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Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer: An Analysis of the National Cancer Database

Kaslow, Sarah R; Hani, Leena; Sacks, Greg D; Lee, Ann Y; Berman, Russell S; Correa-Gallego, Camilo
BACKGROUND:Adherence to evidence-based guidelines for gastric cancer is low, particularly at the hospital level, despite a strong association with improved overall survival (OS). We aimed to evaluate patterns of hospital and regional adherence to National Comprehensive Cancer Network guidelines for gastric cancer. METHODS:Using the National Cancer Database (2004-2015), we identified patients with stage I-III gastric cancer. Hospital-level guideline adherence was calculated by dividing the patients who received guideline adherent care by the total patients treated at that hospital. OS was estimated for each hospital. Associations between adherence, region, and survival were compared using mixed-effects, hierarchical regression. RESULTS:Among 576 hospitals, the median hospital guideline adherence rate was 25% (range 0-76%) and varied significantly by region (p = 0.001). Adherence was highest in the Middle Atlantic (29%) and lowest in the East South Central region (19%); hospitals in the New England, Middle Atlantic, and East North Central regions were more likely to be guideline adherent than those in the East South Central region (all p < 0.05), after adjusting for patient and hospital mix. Most (35%) of the adherence variation was attributable to the hospital. Median 2-year OS varied significantly by region. After adjusting for hospital and patient mix, hazard of mortality was 17% lower in the Middle Atlantic (hazard ratio 0.82, 95% confidence interval 0.74-0.90) relative to the East South Central region, with most of the variation (54%) attributable to patient-level factors. CONCLUSIONS:Hospital-level guideline adherence for gastric cancer demonstrated significant regional variation and was associated with longer OS, suggesting that efforts to improve guideline adherence should be directed toward lower-performing hospitals.
PMID: 36123415
ISSN: 1534-4681
CID: 5333102

ASO Visual Abstract: Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer-An Analysis of the National Cancer Database

Kaslow, Sarah R; Hani, Leena; Sacks, Greg D; Lee, Ann Y; Berman, Russell S; Correa-Gallego, Camilo
PMID: 36245050
ISSN: 1534-4681
CID: 5360052

Natural History of Stage IV Pancreatic Cancer. Identifying Survival Benchmarks for Curative-intent Resection in Patients With Synchronous Liver-only Metastases

Kaslow, Sarah R; Sacks, Greg D; Berman, Russell S; Lee, Ann Y; Correa-Gallego, Camilo
OBJECTIVE:To evaluate long-term oncologic outcomes of patients with stage IV pancreatic ductal adenocarcinoma (PDAC) and identify survival benchmarks for comparison when considering resection in these patients. SUMMARY BACKGROUND DATA/BACKGROUND:Highly selected cohorts of patients with liver-oligometastatic pancreas cancer have reported prolonged survival following resection. The long-term impact of surgery in this setting remains undefined due to a lack of appropriate control groups. METHODS:We identified patients with clinical stage IV PDAC with synchronous liver metastases within our cancer registry. We estimated overall survival (OS) among various patient subgroups using the Kaplan-Meier method. To mitigate immortal time bias, we analyzed long-term outcomes of patients who survived beyond 12 months (landmark time) from diagnosis. RESULTS:We identified 241 patients. Median OS was 7 months (95%CI 5-9), both overall and for patients with liver-only metastasis (n=144). Ninety patients (38% of liver-only; 40% of whole cohort) survived at least 12 months; those who received chemotherapy in this subgroup had a median OS of 26 months (95%CI 17-39). Of these patients, those with resectable or borderline resectable primary tumors and resectable liver-only metastasis (n=9, 4%) had a median OS of 39 months (95%CI 13-NR). CONCLUSIONS:The 4% of our cohort that were potentially eligible for surgery experienced a prolonged survival compared to all-comers with stage IV disease. Oncologic outcomes of patients undergoing resection of metastatic pancreas cancer should be assessed in the context of the expected survival of patients potentially eligible for surgery and not relative to all patients with stage IV disease.
PMID: 36353987
ISSN: 1528-1140
CID: 5357422

