Stephen R. Grant

Disparities in Stage at Diagnosis, Treatment, and Survival in Nonelderly Adult Patients With Cancer According to Insurance Status

PURPOSE The purpose of this study was to determine the association of insurance status with disease stage at presentation, treatment, and survival among the top 10 most deadly cancers using the SEER database. PATIENTS AND METHODS A total of 473,722 patients age 18 to 64 years who were diagnosed with one of the 10 most deadly cancers in the SEER database from 2007 to 2010 were analyzed. A Cox proportional hazards model was used for multivariable analyses to assess the effect of patient and tumor characteristics on cause-specific death. RESULTS Overall, patients with non-Medicaid insurance were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or without insurance coverage (34.7%; P < .001). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery and/or radiation therapy (79.6%) compared with those with Medicaid coverage (67.9%) or without insurance coverage (62.1%; P < .001). In a Cox regression that adjusted for age, race, sex, marital status, residence, percent of county below federal poverty level, site, stage, and receipt of cancer-directed surgery and/or radiation therapy, patients were more likely to die as a result of their disease if they had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P < .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001) compared with non-Medicaid insurance. CONCLUSION Among patients with the 10 most deadly cancers, those with Medicaid coverage or without insurance were more likely to present with advanced disease, were less likely to receive cancer-directed surgery and/or radiation therapy, and experienced worse survival.

Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer

In the United States, an estimated 48 million individuals live without health insurance. The purpose of the current study was to explore the Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer.

Proton versus conventional radiotherapy for pediatric salivary gland tumors: Acute toxicity and dosimetric characteristics

PURPOSE We evaluated acute toxicity profiles and dosimetric data for children with salivary gland tumors treated with adjuvant photon/electron-based radiation therapy (X/E RT) or proton therapy (PRT). METHODS AND MATERIALS We identified 24 patients who had received adjuvant radiotherapy for salivary gland tumors. Data were extracted from the medical records and the treatment planning systems. Toxicity was scored according to the Common Terminology Criteria for Adverse Effects 4.0. RESULTS Eleven patients received X/E RT and 13 PRT, with a median prescribed dose of 60 Gy in each group. In the X/E RT group, 54% of patients developed acute grade II/III dermatitis, 27% grade II/III dysphagia, and 91% grade II/III mucositis, and the median weight loss was 5.3% with one patient requiring feeding tube placement. In the PRT group, 53% had acute grade II/III dermatitis, 0% grade II/III dysphagia, and 46% grade II/III mucositis, with a median weight gain of 1.2%. Additionally, PRT was associated with lower mean doses to several normal surrounding midline and contralateral structures. CONCLUSION In this retrospective study of pediatric salivary tumors, PRT was associated with a favorable acute toxicity and dosimetric profile. Continued follow-up is needed to identify long-term toxicity and survival data.

Impact of insurance status on radiation treatment modality selection among potential candidates for prostate, breast, or gynecologic brachytherapy

PURPOSE The Patient Protection and Affordable Care Act looks to expand both private and Medicaid insurance. To evaluate how these changes may affect the field of radiation oncology, we evaluated the association of insurance status with the use of brachytherapy in cancers for which this treatment technique is used. METHODS AND MATERIALS A total of 190,467 patients met the inclusion criteria, of whom 95,292 (50.0%) had breast cancer, 61,096 (32.1%) had prostate cancer, 28,194 (14.8%) had endometrial cancer, and 5885 (3.1%) had cervical cancer. A multivariate logistic regression model was used to determine the association between insurance status and receipt of brachytherapy among patients treated definitively for prostate and cervical cancer or postoperatively for breast and endometrial cancer. RESULTS The rates of non-Medicaid insurance were 49.9% (cervical), 85.3% (endometrial), 87.4% (breast), and 90.9% (prostate) (P<.001). In a logistic regression, patients who received radiation therapy were less likely to receive brachytherapy if they had Medicaid coverage (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.53-0.61, P<.001) or did not have insurance coverage (OR 0.50, 95% CI 0.45-0.56, P<.001) compared with those with non-Medicaid insurance. On subset analysis, patients with Medicaid coverage or without insurance coverage were significantly less likely to receive brachytherapy than were those with non-Medicaid insurance for all 4 sites, except for patients with endometrial cancer. CONCLUSIONS Despite being a cost-effective treatment modality, brachytherapy is less often used in the definitive or postoperative management of cancer in patients with Medicaid coverage or without insurance. Upcoming health policy changes resulting in the expansion of private insurance and Medicaid will likely increase access to and demand for brachytherapy.

