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Introduction The International Association for the Study of Lung Cancer's (IASLC's) proposal to recategorize the residual tumor (R) classification for resected NSCLC needs validation. Methods Using a 2009 to 2019 population-based multi-institutional NSCLC resection cohort from the United States, we classified resections by Union for International Cancer Control (UICC) and IASLC R criteria and compared the distribution of R classification variables and their survival associations. Results Of 3361 resections, 95.3% were R0, 4.3% were R1, and 0.4% were R2 by UICC criteria; 33.3% were R0, 60.8% were R-uncertain, and 5.8% were R1/2 by IASLC criteria; 2044 patients (63.8%) migrated from UICC R0 to IASLC R-uncertain. Median survival was not reached, 69 (95% confidence interval [CI]: 64–77), and 25 (95% CI: 18–36) months, respectively, for patients with IASLC R0, R-uncertain, and R1 or R2 resections. Failure to achieve nodal dissection criteria caused 98% of migration to R-uncertainty, metastasis to the highest mediastinal node station, 5.8%. Compared with R0, R-uncertain resections with mediastinal nodes, no mediastinal nodes, and no nodes had adjusted hazard ratios of 1.28 (95% CI: 1.10–1.48), 1.47 (95% CI: 1.24–1.74), and 1.74 (95% CI: 1.37–2.21), respectively, suggesting a dose-response relationship between nodal R-uncertainty and survival. Accounting for mediastinal nodal involvement, the highest mediastinal station involvement was not independently prognostic. The incomplete resection variables were uniformly prognostic. Conclusions The proposed R classification recategorization variables were mostly prognostic, except the highest mediastinal nodal station involvement. Further categorization of R-uncertainty by severity of nodal quality deficit should be considered.

Introduction: To evaluate the need for tobacco cessation services within a multidisciplinary clinic (MDC), we surveyed patients on their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program. We further evaluated the association between interest in cessation or willingness to participate in a cessation program and overall survival (OS). Methods: From 2014 to 2019, all new patients with lung cancer in the MDC at Baptist Cancer Center (Memphis, TN) were administered a social history questionnaire to evaluate their demographic characteristics, smoking status, tobacco dependence, interest in quitting, and willingness to participate in a cessation program. We used chi-square tests and logistic regression to compare characteristics of those who would participate to those who would not or were unsure and Kaplan-Meier curves and Cox regression to evaluate the association between cessation interest or willingness to quit and OS. Results: Of 641 total respondents, the average age was 69 years (range: 32–95), 47% were men, 64% white, 34% black, and 17% college graduates. A total of 90% had ever smoked: 34% currently and 25% quit within the past year. Among the current smokers, 60% were very interested in quitting and 37% would participate in a cessation program. Willingness to participate in a cessation program was associated with greater interest in quitting (p < 0.0001), better OS (p = 0.02), and reduced hazard of death (hazard ratio = 0.52, 95% confidence interval: 0.30–0.88), but no other characteristics. Conclusions: Patients with lung cancer in an MDC expressed considerable interest in tobacco cessation services; patients willing to participate in a clinic-based cessation program had improved survival.

Importance: The International Association for the Study of Lung Cancer (IASLC) has proposed a revision of the residual disease (R-factor) classification, to R0, ‘R-uncertain’, R1 and R2. We previously demonstrated longer survival after surgical resection with a lymph node specimen collection kit, and now evaluate R-factor redistribution as the mechanism of its survival benefit. Objective: We retrospectively evaluated surgical resections for lung cancer in the population-based observational ‘Mid-South Quality of Surgical Resection’ cohort from 2009-2019, including a full-cohort and propensity-score matched analysis. Results: Of 3,505 resections, 34% were R0, 60% R-uncertain, and 6% R1 or R2. The R0 percentage increased from 9% in 2009 to 56% in 2019 (p < 0.0001). Kit cases were 66% R0 and 29% R-uncertain, compared to 14% R0 and 79% R-uncertain in non-kit cases (p < 0.0001). Compared with non-kit resections, kit resections had 12.3 times the adjusted odds of R0 versus R-uncertainty.Of 2,100 R-uncertain resections, kit cases had lower percentages of non-examination of lymph nodes, 1% vs. 14% (p < 0.0001) and non-examination of mediastinal lymph nodes, 8% vs. 35% (p < 0.0001). With the kit, more R-uncertain cases had examination of stations 7 (43% vs. 22%, p < 0.0001) and 10 (67% vs. 45%, p < 0.0001).The adjusted hazard ratio (aHR) for kit cases versus non-kit cases was 0.75 (confidence interval [CI]: 0.66–0.85, p < 0.0001). In 2,100 subjects with R-uncertain resections, kit cases had an aHR of 0.79 versus non-kit cases ([CI: 0.64–0.99], p=0.0384); however, in the 1,199 R0 resections the survival difference was not significant (aHR: 0.85[0.68–1.07], p = 0.17). Conclusions and Relevance: A lymph node kit increased overall survival by increasing R0, reducing the probability of R-uncertain resections, and diminishing extreme R-uncertainty.

The adverse prognostic impact of poor pathologic nodal staging has stimulated efforts to heighten awareness of the problem through guidelines, without guidance on processes to overcome it. We compared heightened awareness (HA) of nodal staging quality versus a lymph node collection kit.We categorized curative-intent lung cancer resections from 2009 to 2020 in a population-based, nonrandomized stepped-wedge implementation study of both interventions, into preintervention baseline, HA, and kit subcohorts. We used differences in proportion and hazard ratios across the subcohorts to estimate the effect of the interventions on poor quality (nonexamination of nodes [pNX] or nonexamination of mediastinal lymph nodes) and attainment of quality recommendations of the National Comprehensive Cancer Network, the Commission on Cancer, and the proposed complete resection definition of the International Association for the Study of Lung Cancer across the three cohorts.Of 3734 resections, 39% were preintervention, 40% kit, and 21% HA cases. Cohort proportions were the following: pNX, 11% (baseline) versus 0% (kit) versus 9% (HA); nonexamination of mediastinal lymph nodes, 27% versus 1% versus 22%; Commission on Cancer benchmark attainment, 14% versus 77% versus 30%; International Association for the Study of Lung Cancer-defined complete resection, 11% versus 58% versus 24%; National Comprehensive Cancer Network attainment, 23% versus 79% versus 35% (p0.001 for all, except pNX rate baseline versus HA). Survival rate was significantly higher for both interventions compared with baseline (p0.0001).Resections with HA or the kit significantly improved surgical quality and outcomes, but the kit was more effective. We propose to conduct a prospective, institutional cluster-randomized clinical trial comparing both interventions.

