Introduction All patients with newly diagnosed colorectal cancer are recommended to undergo microsatellite instability (MSI) testing. In addition, mutational testing using biomarkers such as KRAS, NRAS, and BRAF is recommended for patients with metastatic cancers. Testing for these markers is vital as they guide therapeutic decision-making and serve as prognostic indicators. Our study aims to analyze disparities in testing for MSI and KRAS biomarkers based on sociodemographic factors in patients with metastatic colorectal cancer. Furthermore, we explored the survival characteristics in these patients based on sociodemographic factors and on access to biomarker testing. Methods The National Cancer Database (NCDB) was queried for patients diagnosed with metastatic colorectal cancer (MCC). At the bivariate level, we performed chi-squared statistics and multivariate logistic regression modeling to explore variables associated with patients undergoing MSI and KRAS testing. In addition, Multivariate Cox regression and Kaplan-Meier analyses were performed for survival analysis. Results N = 51,913 patients with MCC diagnosed between 2010 to 2017 were included. The median age for Whites was 68.0 years versus 64.0 years for Blacks. Blacks had a lower probability of undergoing MSI testing (OR 0.90, [0.84-0.96] p< 0.0009). Factors associated with a lower likelihood for MSI testing included treatment at a Community Cancer Program (OR 0.61, [0.55-0.66] p<0.0001), residing in areas with people having lower education (OR 0.68, [0.62-0.74] p<0.0001) and in rural areas (OR 0.74, [0.61-0.90] p-value 0024), and a median household income of < $38,000 (OR 0.88, [0.80-0.96] p 0.0040). Patients with no insurance and Medicaid/governmental insurance were also less likely to undergo both MSI and KRAS testing. Blacks had a decreased likelihood of having high MSI levels among patients who underwent testing compared to Whites (OR 0.67, [0.50-0.91] p-value 0.0107). After controlling for confounding variables, survival analysis showed poor survival in patients who did not undergo testing for MSI and KRAS (HR 1.20, [1.17-1.23] p<0.0001 and HR 1.04, [1.01-1.06] p-value 0.0016 respectively). Conclusion Our analysis reveals that sociodemographic factors such as being from a minority race, having no insurance, residing in areas with lower education and rural settings were associated with a lower probability of undergoing MSI testing in patients with metastatic colorectal cancer. This is of concern as our study also reveals that not undergoing biomarker testing is associated with poorer survival. Addressing such sociodemographic discrepancies among racial groups is essential in achieving equitable care and narrowing gaps in outcomes. Citation Format: Saad Sabbagh, Iktej Jabbal, Barbara Dominguez, Mira Itani, Mohamed Mohanna, Arun Nagarajan. Sociodemographic disparities in access to biomarker testing in patients with advanced colorectal cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5550.
(1) Background: Disparities in cancer treatment and outcomes have long been well-documented in the medical literature. With the eruption of advances in new treatment modalities, the long-existing disparities are now being further uncovered and brought to the attention of the medical community. While social health determinants have previously been linked to treatment disparities in lung cancer, we analyzed data from the National Cancer Database to explore sociodemographic and geographic factors related to accepting or declining physician-recommended chemotherapy. Patients diagnosed with metastatic lung cancer between 2004 and 2016 who declined chemotherapy recommended by their physicians were included in this study. Multivariate logistic regression analysis was performed. Cox Regression and Kaplan-Meier analyses were performed to look for survival characteristics. (2) Results: 316,826 patients with Stage IV lung cancer were identified. Factors related to a higher rate of refusal by patients included older age > 70, female sex, low income, lack of insurance coverage, residency in the New England region, and higher comorbidity. Patients living in areas with lower education were less likely to decline chemotherapy. (3) Conclusion: Further understanding of the factors impacting treatment decisions would be essential to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.
Background: Palliative care is an essential component of cancer care; however, factors hindering its reach to the target population remain understudied. We aim to explore whether an association exists between socioeconomic and geographic factors and access to palliative care (PC) in patients with Stage IV breast cancer in the US. Methods: This 2004-2017 National Cancer Database analysis includes patients with Stage IV breast cancer who received palliative care. Access to PC is defined as being either at the patient’s primary healthcare facility or at a referral site. Chi-square tests and a multivariate logistic regression were performed to determine the independent factors predicting access to PC. SAS version 9.4 was used to analyze the data. Results: A total of 18,903 patients were included in the analysis: 15,111 received palliative care services at the same facility and 3,792 were referred elsewhere. Patient age, race, insurance status, Charlson-Deyo score, setting, high school diploma status, median income, facility type, facility location, and distance from healthcare centers were all significantly different between the two groups. On logistic regression, better odds for access to PC were predicted by urban settings (OR: 1.47; 95% CI: 1.30 - 1.67) and being in the Middle Atlantic region (OR: 1.27; 95% CI: 1.07 - 1.52). Distance from the healthcare facility of 4 miles or greater predicted worse odds for access to PC. Comprehensive cancer programs (OR: 1.60; 95% CI: 1.43 - 1.80) and academic/research programs (OR: 2.40; 95% CI: 2.11 - 2.73) held higher odds for access to PC. Having Medicaid/other government insurance (OR: 1.43; 95% CI: 1.24 - 1.65) predicted better odds for access to PC. However, having no insurance was also found to increase access to PC (OR: 1.30; 95% CI: 1.08 - 1.55). Median income and high school diploma status were not significantly associated with the outcome. Conclusion: PC was positively affected by having access to urban settings, nearby healthcare centers, non-community care centers, Medicaid/other governmental insurance, and by being in the Middle Atlantic region of the US. Having no insurance appears to increase palliative care use, which was unexpected but could be explained if patients with no insurance did not receive standard treatment and were instead offered palliative care. This needs to be investigated in future research. Citation Format: Mira Itani, Saad Sabbagh, Mohamed Mohanna, Barbara Dominguez, Hong Liang, Zeina Nahleh. Disparities in factors affecting access to palliative care in patients with stage IV breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 746.
