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.

A B S T R A C T PurposeAlthough adjuvant chemoradiotherapy for resected gallbladder cancer may improve survival for some patients, identifying which patients will benefit remains challenging because of the rarity of this disease. The specific aim of this study was to create a decision aid to help make individualized estimates of the potential survival benefit of adjuvant chemoradiotherapy for patients with resected gallbladder cancer. MethodsPatients with resected gallbladder cancer were selected from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database who were diagnosed between 1995 and 2005. Covariates included age, race, sex, stage, and receipt of adjuvant chemotherapy or chemoradiotherapy (CRT). Propensity score weighting was used to balance covariates between treated and untreated groups. Several types of multivariate survival regression models were constructed and compared, including Cox proportional hazards, Weibull, exponential, log-logistic, and lognormal models. Model performance was compared using the Akaike information criterion. The primary end point was overall survival with or without adjuvant chemotherapy or CRT. ResultsA total of 1,137 patients met the inclusion criteria for the study. The lognormal survival model showed the best performance. A Web browser-based nomogram was built from this model to make individualized estimates of survival. The model predicts that certain subsets of patients with at least T2 or N1 disease will gain a survival benefit from adjuvant CRT, and the magnitude of benefit for an individual patient can vary. ConclusionA nomogram built from a parametric survival model from the SEER-Medicare database can be used as a decision aid to predict which gallbladder patients may benefit from adjuvant CRT.

Background and purpose Target volumes and organs-at-risk (OARs) for radiotherapy (RT) planning are manually defined, which is a tedious and inaccurate process. We sought to assess the feasibility, time reduction, and acceptability of an atlas-based autosegmentation (AS) compared to manual segmentation (MS) of OARs. Materials and methods A commercial platform generated 16 OARs. Resident physicians were randomly assigned to modify AS OAR (AS + R) or to draw MS OAR followed by attending physician correction. Dice similarity coefficient (DSC) was used to measure overlap between groups compared with attending approved OARs (DSC = 1 means perfect overlap). 40 cases were segmented. Results Mean ± SD segmentation time in the AS + R group was 19.7 ± 8.0 min, compared to 28.5 ± 8.0 min in the MS cohort, amounting to a 30.9% time reduction (Wilcoxon p < 0.01). For each OAR, AS DSC was statistically different from both AS + R and MS ROIs (all Steel–Dwass p < 0.01) except the spinal cord and the mandible, suggesting oversight of AS/MS processes is required; AS + R and MS DSCs were non-different. AS compared to attending approved OAR DSCs varied considerably, with a chiasm mean ± SD DSC of 0.37 ± 0.32 and brainstem of 0.97 ± 0.03. Conclusions Autosegmentation provides a time savings in head and neck regions of interest generation. However, attending physician approval remains vital.

BACKGROUND Single-institution data suggest that treatment with radiation and axillary lymph node dissection (ALND) may be an appropriate alternative to mastectomy for T0N+ breast cancer. Population-based multi-institutional data supporting this approach are lacking. METHODS The cause-specific survival (CSS) and overall survival (OS) of women with T0N+M0 ductal, lobular, or mixed breast cancer in the Surveillance, Epidemiology, and End Results database from 1983 to 2006 were analyzed. Groups were defined as: 1) no ALND, mastectomy, or RT (observation); 2) ALND only; 3) mastectomy plus ALND with or without postmastectomy radiation (Mast); and 4) breast-conserving therapy (BCT) with ALND and radiation (BCT). RESULTS In total, 750 of 770,030 patients with breast cancer had T0N+ M0 disease (incidence, 0.10%), and 596 of those patients underwent ALND (79.5%). Patients who underwent Mast or BCT (n = 470) had a 10-year OS rate of 64.9% compared with 58.5% for patients who underwent ALND only (n = 126; P = .02) and 47.5% for patients who underwent observation only (n = 94; P = .04). The 10-year CSS rate was 75.7% for patients who underwent BCT versus 73.9% for patients who underwent Mast (P = .55). In multivariate analysis of CSS for patients who underwent Mast or BCT, the following factors were correlated with an unfavorable outcome: positive estrogen receptor status (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.24–0.96; P = .04), ≥10 positive lymph nodes (HR, 5.7; 95%CI, 2.4–13.4; P ≤ .01), and <10 resected lymph nodes (HR, 42.9; 95%CI, 1.2–7.1; P = .02). Mast did not improve CSS compared with BCT (HR, 1.09; 95%CI, 0.57–2.1; P = .79). CONCLUSIONS Definitive locoregional treatment with either Mast or BCT improved the outcome of patients with T0N+breast cancer, and no difference in survival was observed between the treatments.

The EVT/Guidant bifurcated graft is effective in preventing AAA rupture, and long-term survival is comparable to that with open repair.

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Purpose Receipt of radiation therapy (RT) is a key quality indicator in breast cancer treatment. Prior analyses using population-based tumor registry data have demonstrated substantial underuse of RT for breast cancer, but the validity of such findings remains debated. To address this controversy, we evaluated accuracy of registry RT coding compared to the gold standard of Medicare claims. Methods and Materials Using SEER-Medicare data, we identified 73,077 patients age ≥ 66 diagnosed with breast cancer from 2001-2007. Underascertainment (1-sensitivity), sensitivity, specificity, kappa, and chi-square were calculated for RT receipt determined by registry data vs. claims. Multivariate logistic regression characterized patient, treatment, and geographic factors associated with underascertainment of RT. Findings in the SEER-Medicare registries were compared to three non-SEER registries (Florida, New York, and Texas). Results In the SEER-Medicare registries, 41.6% (n=30,386) of patients received RT according to registry coding versus 49.3% (n=36,047) according to Medicare claims (P<0.001). Underascertainment of RT was more likely if patients resided in a newer SEER registry (OR 1.70, 95%CI 1.60-1.80;P<0.001), rural county (OR 1.34, 95%CI 1.21-1.48;P<0.001) or if RT was delayed (OR 1.006/day, 95%CI 1.006-1.007,P<0.001). Underascertainment of RT receipt in SEER registries was 18.7% (95% CI 18.6-18.8%), compared to 44.3% (95% CI 44.0-44.5%) in non-SEER registries. Discussion Population-based tumor registries are highly variable in ascertainment of RT receipt and should be augmented with other data sources when evaluating quality of breast cancer care. Future work should identify opportunities for the radiation oncology community to partner with registries to improve accuracy of treatment data.

Background Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared to 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 18–64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007–2012 were obtained from SEER. 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 hazard ratios (HRs). Results Blacks had similar CSM to whites among the uninsured (HR=1.01, 95% CI=0.96–1.05), but higher CSM among the Medicaid (HR=1.04, 95% CI=1.01–1.07) and non-Medicaid (HR=1.14, 95% CI=1.12–1.16) strata. Hispanics had lower CSM compared to 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 to 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.