Impact of care at NCI comprehensive cancer centers (NCICCC) on outcomes in children, adolescents, and young adults (AYA) with central nervous system tumors (CNSt).

Abstract

123 Background: AYA (15-39yo) have not seen the same survival improvement as younger cancer patients with similar diagnoses (dx), leaving an AYA Gap. Treatment on pediatric trials is associated with superior survival in 15-21yo. However, impact of care at NCICCC for complex diseases with poor prognosis that require evidence-based care available at NCICCC (e.g. CNSt), remain unstudied. Methods: We constructed a cohort of 560 children (0-14yo) and 785 AYA with newly-dx CNSt, reported to the LA County (LAC) cancer registry between 1998 and 2008. While 82% of children (0-14y) and 65% of young AYA (15-18y) were treated at one of 3 NCICCC or 3 COG sites in LAC, only 17% of older AYA (19-39y) were treated at one of 3 NCICCC. We sought to determine the impact of NCICCC/COG on overall survival (OS) and barriers to access to care at NCICCC/COG in AYA with CNSt. Since distance to NCICCC/COG could serve as a barrier to accessing care, Geographic Information Systems were used to derive distance between patient’s residence to the nearest NCICCC/COG. Results: OS rates were uniformly good for children and AYA with grade 1 CNSt (96 vs. 89% at 5y, p=0.2) and uniformly poor for children and AYA with grade 3/4 CNSt (43 vs. 43% at 5y, p=0.6). Among patients with WHO grade 2 CNSt, AYA had worse outcome (HR=1.9, p<0.01) after adjustment for race/ ethnicity, SES, and gender. This difference in outcome between AYA and children was abrogated by care at NCICCC (HR 1.4, p=0.2). Furthermore, patients cared at non-NCICCC saw worse outcome (HR=1.6, p=0.04). Compared with children, young AYA (15-18yo) were less likely to receive care at NCICCC (OR=0.3, p=0.02); race/ ethnicity, SES and distance to NCICCC did not influence care at NCICCC. Among older AYA (19-39yo), low SES (OR 0.4, p=0.01), public/ no insurance (OR 0.3, p<0.01) and longer distance to NCICCC (5-12mi: OR=0.3 , p<0.01; >12mi OR 0.5 , p=0.05) reduced likelihood to receive care at NCICCC. Conclusions: Population-based data reveal that receipt of care at NCICCC abrogates the inferior outcome in AYA with WHO grade 2 CNSt. Young AYA are less likely to use NCICCC than children, as are older AYA with low SES, public/ no insurance, or living > 5 miles from an NCICCC.

Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers

“…For example, during our study period, 92.9% of pediatric oncology patients (aged 14 years) and 22.3% of older adult oncology patients (aged 40 years) received treatment at an SCC. 13,14,30 We observed that Hispanics were less likely than non-Hispanic whites to always receive care from an SCC. This may be explained by patient preference 28 to have procedures done close to home, although traveling to a higher quality center might improve their outcome, or it could be reflective of local physician referral networks.…”

“…2 In addition, cancer mortality has declined in all age groups except for those between ages 15 and 29 years in the last 3 decades. 1 When patients with cancer are treated at specialized cancer centers (SCCs), such as Children's Oncology Group (COG)-designated [6][7][8][9] or National Cancer Institute (NCI)-designated cancer centers, [10][11][12][13][14][15] they have improved overall survival compared with patients who are treated at non-SCCs. One factor may be limited access to specialized centers of cancer care.…”

“…Treatment at these centers may lead to improvement in quality of life and survival because of state-of-the-art diagnostics, expertise, treatment protocols, 16 and clinical trial enrollement. 13,14,[19][20][21] However, to more fully understand the nexus of a patient's care, it is important to consider all of the different hospitals where patients receive their cancer care. 13 Population-based research in AYA oncology has traditionally used cancer registry data that capture the initial diagnosing or treating facility.…”

Early mortality and complications in hospitalized adult Californians with acute myeloid leukaemia

“…(Birkmeyer et al , 2005; Paulson et al , 2008; Luchtenborg et al , 2013) Population-based studies conducted in Los Angeles County also showed improved overall survival among adult patients with adult-onset cancers (breast, colorectal, pancreatic, gastric and lung) and adolescent and young adult patients with haematological malignancies treated at NCI-designated cancer centres. (Wolfson et al , 2014; Wolfson et al , 2015)…”

Models of care for adolescent and young adult cancer programs

“…Although these factors may not present a barrier in countries where government‐funded healthcare predominates, the US health system poses additional complexities. North American data demonstrated that treatment in a Children's Oncology Group (COG) or National Cancer Institute‐designated comprehensive care center (NCICCC) was associated with a survival advantage for 15‐ to 39‐year‐olds with hematological malignancies and brain tumors . Insurance status, socioeconomic status, distance from patient's home to the nearest NCICCC, and, for some tumors, African‐American/Hispanic ethnicity reduced the likelihood of older AYA being treated at such a site.…”