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6581 Background: Hospital readmission are associated with unfavorable patient outcomes and increased costs to the healthcare system. Devising interventions to reduce risks of readmission requires understanding patients at highest risk. Cancer patients represent a unique population with distinct risk factors. The purpose of this study was to define the impact of a cancer diagnosis on the risks of unplanned 30-day readmissions. Methods: We identified non-procedural hospital admissions between January through November 2017 from the National Readmission Database (NRD). We included patients with and without a cancer diagnosis who were admitted for non-procedural causes. We evaluated the impact of cancer on the risk of 30-day unplanned readmissions using multivariable mixed-effects logistic regression models. Results: Out of 18,996,625 weighted admissions, 1,685,099 (8.9%) had record of a cancer diagnosis. A cancer diagnosis was associated with an increased risk of readmission compared to non-cancer patients (23.5% vs. 13.6%, p < 0.001). However, among readmissions, cancer patients were less likely to have a preventable readmission (6.5% vs. 12.1%, p < 0.001). When considering the 10 most common causes of initial hospitalization, cancer was associated with an increased risk of readmission for each of these 10 causes (OR range 1.1-2.7, all p < 0.05) compared to non-cancer patients admitted for the same causes. Compared to patients aged 45-64, a younger age was associated with increased risk for cancer patients (OR 1.29, 95%CI [1.24-1.34]) but decreased risk for non-cancer patients (OR 0.65, 95%CI [0.64-0.66]). Among cancer patients, cancer site was the most robust individual predictor for readmission with liver (OR 1.47, 95%CI [1.39-1.55]), pancreas (OR 1.36, 95%CI [1.29-1.44]), and non-Hodgkin’s lymphoma (OR 1.35, 95%CI [1.29-1.42]) having the highest risk compared to the reference group of prostate cancer patients. Conclusions: Cancer patients have a higher risk of 30-day readmission, with increased risks among younger cancer patients, and with individual risks varying by cancer type. Future risk stratification approaches should consider cancer patients as an independent group with unique risks of readmission.

e18618 Background: Cancer patients frequently utilize the Emergency Department (ED) for a variety of diagnoses, both related and unrelated to their cancer. Patients with cancer have unique risks related to their cancer and treatment which could influence ED-related outcomes. A better understanding of these risks could help improve risk-stratification for these patients and help inform future interventions. This study sought to define the increased risks cancer patients face for inpatient admission and hospital mortality among cancer patients presenting to the ED. Methods: From the National Emergency Department Sample (NEDS) we identified patients with and without a diagnosis of cancer presenting to the ED between 2016 and 2018. We used International Classification of Diseases, version 10 (ICD10-CM) codes to identify patients with cancer, and to identify patient’s presenting diagnosis. Multivariable mixed-effects logistic regression models assessed the influence of cancer diagnoses on two endpoints: hospital admission from the ED, and inpatient hospital mortality. Results: There were 340 million weighted ED visits, of which 8.3 million (2.3%) occurred in patients with a cancer diagnosis. Compared to non-cancer patients, patients with cancer had an increased risk of inpatient admission (64.7% vs. 14.8%; p < 0.0001) and hospital mortality (4.6% vs. 0.5%; p < 0.0001). Factors associated with both an increased risk of hospitalization and death included older age, male gender, lower income level, discharge quarter, and receipt of care in a teaching hospital. We identified the top 15 most common presenting diagnoses among cancer patients, and among each of these diagnoses, cancer patients had increased risks of hospitalization (odds ratio [OR] range 2.0-13.2; all p < 0.05) and death (OR range 2.1-14.4; all p < 0.05) compared to non-cancer patients with the same diagnosis. Within the cancer patient cohort, cancer site was the most robust individual predictor associated with risk of hospitalization or death, with highest risk among patients with metastatic cancer, liver and lung cancers compared to the reference group of prostate cancer patients. Conclusions: Cancer patients presenting to the ED have high risks for hospital admission and death when compared to patients without cancer. Cancer patients represent a distinct population and may benefit from cancer-specific risk stratification or focused interventions tailored to improve outcomes in the ED setting.