Introduction The American College of Surgeons Oncology Group Z0030 found no survival difference between patients with early stage NSCLC who had mediastinal nodal dissection or systematic sampling. However, a meta-analysis of 1980 patients in five randomized controlled trials from 1989 to 2007 associated better survival with nodal dissection. We tested the survival impact of the extent of nodal dissection in curative-intent resections for early stage NSCLC in a population-based observational cohort. Methods Resections for clinical T1 or T2, N0 or nonhilar N1, M0 NSCLC in four contiguous United States Hospital Referral Regions from 2009 to 2019 were categorized into mediastinal nodal dissection, systematic sampling, and “neither” on the basis of of the evaluation of lymph node stations. We compared demographic and clinical characteristics, perioperative complication rates, and survival after assessing statistical interactions and confounding. Results Of the 1942 eligible patients, 18% had nodal dissection, 6% had systematic sampling, and 75% had an intraoperative nodal evaluation that met neither standard. In teaching hospitals, nodal dissection was associated with a lower hazard of death than “neither” resections (0.57 [95% confidence interval: 0.41–0.79]) but not systematic sampling (0.74 [0.40–1.37]) after adjusting for multiple comparisons. There was no significant difference in hazard ratios at nonteaching institutions (p > 0.3 for all comparisons). Perioperative complication rates were not significantly worse after mediastinal nodal dissection or systematic sampling, compared with “neither,” (p > 0.1 for all comparisons). Conclusions In teaching institutions, mediastinal nodal dissection was associated with superior survival over less-comprehensive pathologic nodal staging. There was no survival difference between teaching and nonteaching institutions, a finding that warrants further investigation.

Early diagnosis and treatment of lung cancer are of significant importance. In this paper, a system-theoretic method is introduced to analyze the diagnosis-to-treatment process for lung cancer patients who receive surgical resections. The complex care delivery process is decomposed into a collection of serial processes, each consisting of combinations of various tests and procedures. Closed formulas are derived to estimate the mean and coefficient of variation of waiting time during the diagnosis-to-surgery process. Simple indicators based on the data collected on the clinic/hospital floor are derived to identify the bottlenecks, i.e., the waiting times that impede the whole delivery process in the strongest manner. In addition, by approximating waiting times using Gamma distributions, an algorithm is introduced to evaluate the waiting-time performance, i.e., the probability to finish the diagnosis-to-surgery process within a desired or given time interval. Finally, a case study at Baptist Memorial Health System is introduced to illustrate the applicability of the method and provide recommendations for improvement. Note to Practitioners —Lung cancer is the primary cause of cancer deaths in the U.S. It has a very low five-year survival rate, and only a small percentage of lung cancer cases are diagnosed at an early stage. Particularly, the diagnosis-to-treatment process is a long, complex procedure in which patients experience substantial delays. Thus, reducing diagnosis-to-treatment time is critical, as prolonged waiting times may lead to advanced cancer stage and/or decreased survival rates. In this paper, to analyze the diagnosis-to-treatment process for lung cancer patients who receive surgical resections, a novel analytical method is introduced. First, five critical steps in diagnosis-to-surgery process are considered: 1) chest X-ray and/or CT scan; 2) diagnostic biopsy; 3) noninvasive staging; 4) invasive staging; and 5) surgery. Then, we decompose the complex care delivery process into multiple serial processes, where each process represents a unique sequence of diagnosis steps that patients may go through. To evaluate the system performance, formulas to calculate the mean and variability of waiting time during the diagnosis-to-surgery process are derived. An approximation algorithm is developed to evaluate the probability to finish the diagnosis-to-surgery process within a desired or given time interval, referred to as waiting-time performance. In addition, to identify the bottleneck waiting time whose improvement will lead to the largest reduction in overall waiting time, we present simple indicators based on the data collected on the clinic/hospital floor. Finally, we introduce a case study at Baptist Memorial Hospital. It is shown that the steps between chest X-ray and/or CT scan and diagnostic biopsy and the steps between noninvasive staging and surgery are the most critical ones. Such a method provides a quantitative tool for the analysis and improvement of lung cancer diagnosis-to-surgery process.

Background: Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. Methods: We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. Results: Implementation: The multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being “very satisfied” with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial minorities, with a higher proportion of stage IV patients in the serial care arm. Conclusions: This study demonstrates a comprehensive implementation of a multidisciplinary model of lung cancer care, which will advance the science behind implementing this much-advocated clinical care model.

251 Background: Lung cancer care is complex, but, for quality improvement, can be simplified into five ‘nodal points’: lesion detection, diagnostic biopsy, radiologic staging, invasive staging, and treatment. We previously demonstrated great heterogeneity in passage through these nodal points in patients who received surgical resection for lung cancer in our healthcare system. However, examining only surgical patients may underestimate the enormity of the opportunity for quality improvement. With the aim of identifying quality gaps in pre-treatment evaluation for lung cancer, we evaluated the flow of care through these nodal points within a community-based healthcare system. Methods: We classified lung cancer care procedures received by all suspected lung cancer patients treated within the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN between 2014 and 2019, into five nodal points. We compared the frequency of, and time intervals between, nodal points among patients receiving surgical, nonsurgical (chemotherapy/radiation), or no definitive treatment, using Chi-square or Kruskal Wallis tests, where appropriate. Results: Of 1304 eligible patients: 11% had no pre-treatment diagnostic procedure, 20% no PET/CT, and 39% no invasive staging. 39% of patients underwent surgical resection, 51% received non-surgical treatment, and 10% received no treatment. Patients who had surgery were less likely than those who had non-surgical treatment to get a diagnostic test, radiologic staging, and invasive staging (Table). Patients who had non-surgical treatment were more likely to pass through all five nodal points (50% v 68%, p

200 Background: Few existing studies examined lung cancer patients and caregivers’ satisfaction with the team-based multidisciplinary care (MD) in comparison to the usual serial care (SC). We hypothesized that MD, by providing early and concurrent input from key specialists collaborating as a team with patients and caregivers to develop a consensus care plan, can improve patients and caregivers’ satisfaction with care, compared to SC, in which multiple specialists independently screen, diagnose, and treat patients through a fragmented sequence of referrals. Methods: Data on newly diagnosed lung cancer patients, enrolled in a prospective matched cohort comparative effectiveness trial of MD or SC between Oct. 9th, 2014 and July 5th, 2017 in a Mid-South community hospital system, were collected at baseline, 3- and 6-month periods to assess patient and caregiver’s satisfaction with these two care-delivery models. Measures of satisfaction were adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Multivariate mixed linear models were used to examine the cross-group differences, the time-related variances, and how the interaction between groups and time-periods influenced patients’ and caregivers’ satisfaction. Results: Compared with SC (N = 297), patients in MD (N = 159) were older (66 vs. 69 years), more in an early cancer stage (33% vs. 41% in stage I or II), and lower in performance score (35% vs. 45% asymptomatic). Demographic and social-economic characteristics of caregivers in MD (N = 97) and SC (N = 122) were not significantly different. Patients and caregivers in MD were more likely than those in SC to perceive their care to be better than that received by other patients (p =.003 and p

