Purpose Renal cell carcinoma is increasingly diagnosed at stage I, and among stage I cases mean tumor size has been decreasing. Previous reports suggest that nephron sparing surgery is underused for ...small renal cell carcinomas. We determined updated, population based treatment trends for stage I renal cell carcinoma. Materials and Methods The National Cancer Data Base, which captures approximately 70% of all cancer diagnoses in the United States, was queried for renal cell carcinoma in adults diagnosed between 1993 and 2007. Trends in treatment, including no surgery, total nephrectomy, partial nephrectomy and focal ablation, were analyzed among all stage I tumors and small stage I tumors categorized by size. Logistic regression was used to identify predictors of nephron sparing surgery (partial nephrectomy or focal ablation). Results During the study period we identified 242,740 renal cell carcinomas, of which 127,691 were stage I. For all stage I tumors partial nephrectomy increased from 6.3% to 32.2% of cases and ablation increased from 1.0% to 6.8%. For tumors less than 2.0, 2.0 to 2.9 and 3.0 to 3.9 cm partial nephrectomy increased from 15.3% to 61.1%, 11.0% to 44.2% and 7.2% to 31.1%, respectively (each p <0.001). Female gender, black race, Hispanic ethnicity, lower income, older age and treatment at community hospitals were associated with lower use of nephron sparing. Conclusions While total nephrectomy is still likely overused for small renal cell carcinoma, nephron sparing surgery for stage I renal cell carcinoma has increased substantially in the last 15 years with about 4-fold increases across tumor sizes. These trends appear to be ongoing but sociodemographic disparities exist which must be rectified.
Objective
To examine the association of hospital volume and 90‐day mortality after cystectomy, conditional on survival for 30 days.
Patients and Methods
The National Cancer Data Base was used to ...evaluate 30‐ and 90‐day mortality for 35 055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals.
Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low‐volume hospital: <10 procedures; intermediate‐volume hospital: 10–19 procedures; high‐volume hospital: ≥20 procedures).
Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90‐day mortality independently of shorter‐term mortality, 90‐day mortality conditional on 30‐day survival was assessed in the multivariate modelling.
Results
Unadjusted 30‐ and 90‐day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high‐volume hospitals, and 3.2 and 8.0% among low‐volume hospitals, respectively.
Compared with high‐volume hospitals, the adjusted risks among low‐volume hospitals (odds ratio 95% CI) of 30‐ and 90‐day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3–1.9), and 1.2 (1.0–1.4), respectively.
Conclusions
A low hospital volume was associated with greater 30‐ and 90‐day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata.
The stronger association between volume and 30‐day mortality suggests that quality‐reporting efforts should focus on shorter‐term outcomes.
Abstract On the basis of the National Cancer Data Base (NCDB), we describe the disease characteristics and use of conventional prognostic parameters in a hospital-based cohort of pathologically ...confirmed renal cell carcinomas (RCCs). Between 1993 and 1998, the NCDB obtained 149 424 cases of kidney (and renal pelvis) cancers from registries all over the United States. This database was queried for 47 909 histologically specified RCCs. Survival outcome was analyzed based on conventional clinical and pathologic parameters reported to the database (up to 2003). Renal cell carcinoma was more common in men (male-female ratio = 1.6:1). The mean age was 62.6 years. Most (66.6%) were organ-confined (stage I/II) at the time of diagnosis. The mean tumor size was 6.49 cm. The 5-year observed survival of RCC was 62.9% for male and 68.1% for female and was 81.0% for younger than 40 years old and 64.2% for older than 40 years old. The 5-year observed survival of RCC patients by the fifth edition 1997 American Joint Committee on Cancer TNM staging were stages I, 77.8%; II, 72.8%; III, 55.0%; and IV, 16.9%, demonstrating a dramatic decline in patient survival at stage IV. By reported pathologic grade, significant stratification was achieved in the observed survival for RCC overall irrespective of histologic subtypes (grade 1, 77.8%; 2, 69.6%; 3, 48.8%; and 4, 35.3% 5-year observed survival). These large NCDB data in RCC confirm the importance of pathologic evaluation of traditional prognostic parameters of stage and grade in RCC and is a powerful resource in defining cancer patient characteristics and analysis of prognostic variables that helps influence future cancer care planning and resource allocation.
Objectives: We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services. Methods: We used ...a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services. Results: Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care. Conclusions: VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.
Regionalization to higher volume centers has been proposed as a mechanism to improve short-term outcomes following complex surgery.
