically better or worse survival, suggesting that, using NCDB data, survival may not be a good metric to determine relative quality of cancer care at this level.

Impact of age and comorbidity on treatment of non-small cell lung cancer recurrence following complete resection: A nationally representative cohort study

OBJECTIVE Older patients with non-small cell lung cancer (NSCLC) are less likely to receive guideline-recommended treatment at diagnosis, independent of comorbidity. However, national data on treatment of postoperative recurrence are limited. We evaluated the associations between age, comorbidity, and other patient factors and treatment of postoperative NSCLC recurrence in a national cohort. MATERIALS AND METHODS We randomly selected 9001 patients with surgically resected stage I-III NSCLC in 2006-2007 from the National Cancer Data Base. Patients were followed for 5 years or until first NSCLC recurrence, new primary cancer, or death, whichever came first. Perioperative comorbidities, first recurrence, treatment of recurrence, and survival were abstracted from medical records and merged with existing registry data. Factors associated with active treatment (chemotherapy, radiation, and/or surgery) versus supportive care only were analyzed using multivariable logistic regression. RESULTS Median age at initial diagnosis was 67; 69.7% had >1 comorbidity. At 5-year follow-up, 12.3% developed locoregional and 21.5% developed distant recurrence. Among patients with locoregional recurrence, 79.5% received active treatment. Older patients (OR 0.49 for age >75 compared with <55; 95% CI 0.27-0.88) and those with substance abuse (OR 0.43; 95% CI 0.23-0.81) were less likely to receive active treatment. Women (OR 0.62; 95% CI 0.43-0.89) and patients with symptomatic recurrence (OR 0.69; 95% CI 0.47-0.99) were also less likely to receive active treatment. Among those with distant recurrence, 77.3% received active treatment. Older patients (OR 0.42 for age >75 compared with <55; 95% CI 0.26-0.68) and those with any documented comorbidities (OR 0.59; 95% CI 0.38-0.89) were less likely to receive active treatment. CONCLUSION Older patients independent of comorbidity, patients with substance abuse, and women were less likely to receive active treatment for postoperative NSCLC recurrence. Studies to further characterize these disparities in treatment of NSCLC recurrence are needed to identify barriers to treatment.

Survival as a measure of quality of cancer care and advances in therapy: Lessons learned from analyses of the National Cancer Data Base (NCDB).

173 Background: Many quality metrics of cancer care are process measures, based on whether a patient received recommended treatment for diagnosis and stage of their disease. Survival is dependent on patient characteristics, disease specifics, and care received (surgery, systemic therapies, radiation). Some argue survival is the ultimate measure of cancer care quality. Survival calculated from registry data may be a better indication of the real effects of new therapies as it contains a broad representation of patients who may not meet the eligibility criteria for clinical trials. METHODS The NCDB is composed of registry data from approximately 1,500 hospital based cancer programs, and includes stage, demographic data, co-morbidities, treatments, and vital status. Survival analyses were derived from NCDB data for all stages of breast cancer, non-small cell lung cancer (NSCLC), and pancreatic cancer. These diseases were selected because breast cancer has a high survival rate, whereas NSCLC and pancreatic cancer are diseases with a poor prognosis, but recent advances may have improved survival. Un-adjusted and risk adjusted survival were analyzed by socioeconomic, tumor, and hospital factors including stage, comorbidities, diagnosis year (to assess new treatment trends), and type of institution (academic, comprehensive community, and community cancer programs). RESULTS Results for these diseases and variables noted will be presented. Whereas better un-adjusted survival rates were often seen at academic cancer programs, differences disappeared after risk-adjustment. Improved survival was seen in more recent years, probably representing new treatment effects, though gains were modest and stage dependent. CONCLUSIONS Measuring survival across hospitals and regions is critical to understanding the state of cancer treatment nationally and the effect of quality and therapy advances on patients across a variety of clinical settings. Methodologic challenges in analyzing and interpreting survival data must be realized, and continued innovation in the collection and analysis of data is needed.

Using the American College of Surgeons cancer registry to drive quality.

A discussion of the uses and future plans of the National Cancer Data Base, which has been reengineered in recent years for applying and reporting quality measure data and most recently for rapid case ascertainment and patient care tracking.