13 Background: Early detection of lung cancer provides the best opportunity for long-term survival. In 2021 US Preventive Services Task Force (USPSTF) expanded the 2013 risk-based Low-dose CT (LDCT) screening criteria, in part to reduce unintended race and gender disparities in lung cancer detection. We evaluated the impact of the updated USPSTF criteria in a cohort of patients from an incidental lung nodule program (ILNP). Methods: We implemented an ILNP in a community healthcare system in the mid-south US. Patients with lung lesions on routinely-performed radiologic studies were triaged using evidence-based guidelines. We prospectively tracked patient demographics, clinical characteristics, procedures, complications, and health outcomes. We classified all patients in the ILNP cohort based on USPSTF 2013 and 2021 screening criteria. Statistical analysis used the chi-square test. Results: The ILNP cohort included 14,642 patients from 2015-2021. This cohort was 56% female, 65% White, 29% Black, with a median age of 64 years. Overall 1,581 (10.8%) met 2013 and 2,051 (14.0%) met 2021 USPSTF criteria. 1.9% of subjects eligible by 2013 criteria were diagnosed with lung cancer compared to 2.2% by 2021 criteria. 470 additional patients met screening criteria when we expanded from USPSTF 2013 to 2021. As expected, these patients were younger and less likely to have Medicare insurance. These additional eligible patients were significantly more likely to be female (58% v 49%, p = 0.0011) or Black (28% vs. 18%, p < 0.0001) compared to those eligible by 2013 criteria. 44 of the 470 (9%) were diagnosed with cancer: 36% adenocarcinoma, 18% squamous, and 11% small cell, 11% non-lung primary, 9% non-small cell lung cancer NOS, and 15% other or unknown histology. The median tumor size was 3 cm with an interquartile range from 1.7 to 4.2 cm. The clinical stage distribution was 34% I, 4.5% II, 15.9% III, and 31.8% IV. Conclusions: In this selective community-based cohort, USPSTF 2021 criteria identified a higher percentage of subjects with lung cancer and were more inclusive of women and minorities compared to USPSTF 2013 criteria.

8553 Background: Lung cancer early detection improves survival, but risk-based low-dose CT screening (LDCT) only identifies a minority of patients. We implemented an ILNP in a community healthcare system, and evaluated its risks and benefits. Methods: Patients with lung lesions on routinely-performed radiologic studies were flagged by radiologists and triaged using evidence-based guidelines. We tracked demographics, clinical characteristics, procedures, complications, and health outcomes. We analyzed ILNP subjects’ eligibility for LDCT by National Lung Screening Trial (NLST), Center for Medicaid Services (CMS), NEderlands Leuvens Screening ONderzoek (NELSON), National Comprehensive Cancer Network (NCCN) Risk Groups 1 and 2 (screening recommended), NCCN Risk Group 3 (screening not currently recommended), and US Preventive Services Task Force (USPSTF) criteria from 2013 and 2020. Statistical analysis used the chi-square test and Kaplan Meier method. Results: From 2015-2020, 13,710 patients were evaluated in the ILNP program: median age, 64 years; 42% male; 65% White, 29% Black; 667 (4.9%) were diagnosed with lung cancer. Lung cancers diagnosed from ILNP were 39% adenocarcinoma / 20% Squamous Cell with clinical stage distribution 49% I, 8% II, 17% III, and 16% IV. 832 (6.1%) had invasive diagnostic testing- CT-guided biopsy (50%), bronchoscopy (30%), and/or EBUS (26%); 11% of the 832 had >1 invasive diagnostic test. The most common complications from invasive testing were pneumothorax and chest tube placement. Only 11%-20% of all ILNP patients would have been eligible for LDCT. In ILNP patients diagnosed with lung cancer, only 33% were eligible for screening by NLST criteria; the proportion increased substantially when USPSTF 2020 or NCCN Group 2 criteria were applied (Table). Compared to NLST, NCCN Group 2 criteria increased screening eligibility among cancer patients by 22% (from 33% to 55%), while only increasing screening eligibility by 6% (from 8% to 14%) in non-cancer patients. Aggregate 1-year and 3-year survival rates for lung cancer patient diagnosed through ILNP were 76% (95% CI: 73, 80) and 64% (95% CI: 59, 69). Conclusions: The ILNP identified early-stage lung cancer more frequently than most LDCT programs, with promising survival rates. The majority of subjects with lung cancer were not eligible for LDCT, we still need to optimize risk-based screening criteria. Even with new, expanded criteria for LDCT, structured ILNP is necessary to expand early detection of lung cancer.[Table: see text]

55 Background: Lung cancer care delivery is complex, with disparate quality and outcomes. Prospective multidisciplinary case planning is a recommended but poorly validated solution. We conducted a prospective comparative effectiveness trial to evaluate the impact of multidisciplinary care on care processes and long-term survival in a large community-based healthcare system. Methods: We previously reported primary objective results comparing patients in the multidisciplinary clinic (MDC) with those not cared for in the MDC i.e. usual, SC. However, a subset of the SC subjects (and all MDC subjects) were discussed at a weekly MTOC. In this secondary analysis, we compare all subjects who were prospectively discussed at MTOC (with or without MDC) with ‘true’ SC (TSC). Subjects were frequency matched by age range, race, insurance, performance status, and initial clinical stage. We compared the thoroughness of staging, use of guideline-concordant treatment, and survival. Models were stratified by frequency matched variables and adjusted for age, sex, and histology as covariates. Statistical methods included chi-square, logistic regression with adjusted Odds Ratios (aOR), and Proportional Hazards models with adjusted Hazard Ratios (aHR); both with 95% confidence intervals. Results: Of 526 subjects enrolled, 246 (47%) were discussed at MTOC. MTOC patients were older (median age 68 v 66, p = 0.03), less intense smokers (p = 0.03), and more commercially insured (p = 0.02). Fewer MTOC subjects were clinical stage IV (33% v 45%, p = 0.01). The MTOC patients had significantly greater odds of bimodal staging (aOR: 2.2 [1.3, 3.8]), trimodal staging (2.6 [1.8, 3.8]), invasive stage confirmation (2.6 [1.7, 3.9]), and mediastinal stage confirmation (2.4 [1.6, 3.6]; all p < 0.01). The additional stage confirmation resulted in more patients who were up- or down-staged in MTOC (44% v 33%, p = 0.03). MTOC patients were twice as likely to receive National Comprehensive Cancer Network guideline-concordant treatment (aOR: 2.0 [1.3, 3.2]). Despite more thorough care, time from initial lesion detection to treatment was similar (mean: 2.86 vs. 2.83 months, p = 0.71). Health-related quality of life measures did not differ between the two arms (P = 0.07 to 0.99). We found no difference in overall (aHR: 1.1 [0.9, 1.4]) or disease free survival (aHR: 1.1 [0.9, 1.3]) between MTOC and TSC. Conclusions: MTOC improved the thoroughness of care and delivery of appropriate treatment, without delays in treatment initiation or survival improvement.