The objective of this study was to assess trends in regionalization ...and mortality for patients undergoing radical cystectomy (RC).
An observational study of patients receiving RC in the United States from 2004 to 2013.
Data for patients receiving RC were extracted from the National Cancer Database.
The primary exposure was hospital volume; low-volume hospitals (LVH) included those with <5 RC/year and high-volume hospitals (HVH) were those with ≥30 RC/year. Trends in the volume were assessed, as were 30- and 90-day mortality. Cochrane-Armitage tests were performed for volume, and propensity score-weighted proportional hazard regression was used to assess mortality.
A total of 47,028 RC were performed in 1162 hospitals from 2004 to 2013. The proportion of RC at LVH declined from 29% to 17% (P<0.01), whereas that of HVH increased from 16% to 33% (P<0.01). Unadjusted 30- (P=0.02) and 90-day (P<0.001) mortality decreased, and the absolute decrease was greatest at LVH (4.8% vs. 2.6%, P=0.03), whereas rates for HVH remained stable (1.9% vs. 1.4%, P=0.34). Following risk-adjustment, relative to treatment at HVH, treatment at LVH was associated with increased 30-day (hazard ratio: 1.66, 95% CI: 1.53-1.80) and 90-day mortality (hazard ratio: 1.37, 95% confidence interval: 1.30-1.44).
Regionalization of RC to HVH was observed from 2004 to 2013. Treatment at LVH was associated with 66% and 33% relative increases in hazard of death at 30 and 90 days, respectively. These findings support the selective referral of complex cases to higher volume centers.
Purpose Bladder cancer survival is consistently lower in female and black patients than in male and white patients. We compared trends and differences according to clinical, demographic and facility ...characteristics by patient race and gender to identify the impact of these characteristics on survival. Materials and Methods We identified bladder transitional cell carcinoma cases diagnosed in 1993 to 2007 from the National Cancer Data Base. Trends in grade and stage distribution between 1993 and 2007 were analyzed. Survival differences by race and gender were compared using 5-year relative survival and multivariate Cox regression. Results There were 310,257 white male, 102,345 white female, 13,313 black male and 7,439 black female patients. Black and female patients had a higher proportion of muscle invasive tumors than white and male patients, and black patients had a larger proportion of higher grade tumors. The incidence of stage 0a and of high grade tumors significantly increased with time. Multivariate analysis showed a significantly lower HR in white females than in white males (HR 0.9) but a significantly higher HR in black males and females (HR 1.2). The higher mortality risk in black males and females was primarily limited to late stage disease (HR 1.3). Conclusions Survival differences by race and gender are partially explained by differences in tumor and demographic characteristics in black males and females, and fully explained by these characteristics in white females. Treatment delays and under treatment due to comorbid conditions, age and other factors may also contribute to these disparities.
Abstract Purpose Prostate-specific antigen (PSA) based screening for prostate cancer has had a significant impact on the epidemiology of the disease. Its use has been associated with a significant ...reduction in prostate cancer mortality, but has also resulted in the overdiagnosis and overtreatment of indolent prostate cancer, exposing many men to the harms of treatment without benefit. The U.S. Preventive Service Task Force (USPSTF) issued a recommendation against screening men over 75 in 2008, and against routine screening for all men in 2012, indicating that, in their interpretation, the harms of screening outweigh the benefits. Herein, we review the changes in use of PSA testing, changes in the use of prostate biopsy, and changes in the incidence of prostate cancer and stage at presentation since 2012. Materials and Methods An English-language literature search was performed for search terms that included “prostate-specific antigen,” “screening,” and “United States Preventive Services Task Force” in various combinations. In total, 26 original studies have been published about the effects of the USPSTF recommendations on PSA screening or prostate cancer incidence in the United States. The last search was performed on December 1st , 2016. Results Review of the literature from 2012 through the end of 2016 indicates that there has been a decline in both PSA testing and prostate biopsy. As a result, there has been a decline in the incidence of localized prostate cancer, including low-, intermediate-, and high-risk disease. The data regarding stage at presentation have yet to mature, but there are some early signs of a shift toward higher burden of disease at presentation. Conclusions These findings raise concern for a reversal of the observed improvement in prostate cancer-specific mortality over preceding decades. Alternative screening strategies would a) incorporate the patient’s preferences by engaging in shared decision making; b) preserve the survival benefits associated with screening; c) improve on the specificity of screening to reduce unnecessary biopsies and detection of low-risk disease; and d) promote the use of Active Surveillance for low-risk cancers if they are detected.
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