Insurance Status and Racial Disparities in Cancer-Specific Mortality in the United States: A Population-Based Analysis

Background: Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared with whites. Private insurance confers CSM benefit, but few studies have examined the relationship between insurance status and racial disparities. We sought to determine differences in CSM between races within insurance subgroups. Methods: A population-based cohort of 577,716 patients age 18 to 64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007 to 2012 were obtained from Surveillance, Epidemiology, and End Results. A Cox proportional hazards model for CSM was constructed to adjust for known prognostic factors, and interaction analysis between race and insurance was performed to generate stratum-specific HRs. Results: Blacks had similar CSM to whites among the uninsured [HR = 1.01; 95% confidence interval (CI), 0.96–1.05], but higher CSM among the Medicaid (HR = 1.04; 95% CI, 0.01–1.07) and non-Medicaid (HR = 1.14; 95% CI, 1.12–1.16) strata. Hispanics had lower CSM compared with whites among uninsured (HR = 0.80; 95% CI, 0.76–0.85) and Medicaid (HR = 0.88; 95% CI, 0.85–0.91) patients, but there was no difference among non-Medicaid patients (HR = 0.99; 95% CI, 0.97–1.01). Asians had lower CSM compared with whites among all insurance types: uninsured (HR = 0.80; 95% CI, 0.76–0.85), Medicaid (HR = 0.81; 95% CI, 0.77–0.85), and non-Medicaid (HR = 0.85; 95% CI, 0.83–0.87). Conclusions: The disparity between blacks and whites was largest, and the advantage of Hispanic race was absent within the non-Medicaid subgroup. Impact: These findings suggest that whites derive greater benefit from private insurance than blacks and Hispanics. Further research is necessary to determine why this differential exists and how disparities can be improved. Cancer Epidemiol Biomarkers Prev; 26(6); 869–75. ©2017 AACR.

Factors associated with improved biochemical response to neoadjuvant androgen deprivation therapy before definitive radiation therapy in prostate cancer patients.

Background:In prostate cancer patients treated with androgen deprivation therapy (ADT) and radiation therapy (RT), a pre-RT PSA level ⩾0.5 ng ml−1, determined after neoadjuvant ADT and before RT, predicts for worse survival measures. The present study sought to identify patient, tumor and treatment characteristics associated with the pre-RT PSA in prostate cancer patients.Methods:We reviewed the charts of all patients diagnosed with intermediate- and high-risk prostate cancer and treated with a combination of neoadjuvant (median, 2.2 and 2.5 months, respectively), concurrent, and adjuvant ADT and RT between 1990 and 2011.Results:A total of 170 intermediate- and 283 high-risk patients met inclusion criteria. On multivariate analysis, both intermediate- and high-risk patients with higher pre-treatment PSA (iPSA) were significantly less likely to achieve a pre-RT PSA <0.5 ng ml−1 (iPSA 10.1–20 ng ml−1: P=0.005 for intermediate risk; iPSA 10.1–20 ng ml−1: P=0.005, iPSA >20 ng ml−1: P<0.001 for high risk). High-risk patients undergoing total androgen blockade were more likely to achieve a pre-RT PSA <0.5 ng ml−1 (P=0.031). We observed an interaction between race and type of neoadjuvant ADT (P=0.074); whereas African-American men on total androgen blockade reached pre-RT PSA <0.5 ng ml−1 as frequently as other men on total androgen blockade (P=0.999), African-American men on luteinizing hormone-releasing hormone (LH-RH) agonist monotherapy/orchiectomy were significantly less likely to reach pre-RT PSA <0.5 ng ml−1 compared with other men on LH-RH monotherapy/orchiectomy (P=0.001).Conclusions:Our findings suggest that total androgen blockade in the neoadjuvant period may be beneficial compared with LH-RH monotherapy for achieving a pre-RT PSA <0.5 ng ml−1 in African-American men with high-risk prostate cancer. In addition, men with higher iPSA are more likely to have a pre-RT PSA greater than 0.5 ng ml−1 in response to neoadjuvant ADT and are therefore candidates for clinical trials testing newer, more aggressive hormone-ablative therapies.

A brighter future? The impact of insurance and socioeconomic status on cancer outcomes in the USA: a review

Uninsured and Medicaid-insured cancer patients have been shown to present with more advanced disease, less often receive cancer-directed therapy and suffer higher rates of mortality than those with private insurance. The Patient Protection and Affordable Care Act was signed into law in March of 2010 and seeks to increase rates of public and private health insurance. Although several provisions will in particular benefit those with chronic and high-cost medical conditions such as cancer, the extent to which disparities in cancer care will be eliminated is uncertain. Further legislative changes may be needed to ensure equal and adequate cancer care for all patients regardless of insurance or socioeconomic status.