105 Background: Medicaid patients with lung cancer have poorer outcomes than non-Medicaid patients, partly because of suboptimal care quality. The Association of Community Cancer Centers (ACCC) launched a project to develop, test, and refine an OCCM. Methods: The OCCM comprised 13 areas, spanning care access to supportive care/survivorship. Using the OCCM, 7 cancer programs in 6 US states conducted self-assessments of care delivery systems and implemented quality improvement projects. Sites worked with ACCC to conduct data benchmarked projects. Data collection and analysis were centralized. Statistical analyses used Kruskal−Wallis and chi-squared tests. Results: There were 926 patients (257 Medicaid/dual eligible; 669 non-Medicaid) across 7 sites. Medicaid/dual eligible patients were 52% male, 69% Caucasian, 48% active smokers, and 45% clinical stage III/IV. Prospective multidisciplinary case planning (PMCP), patient care access, and tobacco cessation were commonly selected for projects. PMCP evaluation used fortnightly tumor board (FTB), virtual tumor board (VTB), and multidisciplinary team huddle (MTH). Presentation of eligible patients was higher for VTB and MTH (FTB: 23%, VTB: 100%, MTH: 100%, p < 0.0001). While FTB and MTH discussed all cases prospectively, VTB achieved 80%. Median days (d) from diagnosis to presentation were 18 (FTB), 14 (VTB), and 9 (MTH, p = 0.14). Patient care access was evaluated with timeliness metrics at 2 sites. Site 1: Medicaid patients had a median of 13 d from lesion discovery to diagnosis and 21 d from diagnosis to treatment (not different from non-Medicaid; p = 0.96 and 0.38). 94% met the goal of treatment initiation within 45 d. Site 2: Medicaid patients had a median of 16 d from discovery to diagnosis and 27 d from diagnosis to treatment (not different from non-Medicaid; p = 0.68 and 0.83). Similar benchmarks were collected and compared for other assessment areas. Sites identified enhanced collaboration and improved programming (e.g., patient navigation) as successes. Challenges at project start included inadequate staffing and lack of centralized data collection and benchmarking. Importance of lung cancer–dedicated navigation, PMCP, and Medicaid patient needs were key transferable lessons. Conclusions: The OCCM is useful for cancer programs’ self-assessment of care delivery to Medicaid patients across 13 high-impact areas. Dissemination can advance multidisciplinary coordinated care delivery, but sites may need additional resources to evaluate outcomes.

36 Background: The Multidisciplinary Thoracic Oncology Conference (MTOC) model is easier to implement than the Multidisciplinary Clinic (MDC) model, but does not directly involve patients in decision-making. We compared the processes and outcomes of lung cancer care between patients discussed in a weekly MTOC versus those seen in a MDC. Methods: Prospective observational study of thoroughness of staging, stage confirmation (defined as biopsy of the stage-defining lesion), National Comprehensive Cancer Network guideline-concordant treatment, overall (OS) and event-free (EFS) survival of lung cancer patients in a community healthcare system’s MDC and MTOC from 2014-2019. We used the chi-square test and multivariable logistic regression to evaluate guideline-concordant treatment and stage confirmation; Kaplan-Meier curves and multivariable Cox regression were used to evaluate OS and EFS. We adjusted models for age, sex, race, insurance, smoking status, and histology. Results: 614 patients received care in MDC; 571 in MTOC. MDC patients were older (median age: 69 vs. 67); less likely to be active smokers (44% vs. 47%; p=0.03); more likely to have bimodal (98% v 95%, p=0.02) and trimodal staging (60% v 46%, p

e14010 Background: Medicaid patients with lung cancer often have less favorable outcomes than non-Medicaid patients, which, given provision of care is typically comparable, may be due to socioeconomic disparities between these populations. In 2016, the Association of Community Cancer Centers (ACCC) embarked on a 3-year initiative to develop and test the Optimal Care Coordination Model (OCCM) to improve care coordination for Medicaid patients with lung cancer. A framework of 13 independent care delivery areas, spanning access to care to survivorship and supportive care, aids cancer programs in identifying barriers to access and use of their care, with a focus on Medicaid patients, and therefore enables optimal care coordination. Methods: Seven community-based healthcare systems in 6 U.S. states were selected as OCCM beta testing sites and then supported by the ACCC via site visits and biweekly calls. Sites self-assessed the quality of their care in selected OCCM areas to identify relevant quality improvement projects and improve understanding of needs specific to Medicaid patients. Results: Total patient enrollment across all sites was 926 (257 Medicaid; 669 non-Medicaid). Each site selected 1–2 priority OCCM areas, including patient access to care, prospective multidisciplinary case planning, or tobacco cessation, for projects. Enhanced collaboration, improved programming (e.g., patient navigation and formation of lung health leadership team), and organic programmatic changes due to the OCCM work were identified as successes. Site-specific challenges included inadequate staffing at project start and lack of centralized data collection and coordination. The importance of lung cancer–dedicated navigation, multidisciplinary conference use for treatment planning, and understanding needs specific to Medicaid patients were key transferable lessons. Examples of institutional support received by sites during the project included opportunities for staff training and leadership commitment from other hospital departments to assist with care delivery improvements. Use of the existing OCCM framework; increased staffing, particularly for lung cancer navigation; and expanded community outreach were identified in the sustainability plans. Conclusions: OCCM beta testing helped sites self-assess care delivery and identify areas for improvement. Ultimately, it was apparent that Medicaid patients need to be treated differently to obtain equity of outcomes with non-Medicaid patients.

2064 Background: A standardized, validated tool for capturing symptoms from cancer patients, PRO-CTCAE, has been used to reduce symptom burden, decrease acute care needs, and preserve quality of life. The association between specific PRO-CTCAE symptom scores and single item measures of OWb and PFn were characterized to understand symptom constellations. Methods: A novel Epic-based symptom management program (eSyM) was deployed for GI, GYN, and thoracic cancer patients starting chemotherapy (Memphis Baptist) or having surgery (WVU Medicine). Patients received automated prompts to complete surveys via the patient portal (MyChart) on a fixed schedule, approximately twice/week. Each survey included one OWb item, one PFn item, and at least 6 PRO-CTCAE items (pain, nausea, vomiting, fatigue, anxiety, insomnia). The OWb and PFn items, which were created de novo, included 5 ordinal response options with corresponding pictograms (emojis from very happy to very sad for OWb; a figure walking to one prone in bed for PFn). Composite scores were generated: 0 for no symptoms, 1-2 for mild/moderate symptoms, and 3 for severe symptoms. We describe OWb and PFn and analyze associations between these items and PRO-CTCAE symptom scores. Results: Between 9/10/19-1/22/20, we collected 908 eSyM responses from 166 chemotherapy patients at Baptist (Age, M = 65), and 480 eSyM responses from 97 postoperative patients at WVU (Age, M = 57). The OWb and PFn scores demonstrated moderate correlation with PRO-CTCAE symptom scores (Baptist r = 0.63; WVU r = 0.75), and moderate correlation with mean symptom scores among surgery patients at WVU (r = 0.74); but lower correlation among chemotherapy patients at Baptist (r = 0.53-0.55). Scores improved over time following surgery, but not after initiation of chemotherapy. Among the 730 eSyM responses with none/mild values for both OWb and PFn (52.9% of all responses), only 4.5% reported any severe symptom; among 651 responses with impairment of OWb and/or PFn, 45.2% reported at least one severe symptom. Conclusions: Integration of eSyM into the Epic EHR enabled tracking of OWb, PFn, and PRO-CTCAE items. When asked alongside PRO-CTCAE symptom items, two single item OWb and PFn measures provided distinct information and correlated with symptom burden. These results demonstrate the feasibility of integrating ePRO collection into routine post-operative and medical oncology care and that PRO-CTCAE items provide information that is distinct from that obtained from global metrics of well-being. Clinical trial information: NCT03850912.

