bluuebunny/crossref_metadata_2025_split huggingface dataset:
Disparities in utilization of palliative care during terminal hospitalizations in patients with metastatic cancer: A nationwide analysis.
Authors: Lingamaneni Prasanth , Moturi Krishna Rekha , Vohra Ishaan , Farooq Muhammad Zain , Gupta Shweta 
Published: May 2020

e19027 Background: Palliative care during the end of life is associated with greater patient satisfaction, improved quality of life and lower health care costs. Our aim was to study temporal trends of aggressive end of life care and palliative care during terminal hospitalizations in patients with metastatic cancer. We also studied disparities in palliative care in this population. Methods: Adult patients with metastatic cancer who died in the hospital from January 2012 to December 2017 were identified from the Nationwide Inpatient Sample database. Statistical tests for temporal trends of resource utilization were performed. Multivariable logistic regression was used to evaluate predictors of utilization of palliative care. Results: A total of 443,360 patients met the inclusion criteria. Mean age was 66.5 years. Patients were predominantly white (66.6%) with a slight male preponderance (51.9%). Most common primary cancers were lung (27.1%), GI tract (23.6%) and breast (7.6%). Use of chemotherapy and radiation decreased from 3.4% to 2.4% ( P < 0.001) and 2.8% to 1.4% ( P < 0.001), respectively, over the years. There was no statistically significant change in ICU care (26.6% to 27.2%, P= 0.61) or hospitalization costs ($22k to $23k, P =0.14). There was an increase in use of palliative care, from 45.7% to 61.2% ( P < 0.001). Patients were more likely to receive palliative care if they were older, female or treated at teaching hospitals. Blacks and Hispanics were less likely receive palliative care. Compared to patients insured by Medicare, those with Medicaid and private insurance were more likely to be offered palliative care. ICU care and chemotherapy predicted decreased use of palliative services. Conclusions: There is an overall trend towards increased use of palliative services and decrease in chemotherapy and radiation in terminal admissions. There are racial disparities in the utilization of palliative care services, with previous studies attributing knowledge gap, with mistrust of the system in African Americans, and language barriers in Hispanics to be causes for racial disparities. There is a need to increase efforts towards development of palliative care programs in non-academic hospitals. [Table: see text]
Prognostication based on TNM staging for socioeconomically disadvantaged colorectal cancer patients.
Authors: Lu Yan , Gehr Aaron , Bullock Jolonda , Ghabach Bassam , Neerukonda Latha Sri , Narra Kalyani , Ojha Rohit P. 
Published: May 2020

e19036 Background: The TNM classification system is the global standard for staging solid tumors, but the ability of TNM to differentiate prognostic groups may vary between settings because of differences in case-mix and treatments. Little information is available about prognostication using TNM in safety-net health systems, which provide care for socioeconomically disadvantaged individuals and have limited resources. Therefore, we aimed to assess the ability of TNM to differentiate prognostic groups for colorectal cancer patients in an urban safety-net cancer center. Methods: We used institutional registry data from the JPS Oncology and Infusion Center (Fort Worth, TX), which is a Comprehensive Community Cancer Program. Our eligible population included adults who were diagnosed with first primary colorectal cancer between 2008 and 2017, had TNM pathologic stage I – IV, and received at least part of the first course treatment at JPS. Our outcome of interest was 5-year all-cause mortality and our exposure of interest was TNM pathologic stage. Patients were followed from cancer diagnosis until death, loss to follow up, or end of study (December 31, 2018), whichever occurred first. We used a pseudo-observation approach and generalized linear models with log link to estimate risk ratios (RR) and corresponding 95% confidence limits (CL) comparing 5-year mortality between TNM stages, where stage I was the reference category. Results: Our eligible population comprised 655 colorectal cancer survivors, of whom 85% were aged < 65 years, 54% were male, 60% were racial/ethnic minorities, and 65% were uninsured at time of diagnosis. Stage IV patients had 4.4 times higher risk of 5-year mortality compared with stage I (RR = 4.4, 95% CL: 2.9, 6.6). Stage III patients had 2.1 times higher risk of 5-year mortality compared with stage I (RR = 2.1, 95% CL: 1.3, 3.2). Stage II patients had 1.4 times higher risk of 5-year mortality compared with stage I (RR = 1.4, 95% CL: 0.81, 2.3). Conclusions: Our findings suggest that TNM stages do not adequately differentiate colorectal cancer prognostic groups in a socioeconomically disadvantaged population. Stage IV is distinct, but stages I – III have limited differentiation and notable overlap. The use of TNM stages for colorectal cancer prognostication may be misleading for socioeconomically disadvantaged individuals. Factors beyond TNM should be considered for better prognostication in this population.
Racial disparities in definitive treatment and long-term mortality among US veterans with high-risk localized prostate cancer.
Authors: Parikh Ravi Bharat , Robinson Kyle William , Chhatre Sumedha , Medvedeva Elina , Malkowicz S. Bruce , Jayadevappa Ravishankar 
Published: May 2020

