David I. Shalowitz

Teleoncology for gynecologic cancers

Teleoncology describes cancer care provided remotely to improve access to care in rural or underserved areas. In the United States, 14.8 million women live more than 50 miles away from the closest gynecologic oncologist; 4.3 million women live more than 100 miles distant. Teleoncology may therefore partially relieve the geographic barriers to high-quality gynecologic cancer care these women experience. Little has been published on the feasibility of remote provision of high-quality care for gynecologic cancers, perhaps owing to the particular difficulties inherent in remote management of patients who may require both medical and surgical intervention. In this article, we review the data supporting the use of telemedicine in the treatment of cancer patients with a specific focus on applicability to management of gynecologic malignancies. We further add our groups experience with the treatment of rural, underserved gynecologic cancer patients. We believe that development of teleoncologic systems is critical to ensure that all women have access to high-quality gynecologic cancer care, regardless of where they reside.

Non-surgical management of ovarian cancer: Prevalence and implications

PURPOSE To identify prevalence, correlates and survival implications of non-surgically managed epithelial ovarian cancer (EOC). METHODS The National Cancer Database (NCDB) was queried for EOC cases between 2003 and 2011. Type of treatment, survival data, reasons for non-surgical treatment, clinicopathologic and process-based factors were collected. Logistic regression identified independent predictors of surgical treatment; Cox proportional hazards regression modeled association between time to death and receipt of surgery. RESULTS 172,687 of 210,667 patients (82%) received surgical treatment for EOC. 95% of patients treated non-surgically had stage III, stage IV or unknown stage disease. The reason for non-surgical treatment was unclear in 80% of cases. Black race and uninsurance were significantly associated with non-surgical treatment. Median survival time was 57.4months (95% CI: 56.8-57.9) for surgery with or without systemic treatment compared to 11.9months (95% CI: 11.6-12.2) for systemic treatment alone and 1.4months (95% CI: 1.3-1.4) for no treatment. Relative to surgical treatment, the adjusted hazard ratio for death associated with systemic treatment alone was 1.9 (p<0.001); hazard ratio for untreated patients was 4.7 (p<0.001). Among 29,921 patients older than 75 with Stage III/IV disease, 21.5% received only systemic treatment; 22.8% were entirely untreated. CONCLUSION 18% of EOC patients in the NCDB did not receive surgical treatment. These patients experienced significantly worsened survival. Prospective investigation is needed to determine how often apparent deviation from best-practices guidelines is clinically appropriate. Non-surgically treated patients may be at risk for poor access to gynecologic oncology care and deserve further study.

Survival implications of time to surgical treatment of endometrial cancers

Background: Optimal care for women with endometrial cancers often involves transfer of care from diagnosing physicians (eg, obstetrician‐gynecologists) to treating physicians (eg, gynecologic oncologists.) It is critical to determine the effect of time to treatment on cancer outcomes to set best practices guidelines for referral processes. Objective: We sought to determine the impact of time from diagnosis of endometrial cancer to surgical treatment on mortality and to characterize those patients who may be at highest risk for worsened survival related to surgical timing. Study Design: The National Cancer Database was queried for incident endometrial cancers in adults from 2003 through 2012. Cancers were classified as low risk (grade 1 or 2 endometrioid histologies) or high risk (nonendometrioid and grade 3 endometrioid histologies) and analyzed separately. Demographic, clinicopathologic, and health system factors were collected. Unadjusted and adjusted hazard ratios for mortality were calculated by interval between diagnosis and surgery. Linear regression of patient and health care system characteristics was performed on diagnosis‐to‐surgery interval. Results: For low‐risk cancers (N = 140,078), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.4; 95% confidence interval, 1.3–1.5; and hazard ratio, 1.1; 95% confidence interval, 1.0–1.2, respectively). The 30‐day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (0.7% vs 0.4%; P < .001). Mortality risk was also significantly higher than baseline when time between diagnosis and surgery was >8 weeks. Independent associations with added time to surgery of at least 1 week were seen with black race (1.1 weeks; 95% confidence interval, 0.9–1.4), uninsurance (1.3 weeks; 95% confidence interval, 1.1–1.5), Medicaid insurance (1.7 weeks; 95% confidence interval, 1.5–1.9), and Charlson‐Deyo comorbidity score >1 (1.0 weeks; 95% confidence interval, 0.8–1.2). For high‐risk cancers (N = 68,360), surgery in the first and second weeks after diagnosis was independently associated with mortality risk (hazard ratio, 1.5; 95% confidence interval, 1.3–1.6; and hazard ratio, 1.2; 95% confidence interval, 1.1–1.2, respectively). The 30‐day postoperative mortality was significantly higher among patients undergoing surgery in the first or second week postdiagnosis, compared to patients treated in the third or fourth week postdiagnosis (2.5% vs 1.0%; P < .001). Surgery after the third week postdiagnosis was not associated with a statistically significant increase in the adjusted risk of mortality. Independent associations with added time to surgery of at least 1 week were seen with uninsurance (1.4 weeks; 95% confidence interval, 0.9–1.9) and Medicaid insurance (1.4 weeks; 95% confidence interval, 1.1–1.7). Conclusion: Surgery in the first 2 weeks after diagnosis of endometrial cancer was associated with worsened survival associated with elevated perioperative mortality and treatment in low‐volume hospitals. Delay in surgical treatment was a risk factor for mortality in low‐risk cancers only and was likely associated with poor access to specialty care. We suggest that the target interval between diagnosis and treatment of endometrial cancers be ≤8 weeks; however, referral to an experienced surgeon and adequate preoperative optimization should be prioritized over expedited surgery.