e18678 Background: Older adults over the age of 65 represent the majority of patients diagnosed with (60%), among them, 15-30% have a pre-existing Alzheimer’s disease or related dementia (ADRD) that puts them at higher risk for over and under treatment. Studying the role of pre-existing ADRD in cancer patients is vital to understanding treatment planning behavior, patterns of health care utilization, and adverse treatment outcomes. Massive administrative datasets, or “big data” represent the information rich environment that is useful for this endeavor. Methods: Our study utilized a clinically validated algorithm to assess the prevalence of pre-existing ADRD and cancer across six cancer types. We utilized the SEER-Medicare dataset for analyzing the study years 2004-2015 (N = 337 932). We extracted ICD-9 codes to identify ADRD using the Centers for Medicaid Services Chronic Conditions Warehouse (CCW) algorithm. In sensitivity analysis we compared the prevalence of ADRD+Cancer using the NCI (2014) and CCW algorithms. Results: We found a significant difference between the two algorithms (p < .0001) and a higher overall prevalence of comorbid ADRD+Cancer using the CCW (6.6%). Additionally, we found ADRD+Cancer prevalence was significantly higher among racial and ethnic subgroups compared to White and unstaged tumors compared with any numbered American Joint Committee on Cancer (AJCC) stages (p < .0001). Conclusions: Using a clinically validated algorithm we were able to identify more cases of ADRD+Cancer in big data. This figure remains underestimated for ADRD+cancer compared to clinically-validated studies. Further research into the validation approach and codes that are used for ADRD classification can improve how we identify ADRD in massive administrative data. This is critical given the growing population of diverse older adults in the U.S.

1512 Background: Elderly hospitalized cancer patients face high risks of inpatient hospital mortality. Identifying patients at high risk of hospital mortality could help with risk stratification, and potentially help inform future interventions aimed at improving outcomes. We evaluated the predictive capacity of a high-dimensional machine-learning prediction tool to predict inpatient mortality, and compared the performance of this new tool to existing prediction indices. Methods: We identified cancer patients 75 and over who presented to an emergency department (ED) and were subsequently hospitalized from the National Emergency Department Sample (NEDS) between 2016 and 2018. We used an extreme gradient boosting approach to predict the risk of death during hospitalization. Model covariates included patient demographics, hospital characteristics, and International Classification of Diseases, version 10 (ICD-10) diagnosis codes recorded during the ED visit. The data were split 75%/25% into training/testing datasets. We constructed the model with training data and evaluated performance within the test data using area under the curve (AUC), with an AUC of 1.0 indicating perfect prediction. We compared the performance of this risk prediction model to standard prediction indices including the Hospital Frailty Risk Score, modified 5-item frailty index, and Charlson comorbidity index. Results: We identified 1,892,690 weighted-hospitalizations among elderly cancer patients, of which 133,379 (7.0%) who died in the inpatient setting. Our final predictive model included 238 features, which contained 5 demographic variables, 3 hospital characteristics, and 230 ICD-10 diagnosis codes. The predictive model achieved an AUC of 0.92. Our comparator models including the Hospital Frailty Risk Score, modified 5-item frailty index, and Charlson comorbidity index achieved AUCs of 0.67, 0.56, and 0.60, respectively. Conclusions: Using a high-dimensional machine-learning model enabled a high level of precision in predicting hospital mortality among elderly cancer patients, substantially out-performing existing prediction indices. High-dimensional prediction models show promise in helping to identify patients at risk of severe adverse outcomes, though additional validation is needed as well as research studying how to implement these tools into practice.

