Elyn H. Wang

Adoption of hypofractionated whole-breast irradiation for early-stage breast cancer: a National Cancer Data Base analysis.

PURPOSE To evaluate the relationship of patient, hospital, and cancer characteristics with the adoption of hypofractionation in a national sample of patients diagnosed with early-stage breast cancer. METHODS AND MATERIALS We performed a retrospective study of breast cancer patients in the National Cancer Data Base from 2004-2011 who were treated with radiation therapy and met eligibility criteria for hypofractionation. We used logistic regression to identify factors associated with receipt of hypofractionation (vs conventional fractionation). RESULTS We identified 13,271 women (11.7%) and 99,996 women (88.3%) with early-stage breast cancer who were treated with hypofractionation and conventional fractionation, respectively. The use of hypofractionation increased significantly, with 5.4% of patients receiving it in 2004 compared with 22.8% in 2011 (P<.001 for trend). Patients living ≥50 miles from the cancer reporting facility had increased odds of receiving hypofractionation (odds ratio 1.57 [95% confidence interval 1.44-1.72], P<.001). Adoption of hypofractionation was associated with treatment at an academic center (P<.001) and living in an area with high median income (P<.001). Hypofractionation was less likely to be used in patients with high-risk disease, such as increased tumor size (P<.001) or poorly differentiated histologic grade (P<.001). CONCLUSIONS The use of hypofractionation is rising and is associated with increased travel distance and treatment at an academic center. Further adoption of hypofractionation may be tempered by both clinical and nonclinical concerns.

Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non–Small-Cell Lung Cancer

PURPOSE To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletely resected non-small-cell lung cancer (NSCLC) and evaluate the association between PORT and survival in such patients. PATIENTS AND METHODS We identified patients with pathologic stage N0-2, overall American Joint Committee on Cancer stage II or III NSCLC within the National Cancer Data Base who had undergone a lobectomy or pneumonectomy with positive surgical margins. Only patients coded as receiving external-beam PORT at 50 to 74 Gy or observation were included. To account for perioperative mortality, we excluded patients who survived less than 4 months after diagnosis. Multivariable logistic regression was used to determine factors associated with PORT receipt. Cox proportional hazards regression was performed for multivariable analyses of overall survival. RESULTS Among 3,395 included patients, 1,207 (35.6%) received PORT. Predictors for the use of PORT among this patient population included age less than 60 years, treatment in a nonacademic facility, earlier year of diagnosis, decreased travel distance, lower nodal stage, and chemotherapy receipt. On multivariable analysis adjusting for demographic and clinicopathologic covariates, PORT (hazard ratio, 0.80; 95% CI, 0.70 to 092) was associated with improved survival. Subset analysis by nodal stage showed that PORT improved survival across all nodal stages. CONCLUSION PORT is associated with improved overall survival in patients with incompletely resected stage II or III N0-2 NSCLC. The use of PORT for this population in more recent years has been declining. In the absence of randomized trials evaluating PORT utilization for this patient population, our findings strongly support the delivery of PORT in patients with incompletely resected NSCLC.

Patients Selected for Definitive Concurrent Chemoradiation at High-volume Facilities Achieve Improved Survival in Stage III Non–Small-Cell Lung Cancer

Background: The relationship between provider experience and clinical outcomes is poorly defined in radiation oncology. This study examined the impact of facility case volume on overall survival in patients with stage III non–small cell lung cancer (NSCLC) treated with definitive concurrent chemoradiation therapy (CCRT). Methods: Using the National Cancer Data Base, we identified clinical stage III NSCLC patients diagnosed in 2004 to 2006 who were treated with definitive CCRT to 59.4–74.0 Gy. High-volume facilities (HVF) were defined as those in the ninetieth percentile of annual CCRT volume (≥12 cases/year). Independent predictors of receiving CCRT at HVF were identified using multivariable logistic regression. Overall survival based on receiving CCRT at HVF was assessed using Kaplan–Meier analysis, Cox proportional hazards regression, and propensity score matching. Results: Among 10,072 included patients, 1207 (12.0%) were treated at HVF. Patients in HVF were more likely to have a higher Charlson–Deyo comorbidity score, more advanced nodal stage, higher doses, and 3D-conformal or intensity-modulated radiotherapy. When controlling for demographic and clinical covariates including academic affiliation, treatment at HVF was independently associated with a significantly decreased risk of death (hazards ratio = 0.93; 95% confidence interval: 0.87–0.99; p = 0.03). Propensity score matching showed that these findings were robust (hazards ratio = 0.91; 95% confidence interval: 0.84–0.99; p = 0.04). Conclusions: Our findings suggest that treatment at HVF is associated with improved overall survival among stage III NSCLC patients receiving definitive CCRT, independent of academic affiliation. Further research is needed to determine whether or not efforts supporting centralization of radiotherapy at HVF will improve population-based survival, toxicities, and costs.