A Health Equity Framework to Address Racial and Ethnic Disparities in Melanoma

Kolla, Avani M; Seixas, Azizi; Adotama, Prince; Foster, Victoria; Kwon, Simona; Li, Vivienne; Lee, Ann Y; Stein, Jennifer A; Polsky, David
PMID: 35970385
ISSN: 1097-6787
CID: 5299802

Adherence to guidelines at the patient- and hospital-levels is associated with improved overall survival in patients with gastric cancer

Kaslow, Sarah R; Ma, Zhongyang; Hani, Leena; Prendergast, Katherine; Vitiello, Gerardo; Lee, Ann Y; Berman, Russell S; Goldberg, Judith D; Correa-Gallego, Camilo
BACKGROUND AND OBJECTIVES/OBJECTIVE:Adherence to evidence-based guidelines in gastric cancer is low. We aimed to evaluate adherence to National Comprehensive Cancer Network (NCCN) Guidelines for gastric cancer at both patient- and hospital-levels and examine associations between guideline adherence and treatment outcomes, including overall survival (OS). METHODS:We applied stage-specific, annual NCCN Guidelines (2004-2015) to patients with gastric cancer treated with curative-intent within the National Cancer Database and compared characteristics of patients who did and did not receive guideline-adherent care. Hospitals were evaluated by guideline adherence rate. We identified associations with OS through multivariable Cox regression. RESULTS:Of 37 659 patients included, 32% received NCCN Guideline-adherent treatment. OS was significantly associated with both guideline adherence (51 months for patients receiving guideline-adherent treatment vs. 22 for patients receiving nonadherent treatment, p < 0.001). Treatment at a hospital with higher adherence was associated with longer OS (21 months for patients treated at lowest adherence quartile hospitals vs. 37 months at highest adherence quartile hospitals, p < 0.001), regardless of type of treatment received. CONCLUSIONS:Guideline-adherent treatment was strongly associated with longer median OS. Guideline adherence should be used as a benchmark for focused quality improvement for physicians taking care of patients with gastric cancer and institutions at large.
PMID: 35471731
ISSN: 1096-9098
CID: 5217392

Diagnostic laparoscopy is underutilized in the staging of gastric adenocarcinoma regardless of hospital type: An US safety net collaborative analysis

Leder Macek, Aleeza J; Wang, Annie; Turgeon, Michael K; Lee, Rachel M; Russell, Maria C; Porembka, Matthew R; Alterio, Rodrigo; Ju, Michelle; Kronenfeld, Joshua; Goel, Neha; Datta, Jashodeep; Maker, Ajay V; Fernandez, Manuel; Richter, Harry; Berman, Russell S; Correa-Gallego, Camilo; Lee, Ann Y
BACKGROUND:Diagnostic laparoscopy (DL) is a key component of staging for locally advanced gastric adenocarcinoma (GA). We hypothesized that utilization of DL varied between safety net (SNH) and affiliated tertiary referral centers (TRCs). METHODS:Patients diagnosed with primary GA eligible for DL were identified from the US Safety Net Collaborative database (2012-2014). Clinicopathologic factors were analyzed for association with use of DL and findings on DL. Overall survival (OS) was analyzed by Kaplan-Meier method. RESULTS:Among 233 eligible patients, 69 (30%) received DL, of which 24 (35%) were positive for metastatic disease. Forty percent of eligible SNH patients underwent DL compared to 21.5% at TRCs. Lack of insurance was significantly associated with decreased use of DL (OR 0.48, p < 0.01), while African American (OR 6.87, p = 0.02) and Asian race (OR 3.12, p ≤ 0.01), signet ring cells on biopsy (OR 3.14, p < 0.01), and distal tumors (OR 1.62, p < 0.01) were associated with increased use. Median OS of patients with a negative DL was better than those without DL or a positive DL (not reached vs. 32 vs. 12 months, p < 0.005, Figure 1). CONCLUSIONS:Results from DL are a strong predictor of OS in GA; however, the procedure is underutilized. Patients from racial minority groups were more likely to undergo DL, which likely accounts for higher DL rates among SNH patients.
PMID: 35699351
ISSN: 1096-9098
CID: 5282572

Dermatofibrosarcoma Protuberans: What Is This?

