Jason A. Zell

Prognostic factors for survival of stage I nonsmall cell lung cancer patients : A population-based analysis of 19,702 stage I patients in the California cancer registry from 1989 to 2003

Platinum‐based adjuvant chemotherapy in randomized trials has failed to provide a survival benefit in patients with resected stage I nonsmall cell lung cancer (NSCLC). Using data from the California Cancer Registry (CCR), we explored factors that had detrimental effects on survival in patients with stage I NSCLC to identify a subset of patients at high risk for disease recurrence and subsequent mortality.

Effects of Socioeconomic Status and Treatment Disparities in Colorectal Cancer Survival

Background: Poor survival among colorectal cancer (CRC) cases has been associated with African-American race and low socioeconomic status (SES). However, it is not known whether the observed poor survival of African-American CRC cases is due to SES itself and/or treatment disparities. We set out to determine this using data from the large, population-based California Cancer Registry database. Methods: A case-only analysis of CRC was conducted including all age groups using California Cancer Registry data from 1994 to 2003, including descriptive analysis of relevant clinical variables, race, and SES. CRC-specific survival univariate analyses were conducted using the Kaplan-Meier method. Multivariate survival analyses were done using Cox proportional hazards ratios (HR). Results: Incident cases of colon (90,273) and rectal (37,532) cancer were analyzed, including 91,739 (71.8%) non-Hispanic Whites, 8,535 (6.7%) African-Americans, 14,943 (11.7%) Hispanics, 3,564 (2.8%) Chinese, and 7,950 (6.2%) non-Chinese Asians. African-Americans had a greater proportion of metastatic stage at presentation (P < 0.0001) and decreased CRC-specific survival (P < 0.0001 for colon and rectal cancer). After adjustment for age, sex, histology, site within the colon, and stage, African-Americans [colon: HR, 1.19; 95% confidence interval (95% CI), 1.14-1.25; rectum: HR, 1.27; 95% CI, 1.17-1.38] had an increased risk of death compared with Caucasians. However, after further adjustment for SES and treatment, the risk of death for African-Americans compared with Caucasians was substantially diminished (colon: HR, 1.08; 95% CI, 1.03-1.13; rectum: HR, 1.11; 95% CI, 1.02-1.20). Conclusion: Among CRC cases, disparities in treatment and SES largely explain the observed decreased survival of African-Americans, underscoring the importance of health disparity research in this disease. (Cancer Epidemiol Biomarkers Prev 2008;17(8):1950–62)

Epidemiology of Bronchioloalveolar Carcinoma: Improvement in Survival After Release of the 1999 WHO Classification of Lung Tumors

PURPOSE Classification changes for bronchioloalveolar carcinoma (BAC) by the WHO in May 1999 narrowed its definition. This study was undertaken in an attempt to characterize the impact of these changes on the epidemiology of BAC. PATIENTS AND METHODS This retrospective study involves data analysis from the population-based Cancer Surveillance Programs of three Southern California counties from 1995 to 2003. BAC cases diagnosed after May 1999 are compared with BAC cases before that time by clinicopathologic variables including survival. RESULTS Incident cases (11,969) of non-small-cell lung cancer (NSCLC) were analyzed, including 626 cases of BAC (5.2%). Median overall survival (OS) for BAC patients diagnosed after May 1999 (> 53 months) was significantly improved over median OS for BAC patients before May 1999 (32 months; P = .012). This survival benefit remained after adjustment for sex, smoking status, and stage at presentation (hazard ratio for time of diagnosis before May 1999 compared with a diagnosis after May 1999 = 1.43; P = .015). Median OS for non-BAC NSCLC patients diagnosed before May 1999 (9 months) did not differ from the median OS of such patients afterwards (10 months; P = .09). CONCLUSION This epidemiologic study is the first to demonstrate a survival advantage for BAC patients diagnosed after May 1999 compared with BAC patients diagnosed before this time-a finding that persists after adjustment for sex, smoking status, and stage at presentation. We believe that this observed survival benefit likely reflects changes in the revised 1999 WHO classification.