Variation in pelvic lymph node dissection among patients undergoing radical prostatectomy by hospital characteristics and surgical approach: results from the National Cancer Database.

PURPOSE Clinical practice guidelines recommend pelvic lymph node dissection at the time of surgery for intermediate or high risk prostate cancer. Therefore, we examined the relationship of pelvic lymph node dissection and detection of lymph node metastasis with hospital characteristics and surgical approach among patients with prostate cancer. MATERIALS AND METHODS Using the National Cancer Data Base we identified surgically treated patients with pretreatment intermediate or high risk disease from 2010 to 2011. Primary outcomes were treatment with pelvic lymph node dissection and extended pelvic lymph node dissection, as well as the detection of lymph node metastasis. Multivariate logistic regression models were used to test whether hospital characteristics and surgical approach were associated with each outcome. RESULTS Among the 50,671 surgically treated patients 70.8% (35,876) underwent concomitant pelvic lymph node dissection, 26.6% (9,543) underwent extended pelvic lymph node dissection and 4.5% (1,621) had lymph node metastasis. Pelvic lymph node dissection was performed more often at high volume vs low volume hospitals (81.2% vs 65.4%, adjusted OR 2.20, p=0.01), but less frequently with robotic assisted radical prostatectomy vs open radical prostatectomy (67.5% vs 81.8%, adjusted OR 0.30, p <0.001). Higher odds ratios for lymph node metastasis were also demonstrated with high vs low volume (OR 1.35, p=0.01) and academic vs community hospitals (OR 1.35, p <0.001). However, patients treated with robotic assisted radical prostatectomy had lower odds ratios for lymph node metastasis compared to those undergoing open radical prostatectomy (OR 0.56, p <0.001). CONCLUSIONS In this cohort a third of patients are not receiving guideline recommended treatment with pelvic lymph node dissection for prostate cancer. Pelvic lymph node dissection and detection of lymph node metastasis varied by surgical approach, hospital volume and academic status.

Shared Decision Making and Use of Decision Aids for Localized Prostate Cancer : Perceptions From Radiation Oncologists and Urologists

IMPORTANCE The current attitudes of prostate cancer specialists toward decision aids and their use in clinical practice to facilitate shared decision making are poorly understood. OBJECTIVE To assess attitudes toward decision aids and their dissemination in clinical practice. DESIGN, SETTING, AND PARTICIPANTS A survey was mailed to a national random sample of 1422 specialists (711 radiation oncologists and 711 urologists) in the United States from November 1, 2011, through April 30, 2012. MAIN OUTCOMES AND MEASURES Respondents were asked about familiarity, perceptions, and use of decision aids for clinically localized prostate cancer and trust in various professional societies in developing decision aids. The Pearson χ2 test was used to test for bivariate associations between physician characteristics and outcomes. RESULTS Similar response rates were observed for radiation oncologists and urologists (44.0% vs 46.1%; P=.46). Although most respondents had some familiarity with decision aids, only 35.5% currently use a decision aid in clinic practice. The most commonly cited barriers to decision aid use included the perception that their ability to estimate the risk of recurrence was superior to that of decision aids (7.7% in those not using decision aids and 26.2% in those using decision aids; P<.001) and the concern that patients could not process information from a decision aid (7.6% in those not using decision aids and 23.7% in those using decision aids; P<.001). In assessing trust in decision aids established by various professional medical societies, specialists consistently reported trust in favor of their respective organizations, with 9.2% being very confident and 59.2% being moderately confident (P=.01). CONCLUSIONS AND RELEVANCE Use of decision aids among specialists treating patients with prostate cancer is relatively low. Efforts to address barriers to clinical implementation of decision aids may facilitate greater shared decision making for patients diagnosed as having prostate cancer.

Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort.

OBJECTIVE To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States. MATERIALS AND METHODS We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type. RESULTS During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001). CONCLUSION Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

Adoption of Intensity Modulated Radiation Therapy For Early-Stage Breast Cancer From 2004 Through 2011

PURPOSE Intensity modulated radiation therapy (IMRT) is a newer method of radiation therapy (RT) that has been increasingly adopted as an adjuvant treatment after breast-conserving surgery (BCS). IMRT may result in improved cosmesis compared to standard RT, although at greater expense. To investigate the adoption of IMRT, we examined trends and factors associated with IMRT in women under the age of 65 with early stage breast cancer. METHODS AND MATERIALS We performed a retrospective study of early stage breast cancer patients treated with BCS followed by whole-breast irradiation (WBI) who were ≤65 years old in the National Cancer Data Base from 2004 to 2011. We used logistic regression to identify factors associated with receipt of IMRT (vs standard RT). RESULTS We identified 11,089 women with early breast cancer (9.6%) who were treated with IMRT and 104,448 (90.4%) who were treated with standard RT, after BCS. The proportion of WBI patients receiving IMRT increased yearly from 2004 to 2009, with 5.3% of WBI patients receiving IMRT in 2004 and 11.6% receiving IMRT in 2009. Further use of IMRT declined afterward, with the proportion remaining steady at 11.0% and 10.7% in 2010 and 2011, respectively. Patients treated in nonacademic community centers were more likely to receive IMRT (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.30-1.43 for nonacademic vs academic center). Compared to privately insured patients, the uninsured patients (OR, 0.81; 95% CI, 0.70-0.95) and those with Medicaid insurance (OR, 0.87; 95% CI, 0.79-0.95) were less likely to receive IMRT. CONCLUSIONS The use of IMRT rose from 2004 to 2009 and then stabilized. Important nonclinical factors associated with IMRT use included facility type and insurance status.