e22019 Background: Pediatric cancer patients represent a vulnerable cohort at risk of adverse outcomes after presenting to the emergency department (ED). Given the severity of cancer-related complications and uniqueness of this population, approaches to better risk stratify this cohort could potentially help define future interventions geared towards improving outcomes. We used a high-dimensional machine learning approach to help define the risk of hospitalization after an ED visit among pediatric patients with cancer. Methods: A cohort of cancer patients under 18 was identified from the Nationwide Emergency Department Sample (NEDS) between 2016-2018. We used a lasso regression model to predict inpatient admission after an ED visit. Model covariates included patient demographics, hospital characteristics, and International Classification of Diseases, version 10 (ICD-10) diagnosis codes. The data were split 75%/25% into training/testing data. The model was constructed with training data, and performance assessed on the test data using the area under the curve (AUC), with an AUC of 1.0 indicating perfect prediction. Results: We identified 129,631 pediatric cancer patients who visited the ED, of which 54.5% were subsequently admitted. The final predictive model included 150 variables, including 9 demographic, 6 hospital, and 135 unique ICD-10 codes. The model demonstrated excellent ability to predict hospitalization with an AUC of 0.96. The top 5 most important variables associated with inpatient admission were diagnoses of paralytic ileus/intestinal obstruction, neutropenia, sepsis, aplastic anemia/bone marrow failure, and bacterial infection. Conclusions: Pediatric cancer patients frequently present to the ED with complications of their cancer or their treatment, and over half of these patients are admitted. This study demonstrates the capacity of high-dimensional prediction models to help identify pediatric patients at risk of hospitalization. Additional research is needed to determine how to implement these predictive models in clinical practice.

10534 Background: With the growing indications for germline testing in prostate cancer (PCa), there is accumulating evidence that African American and Hispanic men with PCa are significantly under-tested compared to non-Hispanic white (NHW) men. Given this, little is known about the pathogenic germline variant landscape in Hispanic men with PCa. Methods: This was a retrospective cohort analysis of 17,256 men with PCa who underwent diagnostic germline testing through a commercial laboratory (Invitae) from 2015-2020. Self-identified Hispanic and NHW men were selected for comparative analysis. The primary endpoint was the rate of pathogenic/likely pathogenic (PLP) germline alterations in Hispanic men among 25 genes associated with PCa. Secondary endpoints included comparison of PLP rates in Hispanic vs NHW men, the rate of specific PLP alterations, and the rate of variants of uncertain significance (VUS). Fisher’s exact test was used to compare germline alteration rates for significance. Results: We identified 508 Hispanic and 12,542 NHW men with PCa who underwent testing during the study period. Median age at the time of testing was 69 vs 67 years in Hispanic vs NHW cohorts. A family history of PCa was reported in 21.1% (N=108) vs 27.3% (N=3428) in the Hispanic vs NHW cohorts, respectively (p=0.002). The PLP alteration rate was 7.1% in the Hispanic cohort and this rate was numerically lower but not significantly different when compared to the NHW cohort (9.7%) (p=0.058). A significantly higher rate of VUS was seen in the Hispanic cohort (Table). The four most frequently detected genes with PLP alterations in both cohorts were ATM, BRCA1, BRCA2, and CHEK2. Only the rate of CHEK2 alterations was significantly different between cohorts among all 25 genes analyzed (Table). Conclusions: In this analysis, the PLP alteration rate among Hispanic men was 7.1%, a much higher rate than has been previously reported, and the germline genomic landscape was similar to that of NHW men. The VUS rate was significantly higher among Hispanic men, a known consequence of under-testing among minority populations.These data support germline testing in Hispanic men with prostate cancer and emphasize the importance of improving testing rates.[Table: see text]