2004 Background: Much-advocated, the value and impact of multidisciplinary care and planning (MDC) needs greater evidence. We compared non-small cell lung cancer (NSCLC) patient characteristics, treatment patterns and survival in a large community healthcare system spanning 3 US states with some of the highest lung cancer incidence and mortality rates. Methods: We identified MDC patients in the Tumor Registry NSCLC data from 2011-2017. Because the MDC program was located in metropolitan Memphis, we separated non-MDC patients by location of care resulting in 3 cohorts: MDC, non-MDC metropolitan care and non-MDC regional care. Using National Comprehensive Cancer Network guidelines, we categorized treatment by stage as ‘preferred’, ‘appropriate’ (allowable under certain circumstances). We compared demographic and clinical characteristics across cohorts using chi-squared tests and compared survival using Cox regression with Bonferroni adjustment. We repeated survival analysis with propensity matched cohorts. Results: Of 6259 patients, 14% received MDC, 56% metro care and 30% regional care; MDC had the highest rates of African Americans (34% v 28% v 22%), stage I-IIIB (63 v 40 v 50), urban residents (81 v 78 v 20), stage-preferred treatment rates (66 v 57 v 48), stage-appropriate treatment rates (78 v 70 v 63;), and lowest non-treatment rates (6 v 21 v 28). All p

2028 Background: Tobacco cessation is essential to high quality oncology care. Many patients smoke when diagnosed and continue to smoke during treatment, which adversely affects treatment response and survival. Although most patients are motivated to quit, few receive effective cessation therapy. The multidisciplinary clinic (MDC), where patients, their caregivers, and key specialists coordinate care, is an ideal setting to integrate a cessation program. To assess the need for cessation services within a MDC setting, we surveyed incoming patients about their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program. Methods: The study was conducted in the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN. We evaluated sociodemographic/clinical characteristics, smoking status, and tobacco dependence of consecutive new patients diagnosed with lung cancer from 2014-2019, who completed a social history questionnaire. Current smokers reported their interest in quitting and their willingness to participate in a cessation program. Chi square tests and logistic regression models were used to compare characteristics of those who would participate vs. those who would not/were unsure. Kaplan-Meier curves and multivariable Cox regression were used to evaluate the association between willingness to participate in a cessation program and overall survival, adjusted for age, sex, race, and total pack-years of smoking. Results: Of 641 patients, the average age was 69 years (range: 32-95), 47% were men, 64% white/34% black, and 17% college graduates; 90% had ever smoked, 34% currently smoked, and 24% quit smoking within the past year. Among current smokers, 60% were very interested in quitting and 37% would participate in a clinic-based cessation program. Willingness to participate was associated with greater interest in quitting (p = 0.0010) and greater overall survival (log rank p = 0.01;HR: 0.48, 95% CI: 0.24-0.95) but was not associated with any sociodemographic, clinical, or smoking-related characteristics. Conclusions: Over half (58%) of patients in a community-based MDC program were current smokers/recent quitters. Willingness to participate in a cessation program was associated with improved survival, suggesting patients with favorable prognoses are especially interested in receiving cessation support. There is considerable need for cessation services and relapse-prevention support within a coordinated, MDC lung cancer care setting.

Surgical resection is the main curative modality for non-small cell lung cancer (NSCLC), but variation in the quality of care contributes to suboptimal survival rates. Improving surgical outcomes by eliminating quality deficits is a key strategy for improving population-level lung cancer survival. We evaluated the long-term survival effect of providing direct feedback on institutional performance in a population-based cohort.The Mid-South Quality of Surgical Resection cohort includes all NSCLC resections at 11 hospitals in four contiguous Dartmouth Hospital Referral Regions in Arkansas, Mississippi, and Tennessee. We evaluated resections from 2004 to 2013, before and after onset of a benchmarked performance feedback campaign to surgery and pathology teams in 2009.We evaluated 2,206 patients: 56% preintervention (pre-era) and 44% postintervention (post-era). Preoperative positron emission tomography/computed tomography (46% vs 82%, p0.0001), brain scans (6% vs 21%, p0.0001), and bronchoscopy (8% vs 27%, p0.0001) were more frequently used in the post-era. Patients had 5-year survival of 47% (44% to 50%) in the pre-era compared with 53% (50% to 56%) in the post-era (p = 0.0028). The post-era had an adjusted hazard ratio of 0.85 (95% confidence interval [CI], 0.75 to 0.97; p = 0.0158) compared with the pre-era. This differed by extent of resection (p = 0.0113): compared with the pre-era, the post-era adjusted hazard ratio was 0.49 (95% CI, 0.33 to 0.72) in pneumonectomy, 0.91 (95% CI, 0.79 to 1.05) in lobectomy/bilobectomy, and 0.85 (95% CI, 0.63 to 1.15) in segmentectomy/wedge resections.Overall survival after surgical resection improved significantly in a high lung cancer mortality region of the United States. Reasons may include better selection of patients for pneumonectomy and more thorough staging.

Invasive mediastinal nodal staging is recommended before curative-intent resection in patients with non-small cell lung cancer deemed at risk for mediastinal lymph node involvement. We evaluated the use and survival effect of preoperative invasive mediastinal nodal staging in a population-based non-small cell lung cancer cohort.We analyzed all curative-intent resections for non-small cell lung cancer from 2009 to 2018 in 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions, comparing patients who did not have invasive mediastinal nodal staging with those who did.Preoperative invasive nodal staging was used in 22% of 2916 patients, including mediastinoscopy only in 13%, minimally invasive procedures only in 6%, and both approaches in 3%. Sixty-three percent of patients at risk for nodal disease (tumor size ≥3.0 cm/T2-T4; N1-N3 by computed tomography or positron-emission tomography-computerized tomography criterion) did not undergo invasive staging; among those who did not have invasive testing, 47% had at least 1 of the 3 clinical indications. Mediastinoscopy yielded a median of 3 lymph nodes and 2 nodal stations; 17% of mediastinoscopies and 31% of endobronchial ultrasound procedures yielded no lymph node material. Patients not invasively staged were more likely to have no nodes (6% vs 2%; P .0001) and no mediastinal nodes (20% vs 11%; P .0001) examined at surgery. Invasive staging was associated with significantly better survival (P = .0157).More than a decade after the 2001 American College of Surgeons Patient Care Evaluation report, preoperative invasive nodal staging remains underused and of variable quality, but was associated with survival benefit in high-risk patients.