e19037 Background: Equal access to care may mediate racial disparities among men with localized prostate cancer. We examined the association between African-American race and long-term mortality among men with high-risk prostate cancer in a large equal-access health system. Methods: In this retrospective cohort study, we used the VA Corporate Data Warehouse to identify African-American (AA) and non-Hispanic White Veterans diagnosed with high-risk (prostate-specific antigen [PSA] ≥ 20 ng/mL, Gleason 8-10, or stage ≥ cT2c) localized prostate cancer between January 1st, 2001 and December 31st, 2011 and followed through January 1st, 2019. Veterans who did not receive continuous VA care were excluded. We used descriptive statistics to compare type of therapy received and multivariable Cox proportional hazards regressions to estimate the association between mortality and race. Cox models were adjusted for age, pre-treatment PSA, year of diagnosis, enrollment priority (an individual-level proxy for income and disability need), marital status, Elixhauser comorbidity index, and primary treatment. Results: Among 14,877 Veterans (median age 67 years [interquartile range [IQR] 62-75]), 4,160 (28.0%) were AA. Median followup was 9.0 years (IQR 6.1-11.4). Compared to White men, AA men were more likely to have PSA ≥ 20 (49.9% vs. 40.9%), be unmarried (59.3% vs. 43.3%), have ≥3 comorbidities (46.4% vs. 41.0%), and have high disability and income need (22.0% vs. 18.6%) (all p < 0.001). Over time, AA Veterans were consistently less likely to receive prostatectomy (18.9% vs. 24.9%). Crude mortality rates were 50.6 and 61.6 deaths per 1000 patient-years for AA and White Veterans, respectively. After adjusting for all covariates, AA Veterans had lower all-cause mortality (adjusted hazard ratio [aHR] 0.83, 95% CI 0.79-0.88, p < 0.001) compared to White Veterans. This association was consistent across pre-specified subgroups (Table). Conclusions: Among men with high-risk prostate cancer who received continuous care within a large equal-access health system, African-Americans had lower all-cause mortality compared to Whites. Equal access to care may mitigate or reverse traditional racial disparities in mortality among men with prostate cancer. [Table: see text]
Geographic and demographic disparities in colorectal cancer: A population-based study.
Authors: Rana Navpreet Kaur , Gosain Rohit , Lemini Riccardo , Wang Chong , Nurkin Steven J. , Gabriel Emmanuel M. , Boland Patrick M 
Published: May 2020

e19047 Background: Colorectal cancer is one of the leading causes of cancer deaths in the US. Area of residence affects survival in many cancers, though largely unknown in colorectal cancer. The purpose of this study is to evaluate disparities between the metropolitan, urban and rural populations and the impact on survival in colorectal cancer. Methods: Data was obtained from the National Cancer Database (NCDB) colon, rectosigmoid, and rectal data sets. Patients (pts) were categorized by area of residence: metropolitan (MA), urban (UA), or rural (RA). Gender, race, insurance status, income, marital status, and tumor related data was collected. Univariate and multivariate analyses were performed to evaluate variables affecting overall survival (OS). Results: A total of 973,139 pts, spanning 2004-2013 were included in the study, 83% MA, 15% UA, 2% RA. RA and UA pts were more likely to be white than MA pts (92.7 v 91.4% v 83%). RA and UA were more likely to have lower income, with slightly lesser amounts of women and pts with no comorbidities. Uninsured rates were similar (3.3%). On univariate analysis, OS was worse for RA (HR 1.10) and UA (1.06) pts, as compared with MA. On multivariate analysis, small differences persisted with worse OS for RA (HR 1.02, p = .043) and UA (HR 1.01, p = .003). Black (HR 1.14) and native American (HR 1.17) pts had worse outcomes, while Asian (HR 0.8) pts had improved OS. Women (HR 0.88) and pts with higher incomes ( > 46K or 63K) had improved OS (HR 0.88). Conclusions: This study identifies socio-demographic disparities in colorectal cancer outcomes. Pts from rural and urban areas had worse OS, even though the proportion of minority pts with poor outcomes was lower. The difference in OS for RA and UA remained statistically significant in multivariate analysis, though it was largely corrected when adjusting for influencing variables. Part of this difference may be due to economic disparities, as lower income was linked to worse OS. This can independently limit access to care, especially for geographically isolated individuals. Additional research efforts are needed in order for us to better understand the key issues facing and the optimal means to improve outcomes in at risk populations.
A qualitative study of barriers and facilitators to enrollment of adolescents and young adults onto cancer clinical trials at NCI community oncology research program (NCORP) sites.
Authors: Siembida Elizabeth , Loomans-Kropp Holli Ann , Tami-Maury Irene , Sung Lillian , Pollock Brad H. , Freyer David Robert , Roth Michael 
Published: May 2020