Comorbidity Assessment in the National Cancer Database for Patients With Surgically Resected Breast, Colorectal, or Lung Cancer (AFT-01, -02, -03)

PURPOSE Accurate comorbidity measurement is critical for cancer research. We evaluated comorbidity assessment in the National Cancer Database (NCDB), which uses a code-based Charlson-Deyo Comorbidity Index (CCI), and compared its prognostic performance with a chart-based CCI and individual comorbidities in a national sample of patients with breast, colorectal, or lung cancer. PATIENTS AND METHODS Through an NCDB Special Study, cancer registrars re-abstracted perioperative comorbidities for 11,243 patients with stage II to III breast cancer, 10,880 with stage I to III colorectal cancer, and 9,640 with stage I to III lung cancer treated with definitive surgical resection in 2006-2007. For each cancer type, we compared the prognostic performance of the NCDB code-based CCI (categorical: 0 or missing data, 1, 2+), Special Study chart-based CCI (continuous), and 18 individual comorbidities in three separate Cox proportional hazards models for postoperative 5-year overall survival. RESULTS Comorbidity was highest among patients with lung cancer (13.2% NCDB CCI 2+) and lowest among patients with breast cancer (2.8% NCDB CCI 2+). Agreement between the NCDB and Special Study CCI was highest for breast cancer (rank correlation, 0.50) and lowest for lung cancer (rank correlation, 0.40). The NCDB CCI underestimated comorbidity for 19.1%, 29.3%, and 36.2% of patients with breast, colorectal, and lung cancer, respectively. Within each cancer type, the prognostic performance of the NCDB CCI, Special Study CCI, and individual comorbidities to predict postoperative 5-year overall survival was similar. CONCLUSION The NCDB underestimated comorbidity in patients with surgically resected breast, colorectal, or lung cancer, partly because the NCDB codes missing data as CCI 0. However, despite underestimation of comorbidity, the NCDB CCI was similar to the more complete measures of comorbidity in the Special Study in predicting overall survival.

Questioning the Quality of Thyroid Cancer Data: Thoughts from the Commission on Cancer and the National Cancer Database

Cancer registry data is useful for retrospective analysis of treatment patterns and outcome. It is therefore imperative that data submitted to cancer databases such as the National Cancer Database (NCDB) is as accurate and complete as possible. For most cancer types, patients undergo a single operation as part of the treatment of that cancer; however, thyroid cancer is unique because patients often undergo an initial thyroid lobectomy (TL) followed later by a completion total or subtotal thyroidectomy (TT) as indicated by the initial operative pathology results. As a result, cancer registrars abstracting data regarding patients with thyroid cancer would have to assess whether a second procedure was performed in order to provide accurate surgical data to the cancer database. In a previous study using NCDB data, Kiernan et al. observed that patients with TL were receiving radioactive iodine treatment (RAI), which is not recommended for patients treated with TL. This led the authors to question the accuracy of the surgical codes being reported to national cancer surveillance systems for thyroid patients, and prompted their present study. Using data reported to the Tennessee Cancer Registry (TCR), Kiernan et al. conducted a review of thyroid surgery codes submitted to the TCR for the diagnosis years 2004 through 2011. Submitted surgery codes were deemed as correct or incorrect based on review of submitted textual documentation and by contacting the reporting facility to confirm the submitted surgery code and review the first course of treatment for any subsequent thyroid procedures. Of the 921 TL cases reviewed, the authors identified 40% as being coded incorrectly. In 27% of cases, the TL was revised to TT and, in the remaining cases, the surgery codes were revised from one type of TL to another type of TL.The authors state that identified inaccuracies due to changing from one TL code to another highlights that the Facility Oncology Registry Data Standards (FORDS) manual has multiple codes for procedures that are vague or overlapping and that the definitions likely result in inaccurate coding. The researchers interviewed some cancer registrars to determine the reasons for inaccurate coding and reported that in a single institution the majority of cases that had errant codes submitted were for patients who underwent a completion thyroidectomy after TL. The registrars hypothesized that the second specimen did not contain cancer and therefore they were not prompted by pathology to update the surgical code, and/or additional procedures were not identified at the time of record review for followup or treatment. This study brings attention to, and prompts further discussion on, the quality of thyroid surgical coding included in national cancer surveillance systems. Several potential mechanisms to improve thyroid surgery coding have been suggested. As noted in the article, the NCDB is currently involved in a major revision of the FORDS manual. The findings in this article were shared with the FORDS Revision Project Thyroid expert panel for feedback on the current thyroid surgery codes. Please refer to Appendix B: Site-Specific Surgery Codes for Thyroid, page 418 of the current FORDS manual (FORDS: Revised for 2016), for a listing of surgical codes for thyroid and their respective Society of Surgical Oncology 2016