8558 Background: The presence of micro-residual (R1) or macro-residual (R2) disease in non-small cell lung cancer (NSCLC) is associated with a higher risk of recurrence. The benefits of post-operative radiation therapy (PORT) in incompletely resected NSCLC is not clear. The purpose of this study is to compare median overall survival (mOS) of treatment modalities in the post-operative setting for resected stage I-IIIA NSCLC with residual disease (R1/R2) and to determine if PORT provides benefit in this patient population using the National Cancer Database (NCDB). Methods: From the NCDB dataset for the years of 2006-2016, we extracted patients diagnosed with stage I-IIIA NSCLC and who had incomplete resection with residual disease (R1/R2). Kaplan-Meier analysis was performed to differentiate the effect of different post-operative treatment modalities, concurrent chemo-radiotherapy (CCRT), sequential chemo-radiotherapy (SCRT) and chemotherapy (CT) alone on mOS. Subsequently, univariate Cox regression was used to identify statistically significant variables, then multivariate Cox regression was performed to establish variables that contributed to the survival. Lastly, multinomial logistic regression was utilized to establish association of the independent factors. SAS version 9.4 was used to analyze the data. Results: Among the 2701 patients who met inclusion criteria, the average age was 64.1, 64.8 and 65.9 year old for CCRT, SCRT and CT, respectively. Male's constituted 53.6% and white's were 88.1%, and patient's were distributed equally across clinical stages. The majority of patients received SCRT (51.7%) followed by CT alone (39%), and CCRT (9.2%). There were no statistically significant differences in mOS between the different treatment modalities (p=0.220). Patients with R2 were 177% more likely to receive CCRT than CT compared to R1 (OR 2.77, CI 1.86-4.13 and p<0.001). Male's were 28% more likely to receive SCRT than CT compared to females (OR 1.28, CI 1.08-1.52 and p=0.0041). Nodal involvement was associated with decreased mOS with N2/N3 having 37% lower mOS compared to N0 (HR=1.37, CI 1.19-1.57 and p<0.0001). Patients who had R2 disease had a 38% lower mOS compared to those R1 (HR 1.38%, CI 1.19-1.62, p<0.0001). Conclusions: Despite the risk of unfavorable outcomes for patients with residual disease after surgery for NSCLC, the addition of radiotherapy, either concurrently or sequentially, to CT did not offer statistically significant mOS benefit compared to CT alone. Given the known toxicities of radiation, and the lack of impact on survival, the benefit of post-operative radiation is questionable among patients with residual disease after resection.
e16097 Background: Surgical resection is established as the only potentially curative approach for patients with early stage and regional gastric cancer. With a high risk of recurrence that ranges between 40% to 60% for stage II and III disease, combination therapies including chemotherapy and radiation that complement surgery were incorporated as standard of care for Stage >IB disease with clear survival benefit over surgery alone. While the National Comprehensive Cancer Network (NCCN) guidelines recommend neoadjuvant chemoradiation (NCR) or perioperative chemotherapy (PC) for clinical Stage T2 or higher, there has been no consensus on the optimal treatment approach for these patients. Our study sought to compare survival differences between the two therapies. Additionally, we analyzed predictive factors and shifting trends in the choice of treatment over the period of our study i.e., 2010 to 2017. Methods: The National Cancer Database was used to analyze patients with non-metastatic regional gastric cancer diagnosed from 2010 to 2017 staged as clinical T2 or higher. Demographic data and clinicopathological tumor characteristics were assessed using chi-square analysis to assess baseline differences between both groups. The primary outcome was to determine differences in overall survival (OS) using Kaplan Meier (KM) and Cox proportional hazards analysis. The secondary outcome was to evaluate patient related factors associated with the choice of treatment. Results: N = 7475 patients with non-metastatic clinical T2+ gastric cancer were included in the study (NCR: n = 5394, 72.16% vs. PC: n = 2081, 27.84%). The majority of patients were of male sex (75.9%) and within the 50-69 age group (64.5%) for both groups. T3 clinical staging was the most prevalent among both groups (78.0% and 70.3% respectively). Patients receiving PC had longer median OS (49.480 months) than those undergoing NCR (40.970 months). KM curve showed a higher cumulative survival with PC over NCR at 1-year, 3-year, and 5-year endpoints (0.93 vs. 0.85, 0.58 vs. 0.54, and 0.46 vs. 0.40, p<0.0001). Moreover, on multivariate cox regression analysis, OS was inferior in the NCR group (HR 1.57, p<0.001) compared to PC after adjusting for significant covariates. In a subgroup analysis for clinical T3 and T4 tumors, NCR remained associated with worse OS (HR 1.83, p <0.0001) compared to PC. Lastly, patients in the 70-79 and 80-100 age group preferred NCR over the PC approach (OR 0.737 and OR 0.50, p 0.035 and p 0.008, respectively) when compared to the younger population. Cochran-Armitage Trend Test revealed NCR (p <0.0001) and PC (p <0.0001) had an increased trend by year. Conclusions: In our study, PC showed clear survival benefits over NCR in patients with locoregional gastric cancer. Future large-scale clinical trials would aid in adding to our findings and setting guidelines for optimal management of these patients.
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