e19050 Background: Cancer clinical trials (CCTs) contribute to improving patient survival and quality of life; however, adolescents and young adults (AYAs, 15-39 years old), are underrepresented in CCTs, especially in the community setting. We aimed to identify barriers and facilitators to AYA CCT enrollment in the NCORP. Methods: We conducted 43 one-on-one semi-structured qualitative interviews with key stakeholders involved in the enrollment of AYAs across a diverse group of NCORP primary (n = 5) and affiliate (n = 10) sites. Interviews were conducted remotely by 3 trained interviewers using the Zoom platform. Stakeholders were recruited from high and low AYA enrolling sites (AYA/total site enrollments > 10% and < 3%, respectively). Stakeholders were overall NCORP Site PIs (n = 5), lead NCORP administrators (n = 4), clinical research associates (n = 11), medical and pediatric oncologists involved in the enrollment of AYAs (n = 7), regulatory research associates (n = 5), nurse navigators (n = 6), and patient advocates (n = 5). Interviews were audiotaped and transcribed. Thematic analysis was conducted to identify themes and relate them back to our primary research questions regarding barriers and facilitators to AYA CCT enrollment. Results: Stakeholder views on enrollment barriers centered on 5 main themes: (1) lack of site-level prioritization or discussion of AYA enrollment; (2) limited number of clinical trials for AYAs available nationally, with few trials opened locally; (3) insufficient resources and research staff; (4) concerns about the cost effectiveness of opening AYA trials due to low numbers of eligible patients; and (5) patient misconceptions about CCTs. Stakeholder views on enrollment facilitators centered on 3 main themes: (1) presence of an AYA program focused on increasing enrollment; (2) having a designated site AYA “champion”; and (3) having site leadership identify AYA enrollment as a priority. Stakeholders agreed that incentivizing AYA enrollments via increased reimbursement and/or study credits could potentially lead to increased enrollment. Conclusions: In addition to identifying multiple shared barriers to AYA CCT enrollment, our study also identified possible interventions for enrollment improvement, including designation of AYA “champions”, increased reimbursement for AYA enrollments, and improving AYA’s understanding of CCTs. Further studies are needed to assess the impact of interventions aimed at increasing AYA enrollment across the NCORP.
Differences in clinical characteristics and outcomes between white (W) and non-white (NW) patients with metastatic germ cell tumor (mGCT) treated at Indiana University (IU).
Authors: Espinoza Gutarra Manuel Ricardo , Hanna Nasser H. , Einhorn Lawrence H. , Adra Nabil 
Published: May 2020