Survival for Patients With Invasive Cutaneous Melanoma Among Ethnic Groups: The Effects of Socioeconomic Status and Treatment

PURPOSE Although uncommon, melanoma is associated with poor survival characteristics among African Americans and Hispanics compared with non-Hispanic whites (NHWs). Low socioeconomic status (SES) is also associated with poor survival among patients with melanoma, but it is not known whether this is because of SES itself or because of treatment disparities. We set out to determine this by using the large, population-based California Cancer Registry (CCR) database as a model. PATIENTS AND METHODS We conducted a case-only analysis of CCR data (1993 to 2003), including a descriptive analysis of relevant clinical variables and SES. The SES variable used has been derived from principle component analysis of census block-level CCR data that was linked to census data to address seven indicators of SES. Univariate analyses of overall survival (OS) were conducted using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazard ratios (HRs). RESULTS A total of 39,049 incident patient cases of cutaneous melanoma, including 36,694 in NHWs; 127 in African Americans; 1,996 in Hispanics; and 262 in Asian-Americans, were analyzed. Higher SES was associated with an early stage at presentation (P < .0001), with treatment with surgery (P = .0005), and with prolonged survival (P < .0001). After adjustments for age, sex, histology, American Joint Committee on Cancer stage, anatomic site, treatment, and SES, a statistically significant increased risk of death was observed for African Americans compared with NHWs (HR, 1.60; 95% CI, 1.17 to 2.18); no survival differences were noted for Asians or Hispanics compared with NHWs in the adjusted analysis. CONCLUSION Low SES independently predicts poor outcome among patients with cutaneous melanoma. However, the poor OS observed for African American patients with melanoma is not explained by differences in treatment or SES.

Race, Socioeconomic Status, Treatment, and Survival Time among Pancreatic Cancer Cases in California

Background: Poor survival in pancreatic adenocarcinoma is associated with African-American race and also with low socioeconomic status (SES). However, it is not known whether the observed poor survival of African-American pancreatic adenocarcinoma cases is due to SES itself and/or treatment disparities. We set out to determine this using the large, population-based California Cancer Registry (CCR) database as a model. Methods: We conducted a case-only analysis of CCR data (1989-2003), including descriptive analysis of relevant clinical variables and SES. The SES variable used has been derived from principle component analysis of census block level CCR data linked to census data to address seven major indicators of SES. Overall survival univariate analyses were conducted using the Kaplan-Meier method. Multivariate survival analyses were done using Cox proportional hazards ratios (HR). Results: Incident cases of pancreatic cancer (24,735) were analyzed. Among adenocarcinomas, after adjustment for age, year of diagnosis, and gender, African-Americans [HR, 1.14; 95% confidence interval (95% CI), 1.08-1.21] and Hispanics (HR, 1.06; 95% CI, 1.01-1.11) had an increased risk of death compared with Caucasians. These differences persisted after adjustment for stage. However, after further adjustment for SES, surgery, radiation, and chemotherapy, the risk of death for African-Americans (HR, 1.00; 95% CI, 0.94-1.06) and Hispanics (HR, 0.97; 95% CI, 0.93-1.02) was not statistically different from Caucasians. Conclusions: Differences in treatment and SES likely account for the observed poor survival of African-Americans and Hispanics among pancreatic adenocarcinoma cases. These data highlight the importance of improving access to care for ethnic minority pancreatic cancer patients. (Cancer Epidemiol Biomarkers Prev 2007;16(3):546–52)

Analysis of prognostic factors in Ewing sarcoma using a population-based cancer registry.

Ewing sarcoma is a high‐grade malignancy that most often occurs in children. Because its occurrence in adults has been historically low, few studies have been published on the epidemiology of Ewing sarcoma in this group of patients. By using data from a large, population‐based cancer registry, the authors designed the present study to examine the outcome of children and adult patients with Ewing sarcoma and relevant prognostic factors.

Asian Ethnicity Is a Favorable Prognostic Factor for Overall Survival in Non-small Cell Lung Cancer (NSCLC) and Is Independent of Smoking Status

Background: We previously showed that Asian ethnicity was an independent favorable prognostic factor in non-small cell lung cancer (NSCLC). Many Asian NSCLC patients were never-smokers, and never-smokers had improved survival than ever-smokers. We investigated whether Asian ethnicity is a favorable prognostic factor independent of smoking status. Methods: Retrospective population-based study of NSCLC cases from the cancer surveillance programs of three Southern California counties from 1991 to 2005. Results: A total of 20,140 NSCLC patients with known smoking status were analyzed of which 9.1% were never-smokers and 6.5% were Asians. There was a threefold increase in the percentage of Asian never-smokers as compared with ever-smokers. Asians had the highest overall survival (OS) among the 4 major ethnicities (p < 0.0001) and never-smokers had improved OS over ever-smokers (p = 0.0183) by univariate analyses. By multivariate analyses, Asian ethnicity was an independent and favorable prognostic factor for OS (versus non-Asian; hazard ratio [HR] = 0.861, 95% confidence interval [CI]: 0.808–0.918, p < 0.0001), among smokers (versus non-Asian; HR = 0.867, 95% CI: 0.807–0.931, p < 0.0001), and among never-smokers (versus non-Asian; HR = 0.841, 95% CI: 0.728–0.971, p = 0.0180). Never-smoker was a favorable prognostic factor if ethnicity was not accounted for (versus ever-smoker; HR = 0.936, 95% CI: 0.886–0.988, p = 0.0169) but was no longer an independent favorable prognostic factor (versus ever-smoker; HR = 0.953, 95% CI: 0.902–1.007, p = 0.0861) after accounting for ethnicity. Conclusions: Asian ethnicity is an independent favorable prognostic factor for OS in NSCLC regardless of smoking status.