Vitiello, Gerardo A; Lee, Ann Y; Berman, Russell S
Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive dermal-based sarcoma. Metastatic potential is extremely low, primarily in the setting of fibrosarcomatous transformation. DFSP is characterized by a t(17;22) (q22;q13) translocation that results in active PDGFB signaling. Surgical resection with negative margins (typically including the underlying fascia) is the potentially curative treatment. Delayed wound closure should be considered for cases requiring extensive resection or tissue rearrangement. Tyrosine kinase inhibitors, such as imatinib, have shown response rates of 50% to 60% in patients with locally advanced or metastatic disease. Radiation can be useful for residual or recurrent diseases.
PMID: 35952694
ISSN: 1558-3171
CID: 5287152

Outcomes with adjuvant anti-PD-1 therapy in patients with sentinel lymph node-positive melanoma without completion lymph node dissection

Eroglu, Zeynep; Broman, Kristy K; Thompson, John F; Nijhuis, Amanda; Hieken, Tina J; Kottschade, Lisa; Farma, Jeffrey M; Hotz, Meghan; Deneve, Jeremiah; Fleming, Martin; Bartlett, Edmund K; Sharma, Avinash; Dossett, Lesly; Hughes, Tasha; Gyorki, David E; Downs, Jennifer; Karakousis, Giorgos; Song, Yun; Lee, Ann; Berman, Russell S; van Akkooi, Alexander; Stahlie, Emma; Han, Dale; Vetto, John; Beasley, Georgia; Farrow, Norma E; Hui, Jane Yuet Ching; Moncrieff, Marc; Nobes, Jenny; Baecher, Kirsten; Perez, Matthew; Lowe, Michael; Ollila, David W; Collichio, Frances A; Bagge, Roger Olofsson; Mattsson, Jan; Kroon, Hidde M; Chai, Harvey; Teras, Jyri; Sun, James; Carr, Michael J; Tandon, Ankita; Babacan, Nalan Akgul; Kim, Younchul; Naqvi, Mahrukh; Zager, Jonathan; Khushalani, Nikhil I
Until recently, most patients with sentinel lymph node-positive (SLN+) melanoma underwent a completion lymph node dissection (CLND), as mandated in published trials of adjuvant systemic therapies. Following multicenter selective lymphadenectomy trial-II, most patients with SLN+ melanoma no longer undergo a CLND prior to adjuvant systemic therapy. A retrospective analysis of clinical outcomes in SLN+ melanoma patients treated with adjuvant systemic therapy after July 2017 was performed in 21 international cancer centers. Of 462 patients who received systemic adjuvant therapy, 326 patients received adjuvant anti-PD-1 without prior immediate (IM) CLND, while 60 underwent IM CLND. With median follow-up of 21 months, 24-month relapse-free survival (RFS) was 67% (95% CI 62% to 73%) in the 326 patients. When the patient subgroups who would have been eligible for the two adjuvant anti-PD-1 clinical trials mandating IM CLND were analyzed separately, 24-month RFS rates were 64%, very similar to the RFS rates from those studies. Of these no-CLND patients, those with SLN tumor deposit >1 mm, stage IIIC/D and ulcerated primary had worse RFS. Of the patients who relapsed on adjuvant anti-PD-1, those without IM CLND had a higher rate of relapse in the regional nodal basin than those with IM CLND (46% vs 11%). Therefore, 55% of patients who relapsed without prior CLND underwent surgery including therapeutic lymph node dissection (TLND), with 30% relapsing a second time; there was no difference in subsequent relapse between patients who received observation vs secondary adjuvant therapy. Despite the increased frequency of nodal relapses, adjuvant anti-PD-1 therapy may be as effective in SLN+ pts who forego IM CLND and salvage surgery with TLND at relapse may be a viable option for these patients.
PMID: 36002183
ISSN: 2051-1426
CID: 5374652