BACKGROUND: Accurate pathologic nodal staging improves early-stage non-small-cell lung cancer survival. In an ongoing implementation study, we measured the impact of a surgical lymph node specimen collection kit and a more thorough pathologic gross dissection method, on attainment of guideline-recommended pathologic nodal staging quality. METHODS: We prospectively collected data on curative-intent non-small cell lung cancer resections from 2009–2016 from 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions. We categorized patients into 4 groups based on exposure to the two interventions in our staggered implementation study design. We used Chi-squared tests to examine the differences in demographic and disease characteristics and surgical quality criteria across implementation groups. RESULTS: Of 2,469 patients, 1,615 (65%) received neither intervention; 167 (7%) received only the pathology intervention; 264 (11%) received only the surgery intervention; 423 (17%) had both. Rates of non-examination of lymph nodes reduced sequentially in the order of no intervention, novel dissection, kit, and combined interventions, including non-examination of: any lymph nodes, hilar/intrapulmonary and mediastinal nodes (p

Importance Pathologic nodal stage is the most significant prognostic factor in resectable non-small cell lung cancer (NSCLC). The International Association for the Study of Lung Cancer NSCLC staging project revealed intercontinental differences in N category-stratified survival. These differences may indicate differences not only in cancer biology but also in the thoroughness of the nodal examination. Objective To determine whether survival was affected by sequentially more stringent definitions of pN staging quality in a cohort of patients with NSCLC after resection with curative intent. Design This observational study used the Mid-South Quality of Surgical Resection cohort, a population-based database of lung cancer resections with curative intent. A total of 2047 consecutive patients who underwent surgical resection at 11 hospitals with at least 5 annual lung cancer resections in 4 contiguous US Dartmouth hospital referral regions in northern Mississippi, eastern Arkansas, and western Tennessee (>90% of the eligible population) were included. Resections were performed from January 1, 2009, through January 25, 2016. Survival was evaluated with the Kaplan-Meier method and Cox proportional hazards models. Exposures Eight sequentially more stringent pN staging quality strata included the following: all patients (group 1); those with complete resections only (group 2); those with examination of at least 1 mediastinal lymph node (group 3); those with examination of at least 10 lymph nodes (group 4); those with examination of at least 3 hilar or intrapulmonary and at least 3 mediastinal lymph nodes (group 5); those with examination of at least 10 lymph nodes, including at least 1 mediastinal lymph node (group 6); those with examination of at least 1 hilar or intrapulmonary and at least 3 mediastinal nodal stations (group 7); and those with examination of at least 1 hilar or intrapulmonary lymph node, at least 10 total lymph nodes, and at least 3 mediastinal nodal stations (group 8). Main Outcomes and Measures N category-stratified overall survival. Results Of the total 2047 patients (1046 men [51.1%] and 1001 women [48.9%]; mean [SD] age, 67.0 [9.6] years) included in the analysis, the eligible analysis population ranged from 541 to 2047, depending on stringency. Sequential improvement in the N category-stratified 5-year survival of pN0 and pN1 tumors was found from the least stringent group (0.63 [95% CI, 0.59-0.66] for pN0 vs 0.46 [95% CI, 0.38-0.54] for pN1) to the most stringent group (0.71 [95% CI, 0.60-0.79] for pN0 vs 0.60 [95% CI, 0.43-0.73] for pN1). The pN1 cohorts with 3 or more mediastinal nodal stations examined had the most striking survival improvements. More stringently defined mediastinal nodal examination was associated with better separation in survival curves between patients with pN1 and pN2 tumors. Conclusions and Relevance The prognostic value of pN stratification depends on the thoroughness of examination. Differences in thoroughness of nodal staging may explain a large proportion of intercontinental survival differences. More thorough nodal examination practice must be disseminated to improve the prognostic value of the TNM staging system. Future updates of the TNM staging system should incorporate more quality restraints.

8546 Background: Early detection reduces lung cancer (LC) mortality. We prospectively evaluated LC patients diagnosed through Lung Cancer Screening (LCS) or an Incidental Lung Nodule Program (ILNP) (‘early detection’ programs) compared to routinely diagnosed LC patients in a multidisciplinary program (MDP). Methods: We compare demographics, tumor characteristics, and survival between the three groups diagnosed within the same healthcare system from 2015-2018. The ILNP prospectively tracks patients with suspicious lung lesions on routinely-performed studies flagged by radiologists using a standard macro text. LCS used Medicare eligibility criteria. Statistical methods include the chi-square test, Kruskal-Wallis test, and proportional hazards models with hazard ratios (HR) and 95% confidence intervals. Results: ILNP detected 201 lung cancers from 4713 scans (4.3%), LCS yielded 35 lung cancers from 1540 low-dose CT scans (2.3%), while MDC had 926 LC cases not detected by LCS or ILNP. Mean age at diagnosis for ILNP/LCS/MDC was 70/69/67 years (p = 0.0083); African Americans were under-represented in LCS (25%/11%/32%, p = 0.0104). LCS had the highest proportion with commercial insurance (46%/54%/43%, p = 0.3442). Early detection groups were more likely to have adenocarcinoma histology (ILNP/LCS/MDC: 61%/57%/49%, p = 0.0113). Smoking exposure was highest in LCS cohort (mean pack years: 48/64/52, p = 0.0500); 11% of ILNP, 8% MDC patients were never-smokers. Only 36% ILNP and 39% MDC patients were eligible for LCS by NLST criteria and 30%/40% by NELSON criteria. Reasons for ineligibility included smoking status in 73-90% and age in 7-27% of patients. Stage I/II distribution was (66%/58%/21%, p < 0.0001), stage IV 15%/20%/36%; surgical resection rates were (56%/55%/31%, p < 0.0001). Overall survival was longer in early detection groups (LCS HR: 0.31 [0.11,0.82]; ILNP HR: 0.51[0.33,0.81]) compared to MDC (p = 0.0011). Conclusions: The majority of LC patients were ineligible for LCS, but the ILNP identified LC in a high proportion of such patients, with similar stage re-distribution, curative-intent treatment, and survival rates. Structured ILNP complement LCS for early LC detection, such programs need to be built out.

6549 Background: LC is common and lethal; care-delivery is complex, varies in quality and outcomes, stimulating calls for multidisciplinary treatment planning (MTP) involving key specialists. This much-advocated model lacks rigorous evaluation. We conducted a prospective cohort study of MTP v Serial Care (SC) in a community healthcare system. Methods: Newly-diagnosed LC patients with performance status (PS) 0-2, and their caregivers, were enrolled from a LC multispecialty group clinic (MGC) or single-specialty general oncology clinics. A subset of general oncology clinic patients were discussed in a Multidisciplinary Thoracic Oncology Conference (MTOC), others were not (Serial Care [SC]). In this analysis, we compare MGC and MTOC patients (MTP recipients) to SC patients. Primary endpoint was overall survival (OS); secondary endpoints were measures of quality: staging practices, guideline-concordant treatment, timeliness of care, patient and caregiver satisfaction. We adjusted proportional hazards and logistic models for age, sex, histology, stage, PS, insurance, and race. Results: 254 patients received MTP v 272 SC. After a median 30 months’ follow up, there was no difference in OS (adjusted hazard ratio 1.10 [CI 0.87-1.40], p = .43). Stage-confirmatory biopsy was done in 61% MTP v 45% SC patients (adjusted odds ratio [aOR] 2.59, CI 1.74-3.86, p < .0001); 81% MTP v 68% SC patients received guideline-concordant treatment (aOR 2.04, CI 1.31-3.19, p < .002). Although the time from lesion detection to diagnostic biopsy (25 v 15 days, p = .004) or staging biopsy (29 v 20 days, p = .007) was higher with MTP, there was no difference in time to definitive treatment (60 v 57 days, p = .06). MTP patients and their caregivers reported greater satisfaction with the combined quality of care received from all team members (p < .0001) at baseline, 3 and 6 months. Conclusions: MTP for LC significantly improved the quality of care including the thoroughness of staging, use of guideline-concordant care, and patient satisfaction. Contrary to reports from retrospective analyses, timeliness of care was worse with MTP. Patient and caregiver satisfaction was superior with MTP. Despite improved quality, MTP was not associated with improved LC survival. Clinical trial information: NCT02123797.