Tumor subsite location within the colon is prognostic for survival after colon cancer diagnosis.

PURPOSE: Proximal colon cancers are more likely to present with advanced stage than distal cancers; however, previous reports conflict regarding the independent prognostic significance of tumor location on survival. We examined survival by colon cancer subsite location by use of data from the California Cancer Registry. METHODS: An analysis of colon cancer cases from 1994 to 2004 was conducted, with follow-up through 2006. Colon subsite location was defined as proximal colon (cecum, ascending colon, hepatic flexure), transverse colon, descending colon (splenic flexure, descending colon), and sigmoid colon. Subsite-specific survival analyses were conducted with use of the Kaplan-Meier method and Cox proportional hazards ratios. RESULTS: A total of 82,926 colon cancer cases were identified, including 40,078 proximal (48%), 8,023 transverse (10%), 8,657 descending (10%), and 26,168 sigmoid cancers (32%). A larger proportion of sigmoid cancers (30.5%) presented as Stage I compared with proximal (18.5%), transverse (16.8%), or descending colon cancers (20.1%). Proximal cancers had the greater proportion with high tumor grade (27%), and had a greater mean number of lymph nodes examined. There were no differences in treatment rendered when each colon subsite was stratified by stage. After adjustment for stage, grade, treatment, lymph node examination, and other relevant clinical variables, sigmoid cancers had decreased colorectal cancer-specific mortality compared with proximal tumors (hazards ratio = 0.88; 95% confidence interval, 0.85–0.92). CONCLUSIONS: In this analysis, sigmoid colon cancers were observed to have earlier stage, lower tumor grade, and independently decreased colorectal cancer-specific mortality compared with proximal tumors.

Carcinoma NOS is a Common Histologic Diagnosis and is Increasing in Proportion Among Non-small Cell Lung Cancer Histologies

Background: Recent clinical trials have demonstrated differential survival benefit from chemotherapy regimens according to non-small cell lung cancer (NSCLC) histology. We investigated whether the distribution of carcinoma NOS (not otherwise specified) among NSCLC cases in California have changed over time and determined the prognostic significance of carcinoma NOS. Methods: Retrospective population-based study of 175,298 NSCLC patients diagnosed histologically or cytologically from the statewide California Cancer Registry from 1989 to 2006. Results: Carcinoma NOS accounted for 22.1% of all NSCLC patients, was the most commonly diagnosed cytologically (37.0%), and had the poorest 5-year survival estimates (5.8%) and median overall survival (OS, 5 months) among all NSCLC histologies. The proportion of carcinoma NOS had increased significantly from 1989 to 2006 in both males and females, in both histologically and cytologically diagnosed NSCLC, among all four major ethnicities (whites, African American, Hispanic, and Asian), among all age categories, and among all American Joint Committee on Cancer stages. The very elderly (80+ years) had the highest proportion of carcinoma NOS and cytologically diagnosed NSCLC regardless of period of diagnosis. Cytologically diagnosed NSCLC had significantly decreased OS than histologically diagnosed NSCLC (p < 0.0001). Cox proportional hazards regression analysis applied to stage 4 NSCLC patients indicated carcinoma NOS (vs. adenocarcinoma; hazard ratio 1.061, 95% confidence interval 1.039–1.083, p < 0.0001) and cytologically diagnosed NSCLC (versus histologically diagnosed NSCLC, hazard ratio 1.043, 95% confidence interval 1.024–1.062, p < 0.0001) were independent unfavorable prognostic factors for OS. Conclusions: Carcinoma NOS was a common histologic diagnosis, had been increasing over time among NSCLC, and carried an independent unfavorable prognosis among stage 4 NSCLC patients.

Low socioeconomic status is a poor prognostic factor for survival in stage I nonsmall cell lung cancer and is independent of surgical treatment, race, and marital status

Racial minorities exhibit poor survival with nonsmall cell lung cancer (NSCLC) that generally is attributed to low socioeconomic status (SES). In this study, the authors investigated the role of SES in this survival disparity among patients with stage I NSCLC.