e19053 Background: Patients (pts) with mGCT are curable even when presenting at advanced stages, however its incidence is rising in NW populations. There is lack of data evaluating differences in disease characteristics and outcomes between W and NW pts. Methods: 701 pts with mGCT treated at IU with first-line chemotherapy (FLC) and 462 patients with relapsed mGCT treated with HDCT (high-dose chemotherapy) between 2004 and 2017 at IU were evaluated. Results: Pts treated with FLC had a median follow-up since diagnosis of 4.9 (0.03-19.46) years. 660 (94.1%) W pts and 41 (5.9%) NW (49% Hispanic, 26% Asian, 20% African American and 5% Native American). There were no significant differences in median age at diagnosis, rates of primary tumor site, pathology type (seminoma vs non-seminoma), metastasis sites, mortality, median hCG levels pre-chemotherapy, rates of progression after FLC, or late relapse rates. Higher rates of good risk disease and lower rates of poor risk disease were present among W compared to NW, as well as higher median AFP levels pre-chemotherapy and rates of platinum refractory disease in NW (p < 0.05). Patients treated with HDCT had a median follow up time of 2.08 (0.02-14.49) years since diagnosis. 412 (89.1%) were W and 50 (10.1%) were NW (48% Hispanic, 18% Asian, 26% African American, 2% Native American and 6% other). There were no significant differences in rates pathology type, disease risk, tumor markers, platinum refractory disease, completion of 2 cycles of HDCT, progression after HDCT or status at last follow up. W pts were more likely to receive HDCT as initial salvage chemotherapy compared to NW (P < 0.05). Conclusions: This single-institution study demonstrates that amongst patients undergoing FLC for mGCT, there were higher rates of poor risk disease and platinum refractory disease amongst NW patients. W patients were more likely to receive HDCT as initial salvage chemotherapy compared to NW patients. However these findings did not reflect a significant difference in disease progression or mortality. [Table: see text]
Getting rurality right: Investigating cancer across the rural-urban interface.
Authors: Taylor Amy K. , Schiefelbein Andrea , Zhang Jienian , Krebsbach John , Skala Melissa C. , Eason John , LoConte Noelle K. 
Published: May 2020

e19063 Background: Trends in oncology examine the influence of rural characteristics on cancer patient (pt) treatment and outcomes. Current definitions of rurality are broad and varied, with multiple standardized definitions. Few analyses exist to compare definitions and quality in assessing oncologic outcomes. We aim to determine which index is most suitable to define rurality in cancer research. Methods: 1,567 pancreatic cancer pts from the University of Wisconsin Cancer Registry, representing 84 Midwestern counties and 452 zip codes, were assigned rurality codes based on three indices spanning 1983-2013: Rural-Urban Continuum Code (RUCC), Rural-Urban Commuting Areas (RUCA), and Index of Relative Rurality (IRR). RUCC and IRR were assigned to pts at the county level and RUCA at the zip level. Pt rurality was compared across the three indices and over time via the median and interquartile range and inspected visually with violin plots. We compared indices with Spearman’s Rank Order Correlation (SROC). Results: RUCC 2003, RUCA 2004 (zip), and IRR 2000 were concordant in terms of metropolitan, micropolitan, and rural designations for 66.9% (1,049) of pancreatic cancer registry pts. The rural designation for almost one-third (489, 31.2%) of pts was discordant by one or two levels across the three indices (i.e. classified as metropolitan in one index and micropolitan or rural in another). SROC was 0.73 between RUCC 2003 and RUCA 2004 (zip) indices, 0.82 between IRR 2000 and RUCA 2004 (zip), and 0.85 between RUCC 2003 and IRR 2000. Across the 84 counties of registry pts’ residence, the median and interquartile range of RUCC decreased from 6 (3-7) in 1983 to 4 (2.25-6) in 2013 and of IRR decreased from 0.49 (0.44-0.53) in 2000 to 0.49 (0.43-0.53) in 2010. Across the 452 zip codes, RUCA decreased from 4 (1-10) in 1998 to 3 (1-8) in 2004. Pts’ median RUCC decreased from 3 (2-6) in 1983 to 3 (2-4) in 2013, median RUCA (zip) decreased from 2 (1-7) in 1990 to 1 (1-6) in 2000, and IRR remained constant at 0.42 (0.38-0.49) in 2000 and 2010. Conclusions: RUCC is preferable for state-level cancer studies incorporating rurality as it best distributes pts across the rural-urban interface compared to RUCA (skews urban) and IRR (skews central). County boundaries (RUCC) are consistent over time versus zip (RUCA) and census tract (RUCA). Our findings suggest that while the extremes of rural and urban are well-defined, rurality as a continuum is inconsistently measured. Researchers should continue to incorporate other measures of vulnerability to achieve health equity.
Access to new therapies: FDA accelerated approvals and the corresponding Canadian regulatory and funding decisions.
Authors: Lim Howard John , Hunt Melissa , Beaver Julia A. , Kluetz Paul Gustav , Gravel Christopher , Raven Andrew , Regier Dean , Ho Cheryl 
Published: May 2020

