Helmneh M. Sineshaw

Declining Use of Radiotherapy for Adverse Features After Radical Prostatectomy: Results From the National Cancer Data Base

BACKGROUND Patterns of postoperative radiotherapy (RT) use in prostate cancer (PCa) after the publication of major randomized trials have not been well characterized. OBJECTIVE To describe patterns of postoperative RT use after radical prostatectomy (RP) in patients with adverse pathologic features in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of 97 270 patients with PCa diagnosed between 2005 and 2011 whose presentation and outcomes were recorded in the National Cancer Data Base. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Temporal changes in receipt of postoperative RT and factors associated with receipt of this treatment using the Cochran-Armitage trend test and multiple logistic regression, respectively. RESULTS AND LIMITATIONS Between 2005 and 2011, receipt of postoperative RT decreased steadily from 9.1% to 7.3% (ptrend<0.001). Use of RT with or without androgen deprivation therapy monotonically decreased with advancing age from 8.5% in patients aged 18-59 yr to 6.8% in patients aged 70-79 yr (ptrend<0.001). Receipt of RT was higher at community cancer programs compared with teaching/research centers (14% vs 7.3%; odds ratio [OR]: 2.16; p<0.001), in those with pT3-4 disease and positive margins compared with those with pT3-4 and negative margins (17% vs 5.9%; OR: 2.89; p<0.001), and in patients with a Gleason score of 8-10 compared with those with a Gleason score of 2-6 (17% vs 4.2%; OR: 3.50; p<0.001). Limitations include lack of postprostatectomy prostate-specific antigen level. CONCLUSIONS Postoperative RT use for localized PCa in patients with adverse pathologic features is declining in the United States. PATIENT SUMMARY In this report, we show that use of postoperative radiotherapy in patients with prostate cancer with adverse pathologic features is declining. Patients treated at community cancer programs, those with locally advanced disease and positive margins, and those with a high Gleason score were more likely to receive postoperative radiotherapy.

Insurance status is related to diffuse large B-cell lymphoma survival

Insurance status is associated with stage at diagnosis and treatment for non‐Hodgkin lymphoma (NHL), but no previous studies have addressed the relation between insurance status and survival for patients diagnosed with diffuse large B‐cell lymphoma (DLBCL), the most common subtype of NHL.

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

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.

Management trends in stage I testicular seminoma: Impact of race, insurance status, and treatment facility.

The management of stage I testicular seminoma is evolving rapidly. This study examined modern trends in the management of stage I testicular seminoma and the effects of sociodemographic factors on therapy choice.

Variations in Receipt of Curative-Intent Surgery for Early-Stage Non–Small Cell Lung Cancer (NSCLC) by State

Background: Previous studies reported racial and socioeconomic disparities in receipt of curative‐intent surgery for early‐stage non–small cell lung cancer (NSCLC) in the United States. We examined variation in receipt of surgery and whether the racial disparity varies by state. Methods: Patients in whom stage I or II NSCLC was diagnosed from 2007 to 2011 were identified from 38 state and the District of Columbia population‐based cancer registries compiled by the North American Association of Central Cancer Registries. Percentage of patients receiving curative‐intent surgery was calculated for each registry. Adjusted risk ratios were generated by using modified Poisson regression to control for sociodemographic (e.g., age, sex, race, insurance) and clinical (e.g., grade, stage) factors. Non‐Hispanic (NH) whites and Massachusetts were used as references for comparisons because they had the lowest uninsured rates. Results: In all registries combined, 66.4% of patients with early‐stage NSCLC (73,475 of 110,711) received curative‐intent surgery. Receipt of curative‐intent surgery for early‐stage NSCLC varied substantially by state, ranging from 52.2% to 56.1% in Wyoming, Louisiana, and New Mexico to 75.2% to 77.2% in Massachusetts, New Jersey, and Utah. In a multivariable analysis, the likelihood of receiving curative‐intent surgery was significantly lower in all but nine states/registries compared with Massachusetts, ranging from 7% lower in California to 25% lower in Wyoming. Receipt of curative‐intent surgery for early‐stage NSCLC was lower for NH blacks than for NH whites in every state, although statistically significant in Florida and Texas. Conclusions: Receipt of curative‐intent surgery for early‐stage NSCLC varies substantially across states in the United States, with northeastern states generally showing the highest rates. Further, receipt of treatment appeared to be lower in NH blacks than in NH whites in every state, although statistically significant in Florida and Texas.