Outcomes After Surgical Palliation of Patients With Gastric Cancer

Nohria, Ambika; Kaslow, Sarah R; Hani, Leena; He, Yanjie; Sacks, Greg D; Berman, Russell S; Lee, Ann Y; Correa-Gallego, Camilo
INTRODUCTION/BACKGROUND:Surgery is an option for symptom palliation in patients with metastatic gastric cancer. Operative outcomes after palliative interventions are largely unknown. Herein, we assess the trends of surgical palliation use for patients with gastric cancer and describe outcomes of patients undergoing surgical palliation compared to nonsurgical palliation. METHODS:Patients with clinical Stage IV gastric cancer in the National Cancer Database (2004-2015) who received surgical or nonsurgical palliation were selected. We identified factors associated with palliative surgery. Survival differences were assessed by Kaplan-Meier estimate, Cox proportional hazard regression, and log rank test. RESULTS:Six thousand eight hundred twenty nine patients received palliative care for gastric cancer. Most patients (87%, n = 5944) received nonsurgical palliation: 29% radiation therapy, 57% systemic treatment, and 14% pain management. The number of patients receiving palliative care increased between 2004 and 2015; however, use of surgical palliation declined significantly (22% in 2004, 8% in 2015; P < 0.001). Median overall survival (OS) for the cohort was 5.65 mo (95% confidence interval 5.45-5.85); 1-year and 2-year OS were 24% and 9%, respectively. Older age at diagnosis and diagnosis between 2004 and 2006 were significantly associated with undergoing surgical palliation. Patients who underwent surgical palliation had significantly shorter median OS and a 20% higher hazard of mortality than those who received nonsurgical palliation. CONCLUSIONS:Patients with metastatic gastric cancer experience very short survival. While palliative surgery is used infrequently, the observed association with shorter median OS underscores the importance of careful patient selection. Palliative surgery should be offered judiciously and expectations about outcomes clearly established.
PMID: 35809355
ISSN: 1095-8673
CID: 5280742

Systemic therapy for duodenal adenocarcinoma: An analysis of the National Cancer Database (NCDB)

Kaslow, Sarah R; Prendergast, Katherine; Vitiello, Gerardo A; Hani, Leena; Berman, Russell S; Lee, Ann Y; Correa-Gallego, Camilo
BACKGROUND:National Comprehensive Cancer Network guidelines recommend resection and adjuvant chemotherapy for patients with locally advanced duodenal adenocarcinoma. Outcomes after systemic treatment in this rare malignancy have not been well studied. We examined utilization patterns of systemic treatment and compared overall survival of patients receiving neoadjuvant therapy, surgery alone, and adjuvant therapy. METHODS:Patients with stage 0 to III duodenal adenocarcinoma undergoing curative-intent surgery were identified within the National Cancer Database from 2006 to 2015. Outcomes, including median overall survival and 30- and 90-day mortality, were compared based on treatment sequence (neoadjuvant, adjuvant, or surgery alone). Propensity score matching on likelihood of receiving systemic treatment and landmark analysis were performed to mitigate bias. RESULTS:Of the 2,956 patients meeting inclusion criteria, most patients with known clinical stage had locally advanced disease (72%), of which 53% received systemic therapy (8% neoadjuvant, 45% adjuvant). After landmark analysis on the propensity matched cohort, patients with locally advanced disease who received systemic treatment had longer median overall survival compared to patients who underwent surgery alone (49 vs 40 months, P = .018) and a 20% lower hazard of mortality (hazard ratio 0.80, 95% confidence interval 0.69-0.93, P = .003). Patients who received neoadjuvant and adjuvant therapy had similar survival outcomes. CONCLUSION/CONCLUSIONS:Adjuvant therapy was underutilized in patients with National Comprehensive Cancer Network guideline indications, despite an association with longer median overall survival and decreased hazard of mortality. Neoadjuvant therapy, although rarely used, had similar survival to adjuvant therapy. Given its other potential benefits, systemic treatment in the neoadjuvant setting may be a reasonable option in adequately selected patients with clinically advanced duodenal adenocarcinoma.
PMID: 35437164
ISSN: 1532-7361
CID: 5218192