In the past two decades, there has been a steady increase in the use of stereotactic body radiotherapy (SBRT) as an alternative to surgical intervention for early-stage non-small cell lung cancer ...(NSCLC) patients; however, not much is known about the impact of race and socioeconomic status (SES) on the delivery of SBRT. Here, we conduct a narrative review to examine potential disparities in the use of SBRT. Keyword searches of MEDLINE/PubMed, Web of Science, Embase, and Google Scholar databases were performed for studies focused on race, SES, and the use of SBRT published between 2000 and 2020. Six studies were identified, and showed that minority patients, especially Blacks, were less likely to receive SBRT and had a significantly longer median time between diagnosis to SBRT treatment. Patients with lower income or lower education, as well as those from lower socioeconomic regions were less likely to receive SBRT; they were more likely to receive conventionally fractionated external beam radiation (CFRT) or no treatment. These racial and socioeconomic factors were associated with worse survival in other general early-stage NSCLC studies. In conclusion, the limited number of published studies suggest significant disparities in the treatment of early-stage NSCLC with SBRT. These factors potentially lead to worse survival outcomes among vulnerable patient populations. Equal access to SBRT should be a focus of healthcare delivery systems, to ensure optimal clinical outcomes for patients with early-stage NSCLC.
Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, ...affecting health care access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality.
Patient data were obtained from Surveillance, Epidemiology, and End Results Program database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest: stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality.
Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients, with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white patients. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival.
Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage disease, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.
Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. As systemic therapies improve, patients with lung cancer live longer and thus are at increased risk ...for brain metastases. Understanding how prognosis varies across this heterogeneous patient population is essential to individualize care and design future clinical trials.
To update the current Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for patients with non-small-cell lung cancer (NSCLC) and brain metastases. The DS-GPA is based on data from patients diagnosed between 1985 and 2005, and we set out to update it by incorporating more recently reported gene and molecular alteration data for patients with NSCLC and brain metastases. This new index is called the Lung-molGPA.
This is a multi-institutional retrospective database analysis of 2186 patients diagnosed between 2006 and 2014 with NSCLC and newly diagnosed brain metastases. The multivariable analyses took place between December 2015 and May 2016, and all prognostic factors were weighted for significance by hazard ratios. Significant factors were included in the updated Lung-molGPA prognostic index.
The main outcome was survival. Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios. Log rank tests were used to compare adjacent classes and to compare overall survival for adenocarcinoma vs nonadenocarcinoma groups.
The original DS-GPA was based on 4 factors found in 1833 patients with NSCLC and brain metastases diagnosed between 1985 and 2005: patient age, Karnofsky Performance Status, extracranial metastases, and number of brain metastases. The patients studied for the creation of the DS-GPA had a median survival of 7 months from the time of initial treatment of brain metastases. To design the updated Lung-molGPA, we analyzed data from 2186 patients from 2006 through 2014 with NSCLC and newly diagnosed brain metastases (1521 adenocarcinoma and 665 nonadenocarcinoma). Significant prognostic factors included the original 4 factors used in the DS-GPA index plus 2 new factors: EGFR and ALK alterations in patients with adenocarcinoma (mutation status was not routinely tested for nonadenocarcinoma). The overall median survival for the cohort in the present study was 12 months, and those with NSCLC-adenocarcinoma and Lung-molGPA scores of 3.5 to 4.0 had a median survival of nearly 4 years.
In recent years, patient survival and physicians' ability to predict survival in NSCLC with brain metastases has improved significantly. The updated Lung-molGPA incorporating gene alteration data into the DS-GPA is a user-friendly tool that may facilitate clinical decision making and appropriate stratification of future clinical trials.
There is a dearth of data on cancer care in the incarcerated population, despite being the leading cause of illness-related death in United states' prisons. We retrospectively reviewed the ...demographic and clinicopathologic characteristics of incarcerated individuals who received radiation therapy at a large safety-net hospital.
Following IRB approval, we identified 80 incarcerated patients who presented for radiation therapy between January 2003 and May 2019. Descriptive statistics on the patients, tumor types and stage, treatment factors, and follow-up rates were analyzed.