Access to gynecologic oncology care and the network adequacy standard: Access to Gynecologic Oncology Care

INTRODUCTION Health insurance exchanges under the Affordable Care Act may offer plans with narrow provider networks that contract with a small proportion of physicians or hospitals within the plan’s covered area. These networks are offered as a costcontrol measure for insurers and to allow consumers the option of lower premiums. In an effort to ensure that these narrow provider networks are not overly restrictive, the Affordable Care Act requires that plans offered on exchanges provide “a network that is sufficient in number and types of providers . . . to assure that all services will be accessible to enrollees without unreasonable delay.” The specifics of how commercial and Medicaid plans meet this qualitative network adequacy standard are left for individual states to regulate; beginning in 2018, the Centers for Medicare and Medicaid Services (CMS) will additionally allow states to assume primary responsibility for assessing the adequacy of plans offered on federally facilitated health insurance exchanges. Unfortunately, narrow provider networks may limit access to cancer centers and affiliated oncologists. To specify and standardize the minimum network adequacy standard for health plans, CMS implemented quantitative benchmarks for the numbers of and distance to covered providers in 27 specialties, including primary care (Table 1), that must be met by commercial plans applying to participate under Medicare Part C, also known as Medicare Advantage. These proximity requirements were developed from claims data and are adjusted for the population and rurality of covered counties. Importantly, plans must ensure that 90% of beneficiaries within counties have access to at least 1 provider in the identified specialties within the given time and distance criteria. If the proximity criteria are not met, the plan issuers must “specifically address how issuers meet the reasonable access standard, despite not meeting the time and distance standards.” In addition, in an acknowledgment of providers’ geographic scarcity, all plans must specify how transplantation services will be covered, if needed, regardless of travel time and distance. Although individual plans may have mechanisms for a case-by-case review of requests for coverage of out-of-network services, the inclusion of a specialty within the network adequacy criteria ensures that there is a plan in place for the referral of patients with conditions that benefit from specialty care. Although these quantitative criteria for marketplace regulation currently apply only to plans involving Medicare products, the CMS standards may serve as models for state oversight committees tasked with approving the adequacy of commercial (including exchange) plans and Medicaid plans under their purview in 2018. In its 2018 updated letter to insurers, CMS explicitly acknowledged that some networks may have inadequate access to specialty care; therefore, it “intends to explore factors that contribute to enrollee access to specialty providers.”