e20052 Background: We quantified variation in stage specific, guideline concordant treatment and examined the interaction with rurality and overall survival (OS). Methods: We used tumor registry data for non-small cell lung cancer (NSCLC) patients at 5 institutions in the Mississippi Delta from 2011-2017, including patient demographics, clinical stage, treatment, and OS. We defined rurality by Rural-Urban Commuting Area codes, hospital and patient zip codes; based stage-stratified treatment on National Comprehensive Cancer Network guidelines; used Chi-squared and ANOVA F-tests to assess differences across institutions and logistic regression to assess associations between appropriate care, patient- and institution-level rurality. We used Log-rank tests to examine differences in OS and Cox proportional hazard regression to calculate hazard ratios (HR). Results: 6,259 patients were identified across 2 rural (n = 1255, 20%) and 3 metropolitan (metro) institutions (n = 5004, 80%). There were significant demographic and clinical differences between institutions: proportion of African-Americans (range: 6-37%, p < 0.001), uninsured (3-18%, p < 0.001), patient rurality (17-99%, p < 0.001), ‘no treatment’ rates (17-31%, p < 0.001). Metro patients or those treated at metro institutions were more likely to receive guideline-concordant treatment (odds ratio: 1.34, 95% CI [1.20 - 1.49]; 1.45 [1.28 - 1.65], respectively) than their rural counterparts and had improved OS (HR: 0.89; 95% CI [0.84 - 0.95]; 0.68 [0.63 - 0.72], respectively). They were also less likely to receive ‘no treatment’ (0.62 [0.55 - 0.71], p < 0.001; 0.51 [0.49 - 0.66], p < 0.001, respectively). Among patients with proper care, there were no patient-level rurality based OS differences (p = 0.2203) but those treated at metro institutions had better OS (p < 0.001). When stage-stratified, only advanced-stage patients treated at metro institutions had better survival (p < 0.001), no other differences in OS were detected for early or late-stage patients. Conclusions: Institution-level rurality had greater influence than patient-level rurality on receipt of guideline concordant care and OS. Appropriate care eliminated patient-level rurality OS disparities.

Surgery is the most important curative treatment modality for patients with early-stage non-small cell lung cancer (NSCLC). We examined the pattern of surgical resection for NSCLC in a high incidence and mortality region of the United States over a 10-year period (2004-2013) in the context of a regional surgical quality improvement initiative. We abstracted patient-level data on all resections at 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions in North Mississippi, East Arkansas, and West Tennessee. Surgical quality measures focused on intraoperative practice, with emphasis on pathologic nodal staging. We used descriptive statistics and trend analyses to assess changes in practice over time. To measure the effect of an ongoing regional quality improvement intervention with a lymph node specimen collection kit, we used period effect analysis to compare trends between the preintervention and postintervention periods. Of 2566 patients, 18% had no preoperative biopsy, only 15% had a preoperative invasive staging test, and 11% underwent mediastinoscopy. The rate of resections with no mediastinal lymph nodes examined decreased from 48%-32% (P0.0001), whereas the rate of resections examining 3 or more mediastinal stations increased from 5%-49% (P0.0001). There was a significant period effect in the increase in the number of N1, mediastinal, and total lymph nodes examined (all P0.0001). A quality improvement intervention including a lymph node specimen collection kit shows early signs of having a significant positive effect on pathologic nodal examination in this population-based cohort. However, gaps in surgical quality remain.

Background Pathologic nodal stage is a key prognostic factor for patients with surgically resected lung cancer. We previously described the extent of missed intrapulmonary nodal metastasis in a cohort of patients treated at institutions in metropolitan Memphis, TN. With long-term follow-up, we now quantify the survival impact of missed nodal metastasis. Methods We conducted a prospective cohort study to evaluate inadvertently discarded lymph nodes in re-dissected remnant lung resection specimens from lung cancer patients. Retrieved material was histologically examined and classified as lymph nodes with and without metastasis. Survival information was obtained from hospital cancer registries. We plotted survival distributions with the use of the Kaplan-Meier method and evaluated them with proportional hazards models that controlled for important demographic and clinical factors. Results The study included 110 patients who were 54% women and 69% white. Discarded lymph nodes with metastasis were found in 25 patients (23%). Patients with missed lymph node metastasis had an increased risk of death with an unadjusted hazard ratio of 2.0 ( p = 0.06) and an adjusted hazard ratio of 1.4 ( p = 0.45) compared with patients without missed lymph node metastasis. Patients with more than 2 missed lymph nodes with metastasis had 4.8 times the hazard of death ( p = 0.0005) compared with patients without missed lymph node metastasis (adjusted hazard ratio 6.5, p = 0.0001). Conclusions Metastasis to inadvertently discarded intrapulmonary lymph nodes from lung cancer resection specimens was associated with reduced survival. A more rigorous gross dissection protocol for lung cancer resection specimens may provide prognostically useful information.

e18791Background: Poor pN staging is the main driver of poor long-term survival after NSCLC resection. We used the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to study imp...

e20550Background: Surgical resection is the main curative modality for non-small cell lung cancer (NSCLC), but surgical outcomes are often poor. We evaluated overall survival (OS) in patients befor...

8502Background: Surgical resection is the best curative modality for NSCLC, but overall survival (OS) rates vary with quality of pathologic (p) LN staging. We studied the impact of a pre-labeled LN...

6535Background: Coordinated MD lung cancer care, with all key specialists concurrently providing input to develop a consensus care plan with patients and their caregivers, is much-advocated over th...