Timing of Surgery after Neoadjuvant Chemoradiation in Locally Advanced Non–Small Cell Lung Cancer

Introduction: A subset of patients with potentially resectable clinical stage IIIA NSCLC are managed with trimodality therapy. However, little data exist to guide the timing of surgery after neoadjuvant therapy. This study examined whether the time interval between neoadjuvant chemoradiation (NCRT) and surgical resection affects overall survival. Methods: Patients with clinical stage IIIA disease (T1–3 N2) NSCLC who underwent NCRT were identified in the National Cancer Data Base (NCDB) between 2004 and 2012 and categorized on the basis of the interval between chemoradiation and surgery (0 to ≤3, >3 to ≤6, >6 to ≤9, and >9 to ≤12 weeks). Other clinical stages were excluded. The Kaplan‐Meier method and log‐rank tests were used to compare overall survival rates, and a bootstrapped Cox proportional hazards model was used to determine significant contributors to overall survival. Results: Of the 1623 patients identified, 7.9% underwent an operation 0 to 3 weeks or less after NCRT, 50.5% underwent an operation greater than 3 and less than or equal to 6 weeks after NCRT, 31.9% underwent an operation greater than 6 and less than or equal to 9 weeks after NCRT, and 9.6% underwent an operation greater than 9 and less than or equal to 12 weeks after NCRT. Multivariate survival analysis demonstrated no significant difference in survival in those who underwent an operation within 6 weeks of NCRT. However, significant drops in overall survival were observed in those who had an operation greater than 6 and less than or equal to 9 weeks after NCRT (hazard ratio = 1.33, 95% confidence interval: 1.01–1.76, p = 0.043) and greater than 9 and less than or equal to 12 weeks after NCRT (hazard ratio = 1.44, 95% confidence interval: 1.04–2.01, p = 0.030). Conclusions: The findings from this retrospective study suggest that overall survival may be significantly lower in patients with clinical stage IIIA N2 NSCLC who undergo an operation later than 6 weeks after NCRT. These results discourage unnecessary delays in surgery.

Association Between Radiation Dose and Outcomes With Postoperative Radiotherapy for N0-N1 Non-Small Cell Lung Cancer.

Purpose: To review trends in the use of postoperative radiotherapy (PORT) in the modern era for N0-N1 margin-negative non–small cell lung cancer (NSCLC) following surgical resection and evaluate the association between PORT dose and overall survival. Materials and Methods: We performed a retrospective study of nonmetastatic stage II and III N0-N1 margin-negative NSCLC surgically treated patients within the National Cancer Data Base from 2003 to 2011. Cox proportional hazards regression was performed for multivariable analyses of overall survival and PORT dose. Radiation modalities included nonconformal beam radiation, 3-dimensional conformal radiation (3D-CRT), and intensity-modulated radiation therapy. Results: We identified 2167 (6.7%) and 30,269 (93.3%) patients with surgically resected stage II or III N0-N1 margin-negative NSCLC who were treated with and without PORT, respectively. The proportion of patients treated with PORT (dose range, 45 to 74 Gy) decreased from 8.9% in 2003 to 2006 to 4.1% in 2010 to 2011. Among patients receiving PORT, the use of high-dose (60 to 74 Gy) PORT rose throughout the study period, starting at 34.8% in 2003 to 2006 and rising to 49.3% in 2010 to 2011. Overall, patients who received PORT had worse survival (hazards ratio=1.30; 95% confidence interval, 1.20-1.40) compared with those not receiving PORT. This association was unchanged when limited to patients receiving modern treatment with 3-CRT or intensity-modulated radiation therapy (hazards ratio=1.35; 95% confidence interval, 1.10-1.65). Conclusions: The use of PORT for N0-N1 margin-negative NSCLC decreased from 2003 to 2011. We found no evidence of benefit from PORT for resected N0-N1 margin-negative NSCLC, regardless of dose or technique. PORT should be approached with caution in this group of patients, regardless of radiotherapy technique.

Association between access to accelerated partial breast irradiation and use of adjuvant radiotherapy

The current study was performed to determine whether access to facilities performing accelerated partial breast irradiation (APBI) is associated with differences in the use of adjuvant radiotherapy (RT).