Survival implications of staging lymphadenectomy for non-endometrioid endometrial cancers

PURPOSE To determine, in patients with non-endometrioid endometrial carcinoma, 1) survival benefit associated with pelvic lymphadenectomy (LND), 2) survival benefit for para-aortic lymphadenectomy performed in addition to pelvic lymphadenectomy, and 3) association between number of lymph nodes removed and survival. METHODS Patients with clinical stage I serous carcinoma, clear cell carcinoma, or carcinosarcoma who underwent hysterectomy from 2010 to 2013 were identified from the National Cancer Database. Hazard ratio (HR) for death was assessed using propensity score-weighted multivariable Cox regression models. Subgroup analyses assessed for differences in risk of death among histologic subtypes. RESULTS 7250 patients met study criteria. 930 (13%) did not undergo LND; 2177 (30%) underwent pelvic LND alone; 4143 (57%) underwent pelvic+para-aortic LND. On propensity score-weighted analysis, pelvic LND was associated with decreased risk of death (HR=0.65, 95% CI: 0.59-0.71) compared to no LND. Pelvic+para-aortic LND was associated with decreased risk of death (HR=0.85, 95% CI: 0.79-0.91) compared to pelvic LND for patients with serous carcinoma. Removal of >15 nodes was independently associated with decreased HR for death (HR=0.86, 95% CI: 0.77-0.96); this association persisted when analysis was limited to patients with node-positive disease (HR=0.78, 95% CI: 0.63-0.95). CONCLUSIONS LND is associated with survival benefit in patients with non-endometrioid endometrial cancers. Addition of para-aortic LND to pelvic LND may be most beneficial for patients with serous carcinoma. Systematic lymphadenectomy may be associated with survival benefit through detection and microscopic cytoreduction of occult disease.

Suggestibility of Oncologists’ Clinical Estimates

Funding/Support: This work was supported by grants from the Jiangsu Province of China (BK20131167, RC2011105, and ZX201102), National Nature Science Foundation of China (81270591), National Key Basic Research Program of China (2012CB526600), Jiangsu Provincial Special Program of Medical Science (BL2012005) and the Priority Academic Program Development of Jiangsu Higher Education Institutions (PAPD).

Abstract 3726: Race-based disparities in loss of functional independence after uterine cancer

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Introduction Racial disparities in uterine cancer-related outcomes have been reported. Black uterine cancer patients are more likely to have worse clinical outcomes, which are not fully explained by number of comorbidities. Few studies have investigated the factors that may influence functional independence following surgery for uterine cancer. The goal of this study was to determine if race, preoperative body mass index (BMI) and medical comorbidities are predictors of loss of functional independence. Method: Data from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) were used. All patients were identified by post-operative ICD-9 code. Functional independence was defined as: the patient not requiring assistance from another person for any activities of daily living preoperatively. Loss of independence was defined as requiring discharge to a post-care facility or death, in the immediate postoperative period following hysterectomy. Demographic factors, comorbidities, BMI, intraoperative and postoperative outcomes and discharge status were captured within 30 days of surgery. Statistical analyses included multivariate logistic regression and Wald tests for interaction. Results: 4115 patients were identified with a diagnosis of uterine cancer and were functionally independent preoperatively: 310 (7.5%) were Black and 3805 (92.5%) were non-black. Compared with non-black, Black uterine cancer patients were notable for greater BMI (median 35.4 vs. 32.3, P<0.001), more likely to have one or more comorbidities (76.9% vs. 59.8%, P<0.001), and longer operative time (179.9 mins vs. 159.5 mins, P<0.001). After adjusting for BMI, age, number of comorbidities, pre-operative conditions, major complications, disseminated cancer and days of hospitalization prior to surgery, Black women were not significantly more likely to lose functional independence during the postoperative period than non-Black women. However, a significant interaction (OR 1.14 per 1-unit BMI increase, P<0.001) was found between Black and BMI on loss of functional independence. Interaction plots revealed worse functional outcomes per unit increase in BMI for Black women but not in non-Blacks. Conclusions: The significant interaction between Black race and BMI suggests a 14% increased odds of losing functional independence for each unit of BMI increase for Black uterine cancer patients, meaning that a 10-point increase in BMI would confer a 140% increase in odds of losing functional independence. Black uterine cancer patients with high BMIs may especially benefit from weight loss or interventions to optimize physical function and comorbidity profiles prior to and following surgery, in order to reduce the likelihood of losing functional independence after surgery. Together these efforts may improve disease specific as well as overall health outcomes in Black women with uterine cancer. Citation Format: Lorraine Dean, Xiaochen Zhang, Nawar Latif, Ashley Haggerty, Robert Giuntoli, Sarah Kim, David Shalowitz, Caitlin Stashwick, Mark Morgan, Emily Ko, Kathryn Schmitz. Race-based disparities in loss of functional independence after uterine cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3726. doi:10.1158/1538-7445.AM2015-3726