Importance Lung cancer is the leading cause of cancer death in the United States in all ethnic and racial groups. The overall death rate from lung cancer is higher in black patients than in white patients. Objective To compare the prevalence and types of somatic alterations between lung cancers from black patients and white patients. Differences in mutational frequencies could illuminate differences in prognosis and lead to the reduction of outcome disparities by more precisely targeting patients’ treatment. Design, Setting, and Participants Tumor specimens were collected from Baptist Cancer Center (Memphis, Tennessee) over the course of 9 years (January 2004-December 2012). Genomic analysis by massively parallel sequencing of 504 cancer genes was performed at Dana-Farber Cancer Institute (Boston, Massachusetts). Overall, 509 lung cancer tumors specimens (319 adenocarcinomas; 142 squamous cell carcinomas) were profiled from 245 black patients and 264 white patients. Main Outcomes and Measures The frequencies of genomic alterations were compared between tumors from black and white populations. Results Overall, 509 lung cancers were collected and analyzed (273 women [129 black patients; 144 white patients] and 236 men [116 black patients; 120 white patients]). Using 313 adenocarcinomas and 138 squamous cell carcinomas with genetically supported ancestry, overall mutational frequencies and copy number changes were not significantly different between black and white populations in either tumor type after correcting for multiple hypothesis testing. Furthermore, specific activating alterations in members of the receptor tyrosine kinase/Ras/Raf pathway including EGFR and KRAS were not significantly different between populations in lung adenocarcinoma. Conclusions and Relevance These results demonstrate that lung cancers from black patients are similar to cancers from white patients with respect to clinically actionable genomic alterations and suggest that clinical trials of targeted therapies could significantly benefit patients in both groups.

e18254 Background: Coordinated MDC, in which all key specialists concurrently provide early input, develop and execute a consensus plan of care in collaboration with pts and their caregivers, may improve satisfaction with care. We rigorously evaluated this premise. Methods: Prospective clinical cohort study comparing newly-diagnosed LCa pts receiving MDC (n=156) or SC (n=307) in the same healthcare system. Pts were enrolled before treatment onset. At baseline (study entry) and 3 months later, pts and caregivers completed treatment-related measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, including perceptions of quality of care, satisfaction with care, and extent of involvement in decision making. Satisfaction indices at 3 months will be compared in multiple linear regression models, adjusting for baseline scores and demographic and treatment-related characteristics. Results: Pt characteristics were similar, except for age and stage (Table). At baseline, MDC pts rated their care more positively than SC pts, but satisfaction with provider communication was similar. Three month data are currently being analyzed. Conclusions: MDC provided greater pt satisfaction in the diagnostic phase of LCa care. Further prospective analyses will test the hypothesis that MDC pts experience greater satisfaction with quality of care and provider communication compared to SC pts. Clinical trial information: NCT02123797. [Table: see text]

8522 Background: MDC may improve the quality of care for complex diseases. We compared the use of stage-appropriate treatment for lung cancer patients in a co-located MDC to serially-referred (SC) patients within the same healthcare system. Methods: Prospective cohort study of newly-diagnosed lung cancer patients enrolled before onset of treatment from MDC or the standard clinics (SC). Eligible pts had ECOG PS 0-2. Stage-appropriate treatment selection was determined using National Comprehensive Cancer Network (NCCN) guidelines based on clinical stage just before treatment onset. Differences in stage-based treatment rates were calculated using Chi-squared tests. Results: 162 had MDC and 317 SC. Compared to serial care patients, MDC patients were more likely black (37% v 30%) female (51% vs 48%), older (median 69 vs median 66) and less likely commercially insured (36% v 43%). Surgical resection was more frequently used for early stage patients in MDC: 72% v 58% for stage IA/IB (p = 0.2259); 58% v 31% for stage IIA/B and IIIA (T3N1M0) (p = 0.0375). MDC patients also had trends towards higher rates of recommended concurrent chemoradiation therapy for stage IIIA (T4N0-1M0) (75% vs 53%) (p = 0.5835), IIIB (T1-3N3, T4N2) (78% v 68%), but equal rates of concurrent chemoradiation therapy for stage IIIA (T1-3N2M0) (68% vs 68%). Stage IV patientss were more likely to receive chemotherapy or targeted therapy in MDC v SC (87% vs 80%) (p = 0.3795). Conclusions: Lung cancer patients in the MDC model are more likely to receive recommended stage-appropriate treatment than those in the usual serial care model, despite relatively adverse demographic characteristics. Clinical trial information: NCT02123797.

e20079 Background: Multi-modal staging is associated with improved survival for pts with LCa. We evaluated the thoroughness of clinical staging within and outside a co-located MDC. Methods: Prospective cohort study comparing newly-diagnosed LCa patients in MDC to serially referred (SC) pts within the same healthcare system. Pts were enrolled before treatment began. Stage-confirmation was defined as invasive biopsy of a stage-defining lesion. Bimodal staging involved use of either PET scan or invasive biopsy with CT scan, trimodal staging involved all 3. We used the chi-square test and multivariable logistic regression. Results: From 2014-16, 162 pts were enrolled into MDC, 318 into SC. MDC pts were older (median age 69 v 66), more likely to be black (37% v 29%), and less likely to be commercially insured (36% v 43%) than SC pts. MDC pts had node positive disease identified by PET/CT in 70% of cases, but only 42% in SC (p=0.003). MDC pts were more likely to be clinical M0 (70% vs. 55%). M1b pts were biopsied in 45% of MDC v 36% of SC cases. MDC pts were more likely to have bimodal (90% v 73%) and trimodal staging (51% v 29%) (both p

Background We examined the presurgical evaluation of suspected lung cancer patients in a community-based health care system to establish current benchmarks of care that will lay the groundwork for an evidence-based quality improvement project. Methods We retrospectively reviewed clinical records of all recipients of lung resection at two institutions, and classified all lung cancer relevant procedures into five "nodal points": lesion detection, diagnostic biopsy, radiologic staging, invasive staging, and treatment. We analyzed the frequency of passage through each nodal point, the time intervals between nodal points, and the use of staging modalities. Results Of 614 eligible patients, 92% had lung cancer, 5% had a non-lung primary tumor, 3% had a benign lesion. Six percent received preoperative therapy; 39% of resections were minimally invasive. Ninety-eight percent of patients had a preoperative computed tomography (CT) scan, 27% had no preoperative diagnostic procedure, 22% had no preoperative positron emission tomography (PET)/CT scans, and 88% had no invasive preoperative staging test. Only 10% had trimodality staging with CT, PET/CT, and invasive staging. Twenty-one percent of patients who had an invasive staging test had mediastinal nodal metastasis at resection. The median duration (interquartile range) from initial lesion identification to resection was 84 days (43 to 189) days; from lesion identification to diagnostic biopsy, 28 days (7 to 96); and from diagnostic biopsy to surgery, 40 days (26 to 69). Conclusions There is opportunity for improvement in the thoroughness, accuracy, and timeliness of preoperative evaluation of suspected lung cancer patients in this community cohort. Better coordination of care may significantly improve these benchmarks.

Although thorough pathologic nodal staging provides the greatest prognostic information in patients with potentially curable non-small cell lung cancer, N1 nodal metastasis is frequently missed. We tested the impact of corrective intervention with a novel pathology gross dissection protocol on intrapulmonary lymph node retrieval. This study is a retrospective review of consecutive lobectomy, or greater, lung resection specimens over a period of 15 months before and 15 months after training pathologist's assistants on the novel dissection protocol. One hundred forty one specimens were examined before and 121 specimens after introduction of the novel dissection protocol. The median number of intrapulmonary lymph nodes retrieved increased from 2 to 5 (P