e19066 Background: Accelerated approval (AA) by the FDA enables earlier access to promising new therapies while evidence generation is ongoing. Health Canada (HC) has a similar process with a Notice of Compliance conditional (NOCc) before full approval (NOC). Canada implemented health technology assessment (HTA) for determination of funding through the pan Canadian Oncology Drug Review (pCODR) in 2011. This study evaluated timelines and decisions from AA approval to HC NOC/c to HTA approval and formulary listing. Methods: FDA AA malignant hematology and oncology approvals from Jan 1 2000-Dec 31 2019 were reviewed. HC decisions were reviewed to determine submission/approval status and dates of NOC/c. pCODR decisions were reviewed to determine submission/approval status and dates of decision. First date of provincial formulary listing was collected. Results: In the 20 year time frame, there were 97 AA by the FDA. Current FDA status: 48 full approval, 44 pending verification and 5 withdrawn. Of the 92 AA that remain approved, HC status: 44 received NOC, 24 NOCc, 24 were not submitted for review, 2 currently under review. Of the 5 AA that were withdrawn; 3 were submitted to HC and received NOC/c and all were subsequently withdrawn. From 2011, 31 of 45 HC approved indications were reviewed at pCODR: 17 received a positive recommendation conditional on cost-effectiveness, 9 not recommended, 3 withdrawn by company, 2 pending final decision. Of the 10 not recommended/withdrawn, 6 were subsequently re-submitted and approved. Time from AA to NOC/c was 9.4 m, time from NOC/c to pCODR decision 15.0 m and time from pCODR decision to first formulary listing 18.4 m. Conclusions: Despite significant timeline differences between AA and HC NOC/c all indications that received AA submitted to Canada were granted regulatory approval. Since 2011, 74% of HC approved therapies submitted to pCODR were recommended and added to formularies. Collaboration between FDA and HC, independent regulatory agencies, through innovative programs such as FDA Project Orbis, may improve time from AA to NOC/c. Stringent criteria for HTA recommendation results in lower approval rates however, provision of additional data at re-submission may enable subsequent approval and adoption of treatment.
Inflammatory breast cancer (IBC) in native Hawaiians and Pacific Islanders: Frequency of IBC and impact of socioeconomic status on survival outcomes.
Authors: Miyazaki Kyle S.Y. , Acoba Jared David , Fujii Takeo 
Published: May 2020

e19083 Background: IBC is one of the most aggressive types of breast cancer, accounting for only 1-4% of all breast cancer cases while causing 8-10% of breast cancer related deaths. Previous studies have demonstrated that IBC has distinct epidemiological characteristics, but the prevalence of IBC particularly in Native Hawaiian (NH) and Pacific Islander (PI) populations, and the socioeconomic disparities related to survival outcomes, are not fully understood. Our primary objective was to determine the frequency at which NH and PI breast cancer patients are diagnosed with IBC, and the association between socioeconomic status and overall survival (OS). Methods: Patients with newly-diagnosed primary invasive breast cancer were identified from January 1, 2000 through December 31, 2018 using Queen’s Medical Center Tumor Registry. Clinical T4d was used to differentiate IBC and non-IBC. OS was defined as the time from diagnosis to death or last follow-up. Patients who were alive at the date of last follow-up were censored. Univariate and multivariate cox proportional hazard models were used to assess the effects of variables of interest on OS. Results: A total of 3,715 patients were included in analysis. There were 98 (2.6%) patients with IBC and 3,617 (97.4%) with non-IBC. Proportion of IBC relative to non-IBC was significantly higher in PI (9.0%) than in White (W) (2.7%) (P < 0.001). Proportion of IBC was higher in NH (4.7%) than W but the difference was not statistically significant (P = 0.08). In multivariate analysis among the non-IBC group, OS was significantly shorter for both PI and NH than W (HR 1.72, [95%CI, 1.13-2.6]; P = 0.01, HR 1.48 [95% CI, 1.14-1.93]; P = 0.003, respectively). There were no significant racial differences seen in OS among IBC patients. Being under or uninsured was also significantly associated with short OS outcomes among patients with non-IBC but not those with IBC. Conclusions: PI have a significantly high proportion of IBC relative to non-IBC. Race and insurance status were not associated with OS in IBC although they were significantly associated with short OS in non-IBC. This result suggests that in IBC, the potential effect of racial disparity on OS is negated by the aggressive and insidious nature of the cancer. The effect of a relatively small sample size cannot be excluded, and further study in a larger population is warranted.