Trends in Guideline-Adherent Chemoradiation Therapy for Locally Advanced Cervical Cancer Before and After the Affordable Care Act.

PURPOSE/OBJECTIVE(S) This study assessed trends in guideline-adherent chemoradiation therapy (GA-RT) for advanced-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation in the year 2010. MATERIALS/METHODS National Cancer Database patients treated with definitive chemoradiation for locally advanced cervical cancer (FIGO 2018 Stage IB3-IVA) from 2004-2016 were included. GA-RT was defined according to NCCN guidelines and included: 1) delivery of external beam radiation, 2) brachytherapy, and 3) chemotherapy, 4) no radical hysterectomy. Univariable and multivariable logistic regression were used to determine trends in GA-RT relative to the ACA and identify patient factors independently associated with GA-RT. Survival of GA-RT was also estimated using Kaplan-Meier analysis. RESULTS Thirty-seven thousand seven hundred and seventy-two patients met inclusion criteria (Pre-ACA: 16,169; Post-ACA: 21,673). A total of 33,116 patients had squamous cell carcinoma, and 4,626 patients had other histologies. Forty-five percent of patients were node positive. A total of 14.6% of patients were Stage I, 41.8% were Stage II, 36.4% were Stage III, and 7.9% were Stage IVA. Compared to commercial insurance, patients with Medicare had decreased odds of receiving GA-RT (OR = 0.65; 95% CI:0.61-0.69). Black patients (OR = 0.9; 95% CI:0.85-0.95) were associated with decreased odds of receiving GA-RT. Compared to squamous cell carcinoma, adenocarcinoma and carcinoma NOS were associated with decreased receipt of GA-RT (OR = 0.87; 95% CI: 0.80-0.93 and OR = 0.64; 95% CI: 0.55-0.75, respectively). Increasing T-stage was associated with greater receipt of GA-RT (stages 1B2 [OR = 1.89, 95% CI: 1.53-2.37], 2A2 [OR = 2.29, 95% CI: 1.81-2.92], 2B [OR = 2.1, 95% CI: 1.71-2.61], and 3B [OR = 1.47, 95% CI: 1.19-1.83]). Patients with nodal stage NX were less likely to receive GA-RT compared to N0 (OR = 0.6, 95% CI: 0.52-0.68). Increasing Charlson-Deyo score was associated with decreased receipt of GA-RT (OR = 0.86, 95% CI: 0.82-0.89). In multivariate analysis, all factors remained statistically significant except for race. The percentage of population that was guideline adherent significantly increased post-ACA (pre-ACA 28%; post-ACA 34%; P < 0.001). On univariate analysis, patients were 34% more likely to receive GA-RT after the ACA compared to before the ACA. In the multivariate model, receipt of GA-RT increased by 30% (P < 0.001). Adherence to treatment guidelines increased 2-year overall survival by 15% (GA 76%; Not GA 61%; P < 0.001). The post-ACA cohort was associated with increased 2-year overall survival compared to the pre-ACA cohort (pre-ACA 62%; post-ACA 69%; P < 0.001). CONCLUSION Patients were more likely to be guideline adherent and receive GA-RT after the implementation of the ACA. This increase in guideline adherence was also associated with an increase in 2-year survival, indicating implementation of the ACA may have improved patient outcomes. AUTHOR DISCLOSURE R.J. Thomas: None. D. Provenzano: None. S. Goyal: Partner; Center for Rheumatic Diseases. M. Loew: None. B. Long: None. M. Lopez-Acevedo: None. Y.J. Rao: None.