80 individuals with 82 cancer diagnoses presented for radiation oncology consultation over the study period. The median age was 54 years (range, 46-64). Patients of White, Black, and "other" races comprised 61.3% (n=49), 28.8% (n=23), and 10% (n=8), respectively. Most patients were male (n=75, 93.8%) and English speakers (n=76, 95%). Moreover, 50% (n=40) had a substance use disorder history and 75% (n=60) had a smoking history. The three most common cancer types were prostate (n=12, 14.6%), gastrointestinal (n=14, 17.1%), thoracic (n=17, 20.7%), and head and neck (n=21, 25.6%). The distribution of tumor stage (AJCC) was I (n=12, 14.6%), II (n=12, 14.6%), III (n=14, 17.1%), IV (n=38, 46.3%), and unknown/unavailable (n=6, 7.3%). Of the cohort, 65 patients with 66 cancers (80.5%) received radiation. Among them, the 6-month, 1-year, and 5-year follow-up rates were 41.5%, 27.7%, and 3.1%, respectively. Subset analysis limited to stage I-III patients (n=30) revealed 6-month, 1-year and 5-year follow-up rates of 41.9%, 22.6%, and 3.2%, respectively.
This study highlights inequalities in cancer stage at diagnosis among a vulnerable patient population that is largely excluded from clinical research. Majority of the incarcerated patients presented with stage III & IV cancers and have poor follow up rates even among those with early-stage disease. Efforts to understand and mitigate persistent health inequalities among incarcerated patients are warranted.
To characterize patterns in incidence, management, and costs of malignant spinal cord compression (MSCC) hospitalizations in the United States, using population-based data.
Using the Nationwide ...Inpatient Sample, an all-payer healthcare database representative of all U.S. hospitalizations, MSCC-related hospitalizations were identified for the period 1998-2006. Cases were combined with age-adjusted Surveillance, Epidemiology and End Results cancer death data to estimate annual incidence. Linear regression characterized trends in patient, treatment, and hospital characteristics, costs, and outcomes. Logistic regression was used to examine inpatient treatment (radiotherapy RT, surgery, or neither) by hospital characteristics and year, adjusting for confounding.
We identified 15,367 MSCC-related cases, representing 75,876 hospitalizations. Lung cancer (24.9%), prostate cancer (16.2%), and multiple myeloma (11.1%) were the most prevalent underlying cancer diagnoses. The annual incidence of MSCC hospitalization among patients dying of cancer was 3.4%; multiple myeloma (15.0%), Hodgkin and non-Hodgkin lymphomas (13.9%), and prostate cancer (5.5%) exhibited the highest cancer-specific incidence. Over the study period, inpatient RT for MSCC decreased (odds ratio OR 0.68, 95% confidence interval CI 0.61-0.81), whereas surgery increased (OR 1.48, 95% CI 1.17-1.84). Hospitalization costs for MSCC increased (5.3% per year, p < 0.001). Odds of inpatient RT were greater at teaching hospitals (OR 1.41, 95% CI 1.19-1.67), whereas odds of surgery were greater at urban institutions (OR 1.82, 95% CI 1.29-2.58).
In the United States, patients dying of cancer have an estimated 3.4% annual incidence of MSCC requiring hospitalization. Inpatient management of MSCC varied over time and by hospital characteristics, with hospitalization costs increasing. Future studies are required to determine the impact of treatment patterns on MSCC outcomes and strategies for reducing MSCC-related costs.
To examine the relationship between hospital safety-net burden and (1) receipt of surgery after chemoradiation (trimodality therapy) and (2) survival in esophageal cancer patients.
The National ...Cancer Database was queried to identify 22,842 clinical stage II to IVa esophageal cancer patients diagnosed in 2004 to 2015. The treatment facilities were categorized by proportion of uninsured/Medicaid-insured patients into percentiles. No safety-net burden hospitals (0–37th percentile) treated no uninsured/Medicaid-insured patients, whereas low (38–75th percentile) and high (76–100th percentile) safety-net burden hospitals treated a median (range) of 8.8% (0.87%–16.7%) and 23.6% (16.8%–100%), respectively. Adjusted odds ratios and hazard ratios with 95% confidence intervals were computed, adjusting for patient, tumor, and treatment characteristics.
Compared to no safety-net burden hospital patients, high safety-net burden hospital patients were significantly more likely to be young, Black, and low-income. Age, female sex, Black race, Hispanic ethnicity, nonprivate insurance, lower income, higher comorbidity score, upper esophageal location, squamous cell histology, higher stage, time to treatment, and treatment at a community program or a low-volume facility were associated with lower odds of receiving trimodality therapy. Adjusting for these factors, high safety-net burden hospital patients were less likely to receive surgery after chemoradiation versus no safety-net burden hospital patients (adjusted odds ratio 0.77 95% confidence interval 0.68–0.86, P < .0001); no difference was detected comparing low safety-net burden hospitals versus no safety-net burden hospitals (adjusted odds ratio 1.01 0.92–1.11, P = .874). No significant survival difference was noted by safety-net burden (low safety-net burden hospitals versus no safety-net burden hospitals: adjusted hazard ratio 1.01 0.96–1.06, P = .704; high safety-net burden hospital versus no safety-net burden hospitals: adjusted hazard ratio 0.99 0.93–1.06, P = .859).