Black/White Disparities in Receipt of Treatment and Survival Among Men With Early-Stage Breast Cancer

PURPOSE To examine the extent of black/white disparities in receipt of treatment and survival for early-stage breast cancer in men age 18 to 64 and ≥ 65 years. PATIENTS AND METHODS We identified 725 non-Hispanic black (black) and 5,247 non-Hispanic white (white) men diagnosed with early-stage breast cancer from 2004 to 2011 in the National Cancer Data Base. We used multivariable logistic regression and calculated standardized risk ratios to predict receipt of treatment and a proportional hazards model to estimate overall hazard ratios (HRs) in black versus white men age 18 to 64 and ≥ 65 years, separately. RESULTS Receipt of treatment was remarkably similar between blacks and whites in both age groups. Black and white older men had lower receipt of chemotherapy (39.2% and 42.0%, respectively) compared with younger patients (76.7% and 79.3%, respectively). Younger black men had a 76% higher risk of death than younger white men after adjustment for clinical factors only (HR, 1.76; 95% CI, 1.11 to 2.78), but this difference significantly diminished after subsequent adjustment for insurance and income (HR, 1.37; 95% CI, 0.83 to 2.24). In those age ≥ 65 years, the excess risk of death in blacks versus whites was nonsignificant and not affected by adjustment for covariates. CONCLUSION The excess risk of death in black versus white men diagnosed with early-stage breast cancer was largely confined to those age 18 to 64 years and became nonsignificant after adjustment for differences in insurance and income. These findings suggest the importance of improving access to care in reducing racial disparities in male breast cancer mortality.

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.

Management and outcomes of clinical stage IIA/B seminoma: Results from the National Cancer Data Base 1998-2012

PURPOSE/OBJECTIVE Disease-specific survival for testicular seminoma approaches 100%, even for those with node-positive disease. We sought to describe modern practice patterns, survival outcomes, and factors associated with postoperative therapy for patients with clinical stage (CS) IIA/B disease. METHODS AND MATERIALS Data on patients diagnosed with CS IIA/B seminoma from 1998 to 2012 were extracted from the National Cancer Data Base. Demographic, clinical, treatment, and payer characteristics were evaluated using multivariate regression to identify factors associated with receipt of chemotherapy or radiation therapy (RT) within 6 months of orchiectomy. Five-year Kaplan-Meier overall survival (OS) by CS and treatment was calculated. A Cox proportional hazards regression for 5-year OS was performed. RESULTS A total of 1885 patients were included; 38.5% received chemotherapy and 61.5% received RT. On multivariate analysis, factors associated with receipt of postorchiectomy RT rather than chemotherapy included CS IIA (odds ratio [OR], 3.04; P < .01) and community treatment setting (OR, 1.81-2.76; P < .01). Reduced likelihood of receiving RT was associated with Medicaid insurance (OR, 0.50; P < .01), more recent year of diagnosis (continuous OR, 0.93; P < .01), and primary pathologic tumor 3/4 stage (OR, 0.47; P < .01). On multivariate Cox regression, decreased 5-year OS was associated with receipt of chemotherapy in CS IIA patients (hazard ratio, 13.33; P < .01) but not in CS IIB patients (hazard ratio, 1.39; P = .45). For CS IIA, 5-year OS was 99.4% for orchiectomy and RT versus 91.2% for orchiectomy and chemotherapy (log-rank P < .01). For CS IIB, 5-year OS was 96.1% for orchiectomy and RT versus 92.8% for orchiectomy and chemotherapy (log-rank P = .08). CONCLUSIONS Consistent with national guideline recommendations, our analysis supports preferred status for RT in CS IIA. In addition, these data also support use of RT for CS IIB. CS, treatment year, primary pathologic tumor stage, insurance, and facility type were associated with type of postoperative therapy. Longer follow-up to account for potential late effects of treatment is needed.

Temporal Trends in and Factors Associated With Contralateral Prophylactic Mastectomy Among US Men With Breast Cancer

Temporal Trends in and Factors Associated With Contralateral Prophylactic Mastectomy Among US Men With Breast Cancer Previous studies have reported marked increases in the rates of contralateral prophylactic mastectomy (CPM) among US women who received a diagnosis of unilateral invasive breastcancer, and this increase is particularly evident among younger women.1 Rates of CPM among women vary depending on the population studied, although national statistics show that the percentage of women with unilateral invasive breast cancer undergoing a CPM increased from approximately 2.2% in 1998 to 11% in 2011.1 This increase has occurred despite the lack of evidence for a survival benefit from bilateral surgery, in addition to the complications and associated costs described in Los tumbo et al.2 Factors that are thought to contribute to the increase in the rate of CPM include increased testing for BRCA1/2 mutations, magnetic resonance imaging, and reconstruction surgery for symmetry, among others.3 However, whether the CPM rate is also increasing among US men is unknown.2 Herein, we used a nationwide population-based cancer database, the North American Association of Central Cancer Registries,4 to examine the temporal trends in and the factors associated with CPM among men who received a diagnosis of unilateral invasive breast cancer.

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.