Provider variability in intensity modulated radiation therapy utilization among Medicare beneficiaries in the United States

BACKGROUND In this study, we sought to examine the variation in intensity modulated radiation therapy (IMRT) use among radiation oncology providers. METHODS AND MATERIALS The Medicare Physician and Other Supplier Public Use File was queried for radiation oncologists practicing during 2014. Healthcare Common Procedural Coding System code 77301 was designated as IMRT planning with metrics including number of total IMRT plans, rate of IMRT utilization, and number of IMRT plans per distinct beneficiary. RESULTS Of 2759 radiation oncologists, the median number of total IMRT plans was 26 (mean, 33.4; standard deviation, 26.2; range, 11-321) with a median IMRT utilization rate of 36% (mean, 43%; standard deviation, 25%; range, 4% to 100%) and a median number of IMRT plans per beneficiary of 1.02 (mean, 1.07; range, 1.00-3.73). On multivariable analysis, increased IMRT utilization was associated with male sex, academic practice, technical fee billing, freestanding practice, practice in a county with 21 or more radiation oncologists, and practice in the southern United States (P < .05). The top 1% of users (28 providers) billed a mean 181 IMRT plans with an IMRT utilization rate of 66% and 1.52 IMRT plans per beneficiary. Of these 28 providers, 24 had billed technical fees, 25 practiced in freestanding clinics, and 20 practiced in the South. CONCLUSIONS Technical fee billing, freestanding practice, male sex, and location in the South were associated with increased IMRT use. A small group of outliers shared several common demographic and practice-based characteristics.

Proton Versus Conventional Radiation Therapy for Pediatric Salivary Gland Tumors: Acute Toxicity and Dosimetric Characteristics

in regular fixed jaw delivery mode with FW of 2.5 cm for nasopharyngeal carcinoma (NPC) treatments. Materials/Methods: Eight patients with NPC previously treated with HT in fixed jaw delivery mode with FWof 2.5 cm were replanned by using HT dynamic jaw delivery mode with preset FW of 5 cm. As in the previous plans, all nasopharynx, left, and right nodal planning target volumes (PTVNP, PTVLtN, PTVRtN) were aimed to achieve a volume of 95% covered by the prescribed dose. The maximum dose was limited to less than 115% of the prescribed dose. To evaluate the plan quality, PTV coverage, dose conformity and homogeneity were reported by the dose received by 95% of the target volumes (D95), conformity number (CN), and homogeneity index (HI), respectively. For organs at risk (OARs), the maximum dose (Dmax) and near-maximum dose (D2) of brainstem, spinal cord, optic chiasm, left and right lens, and optic nerves were reported while mean dose (Dmean) of pituitary, left and right parotid glands were also reported according to ICRU 83. The number of monitor units (MU) required was used to evaluate the delivery efficiency. Wilcoxon signed tank test was used to investigate significance of differences in the results between the plans created by the two techniques. A 2-tailed P<.05 was considered statistically significant. Results: For PTVNP, PTVLtN, PTVRtN, there was no statistical significant difference in all PTV coverage, dose conformity, and homogeneity between the two treatment modes. With regard to critical organ sparing, the Dmax and D2 of optic chiasm and Dmean of pituitary, left and right parotid glands were statistical significantly lower using dynamic jaw delivery mode, with a mean decrease of 51.1% 22.0%, 51.1% 22.4%, 40.8% 23.9%, 7.0% 6.9%, 7.2% 6.6%, respectively (PZ.008, .008, .008, .039, and .039, respectively). However, there was no statistical significant difference in Dmax and D2 of brainstem, spinal cord, left and right lens, and optic nerves between the 2 planning techniques. The number of MUs required was significantly lower for dynamic jaw delivery mode, with a mean decrease of 47.9% 2.3% (PZ.008). Conclusion: Our results showed that HT planned with dynamic jaw delivery mode with preset FW of 5 cm provided statistically no difference on plan quality, but with better sparing of optic chiasm, pituitary and parotid glands compared with HT in fixed jaw delivery mode with FW of 2.5 cm. A significant better delivery efficiency was also achieved. Author Disclosure: W. Lam: None. H. Geng: None. C. Kong: None. Y. Ho: None. W. Wong: None. B. Yang: None. K. Cheung: None. S. Yu: None.