Adjusting for patient, tumor, and treatment factors, high safety-net burden hospital patients were less likely to undergo surgery after chemoradiation but without significant survival differences.
Background
Head and neck Merkel cell carcinoma (MCC) is commonly treated with surgery and adjuvant radiotherapy (RT) for high‐risk features. The optimal radiation dose is unknown.
Methods
One ...thousand six hundred twenty‐five eligible patients with head and neck MCC were identified in the National Cancer Data Base (NCDB). Radiation dose was divided into 3 groups: 30 to <50 Gray (Gy), 50‐55 Gy, and >55‐70 Gy. Cox regression was used to compare overall survival (OS) between groups, accounting for age, sex, stage, surgery type, margin status, comorbidities, and use of chemotherapy.
Results
With a median follow‐up of 33.5 months, 3‐year OS was 48.9%, 70.3%, and 58.7% for 30 to <50 Gy, 50‐55 Gy, and >55‐70 Gy, respectively (P < .001). Compared to 50‐55 Gy, doses between 30 to <50 Gy (adjusted hazard ratio HR 1.53; 95% confidence interval CI 1.17‐1.99; P = .002) and >55‐70 Gy (adjusted HR 1.21; 95% CI 1.0‐1.46; P = .06) were associated with worse survival.
Conclusion
Adjuvant radiation doses within 50‐55 Gy may be optimal for head and neck MCC.
Objective
To evaluate whether the revised US Preventive Services Task Force (USPSTF) criteria reduced inequities in lung cancer screening (LCS) eligibility among a racially diverse sample of patients ...with lung cancer.
Methods
This is a retrospective analysis of adults diagnosed with primary lung malignancies at an urban safety net hospital. For all patients and exclusively ever-smokers,
χ
2
tests were used to evaluate differences in LCS eligibility among socio-demographic variables using the 2013 and 2021 USPSTF criteria. Patients who were ineligible for LCS were categorized by reason for exclusion.
Results
Among 678 lung cancer patients (46% female, mean age 66 ± 10 years), 51% were White, and 39% were Black. Using the 2013 guidelines, White patients (57%) would have been more likely to be eligible than Black (37%) and other-race patients (35%) (
P
< 0.0001) at time of cancer diagnosis. Under the 2021 guidelines, White patients (68%) remained more likely to be eligible for LCS than Black (54%) and other-race patients (48%) (
P
= 0.0002). Among exclusively ever-smoking patients, we did not observe a significant difference in eligibility by race under the 2021 USPSTF guidelines (White 73%, Black 65%, and other-race 65%;
P
= 0.48). Sex, ethnicity, education level, and insurance type were not associated with differential screening eligibility under either the 2013 or 2021 guidelines.
Conclusion
The revised 2021 USPSTF LCS guidelines may not be sufficient to eliminate racial inequities in LCS eligibility among patients who go on to be diagnosed with primary lung cancer. Differential rates of lung cancer among never-smokers may contribute to this inequity.
In lung cancer, outcome measurement has been mostly limited to survival. Proper assessment of the value of lung cancer treatments, and the performance of institutions delivering care, requires more ...comprehensive measurement of standardised outcomes.The International Consortium for Health Outcomes Measurement convened an international, multidisciplinary working group of patient representatives, medical oncologists, surgeons, radiation oncologists, pulmonologists, palliative care specialists, registry experts and specialist nurses to review existing data and practices. Using a modified Delphi method, the group developed a consensus recommendation ("the set") on the outcomes most essential to track for patients with lung cancer, along with baseline demographic, clinical and tumour characteristics (case-mix variables) for risk adjustment.The set applies to patients diagnosed with nonsmall cell lung cancer and small cell lung cancer. Our working group recommends the collection of the following outcomes: survival, complications during or within 6 months of treatment and patient-reported domains of health-related quality of life including pain, fatigue, cough and dyspnoea. Case-mix variables were defined to improve interpretation of comparisons.We defined an international consensus recommendation of the most important outcomes for lung cancer patients, along with relevant case-mix variables, and are working to support adoption and reporting of these measures globally.
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