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Considers how antihomosexual discrimination marked by occasional violence remains a divisive fixture in the social landscape of the United States. Protection of gay and lesbian medical students by antidiscrimination clauses in their academic and working lives; Reference to study by Jason Schneider and Saul Levin in the same issue; Growing acceptance of homosexual visibility; Prejudice of admissions officers to homosexuals; Greater harassment of gay physicians than heterosexuals.

Importance: The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known., Objective: To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict., Design, Setting, and Participants: A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction., Interventions: An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator., Main Outcomes and Measures: Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict., Results: Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001)., Conclusions and Relevance: The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict., Trial Registration: ClinicalTrials.gov Identifier: NCT03982459.

Importance: It has previously been demonstrated that immunosuppressed patients with cutaneous squamous cell cancer of the head and neck (cSCC-HN) treated with surgery and postoperative radiotherapy have significantly inferior disease-related outcomes compared with immunocompetent patients, but data on outcomes after disease recurrence are limited., Objectives: To report survival outcomes in patients with cSCC-HN after disease recurrence after surgery and postoperative radiotherapy and to investigate the association of immune status with disease-related outcomes., Design, Setting, and Participants: A multi-institutional study of 205 patients treated at the Cleveland Clinic, Washington University in St Louis, and the University of California, San Francisco, in which patients who underwent surgical resection and postoperative radiotherapy for primary or recurrent stage I to IV (nonmetastatic) cSCC-HN between January 1, 1995, and December 31, 2014, were identified. Patients with any disease recurrence, defined as local, regional, and/or distant failure, were included. Patients were categorized as immunosuppressed if they received a diagnosis of chronic hematologic malignant neoplasm or HIV or AIDS, or were treated with immunosuppressive therapy for organ transplantation 6 months or more before diagnosis. Statistical analysis was conducted from January 1, 1995, to December 31, 2015., Main Outcomes and Measures: Overall survival calculated using the Kaplan-Meier method and compared using the log-rank test., Results: Of the 205 patients in the original cohort, 72 patients (63 men and 9 women; median age, 71 years [range, 43-91 years]) developed disease recurrence after surgery and postoperative radiotherapy. Forty patients (55.6%) were immunosuppressed, and 32 patients (44.4%) were immunocompetent. Locoregional recurrence was the most common first pattern of failure for both groups (31 immunosuppressed patients [77.5%]; 21 immunocompetent patients [65.6%]). After any recurrence, 1-year overall survival was 43.2% (95% CI, 30.9%-55.4%), and median survival was 8.4 months. For patients for whom information on salvage treatment was available (n = 45), those not amenable to surgical salvage had significantly poorer median cumulative incidence of survival compared with those who were amenable to surgical salvage (4.7 months; 95% CI, 3.7-7.0 months vs 26.1 months; 95% CI, 6.6 months to not reached; P = .01), regardless of their immune status., Conclusions and Relevance: Results of this study suggest that patients with cSCC-HN who experience disease recurrence after definitive treatment with surgery and postoperative radiotherapy have poor survival, irrespective of immune status. Survival rates are low for patients with recurrent disease that is not amenable to surgical salvage. The low rate of successful salvage underscores the importance of intensifying upfront treatment to prevent recurrence.

Importance: Patients with head and neck squamous cell carcinoma (HNSCC) who undergo surgical resection in an academic medical center (AC) often receive postoperative adjuvant external beam radiation therapy (RT) at non-ACs closer to home. Few data exist to compare outcomes of these populations., Objective: To evaluate treatment metrics and outcomes in patients with HNSCC who underwent surgical resection at an AC and then received postoperative adjuvant external beam RT at an AC vs a non-AC., Design, Setting, and Participants: Retrospective cohort study in 1 AC and several community RT non-ACs of patient with primary HNSCC treated with surgery at an AC followed by adjuvant therapy at an AC or a non-AC from January 1, 2002, to January 1, 2012., Interventions: We evaluated for between-groups differences in demographics, RT metrics, and survival outcomes. Subgroup analysis by tumor site was then performed., Main Outcomes and Measures: Overall survival, disease-specific survival, and locoregional control rates., Results: A total of 286 patients underwent surgery at the University of California, San Francisco, followed by adjuvant therapy. A total of 214 patients were analyzed. Significant differences in demographic and oncologic variables emerged, including important differences in RT metrics. Patients treated at a non-AC received a lower total RT dose, lower fractional dose, more delays in RT initiation, more breaks in RT, and more early termination of RT. Adjuvant treatment at an AC was associated with improved survival on univariate but not multivariate analysis. Subgroup analysis by SCC tumor site normalized many of the differences between groups, yet still revealed persistent differences in RT metrics. On multivariate analysis, AC treatment was not an independent predictor of survival for any tumor site., Conclusions and Relevance: Better oncologic outcomes were seen in the AC group on univariate analysis, but these improved outcomes were not found on multivariate analysis. Important differences in RT metrics were noted for non-AC treatment sites compared with AC sites. Subgroup analysis by tumor site demonstrated persistent differences in treatment metrics. Standardization of adjuvant HNSCC treatment according to national guidelines should be prioritized at non-AC treatment facilities.