e24097 Background: Radiation therapy plays an important role in symptom palliation for patients with incurable cancer. Currently limited data exists regarding the role of SBRT vs conformal radiation for the palliation of symptoms due to malignancy. We report the symptom management and local control of palliative SBRT for incurable thoracic malignancies at a single institution. Methods: We retrospectively identified patients who underwent palliative SBRT between Jan 1st, 2009 and March 26th, 2019. Patients all had thoracic tumors that were not candidates for curative radiation due to age, stage, comorbidity, and/or prior treatment. We identified courses with total doses between 25-50 Gy (median 40) and total fractions between 3-10 (median 5). Symptoms such as cough, chest pain, hemoptysis, and shortness of breath were assessed at time of consult and first follow-up between 1-6 months post treatment. We also reviewed follow-up CT imaging to evaluate for local control using RECIST criteria. Descriptive statistics were used to evaluate patients’ clinicopathologic data and symptom palliation. Local control was analyzed via Kaplan-Meier method. Results: Of the 76 patients who completed palliative SBRT to 92 total lung lesions, 45 patients reported symptoms at consult and completed 50 courses of radiation to 55 lesions. Within this symptomatic cohort, average age was 71 (range, 42-93), 32 were female (58%), and most were stage IV (n = 42, 76%). Most lesions treated were non-small cell lung cancer (n = 34, 62%) while the most common primary site of metastatic lesions was colorectal (n = 6, 11%). Additional primary sites included breast, renal, sarcoma, and others (n = 15, 27%). Of the 53 lesions treated with follow-up within 6 months, 21 (40%) showed relief of at least 1 symptom and 31 (58%) showed stable symptoms. Only 1 patient (2%) showed symptom progression. All patients with hemoptysis at presentation achieved hemostasis following SBRT. Among 48 treated lesions with follow-up CT imaging, 1 (2%) showed complete response, 28 (58%) showed partial response (PR), 15 (31%) showed stable disease (SD), and 4 (8%) showed progressive disease. With further follow-up (median 23 months), 30 of the 53 lesions with initial PR or SD demonstrated local control until death. Conclusions: There is conflicting literature regarding the ideal palliative radiation dose for thoracic tumors. SBRT has the advantage of allowing a higher biologic dose without protracted treatment courses in the setting of palliation of symptoms. Our symptomatic cohort showed good symptom palliation and long-term local control of treated lesions. Prospective studies are required to further confirm the role of palliative SBRT for symptomatic thoracic tumors.

102 Background: Limited research exists on how risk reduction policies in response to the opioid epidemic have impacted pain management among cancer patients. This study investigated the impact of the Veteran’s Health Administration (VHA) Opioid Safety Initiative (OSI) on opioid prescribing patterns and opioid-related toxicity among patients undergoing definitive cancer treatment. Methods: This retrospective cohort study included 42,064 opioid-naïve patients receiving definitive local therapy for prostate, lung, breast, and colorectal cancer at the VHA from 2011-2016. Interrupted time series analysis with segmented regression was used to evaluate the impact of the OSI, which launched October 2013. The primary outcome was the incidence of new opioid prescriptions with diagnosis or treatment. Secondary outcomes included rates of high daily dose opioid (≥ 100 morphine milligram equivalent) and concomitant benzodiazepine prescriptions. Additional long-term outcomes included persistent opioid use, opioid abuse diagnoses, pain-related ED visits, and opioid-related admissions. Results: Prior to OSI implementation, the incidence of opioid prescriptions among new cancer patients increased from 26.7% (95% CI 25.0 – 28.4) in the first quarter (Q1) of 2011 to 50.6% (95% CI 48.3 – 53.0) in Q3 2013. There was a monthly increase in opioid prescription rate pre-OSI followed by a monthly decrease post-OSI (Table). High-dose opioid prescriptions were rare, and the monthly rate was stable before and after the OSI. Monthly incidence of concomitant benzodiazepine prescriptions was stable pre-OSI and decreased post-OSI. Persistent opioid use increased pre-OSI and decreased post-OSI. Pain-related ED visits had an incidence of 0.8% (95% CI 0.4 – 1.0) in Q1 2011, 0.3% (95% CI 0.1 – 0.6) in Q3 2013, and 1.8% (95% CI 0.9 – 2.7) in Q4 2016, with an increasing monthly rate after the OSI. At three years, the cumulative incidence of opioid abuse was 1.2% for both the pre- and post-OSI groups but opioid-related admissions were greater in the pre-OSI cohort than the post-OSI cohort (0.9% vs. 0.5%, p < 0.001). Conclusions: The OSI was associated with a decrease in new, persistent, and certain high-risk opioid prescribing as well as an increase in pain-related ED visits. Further research on patient-centered outcomes is required to optimize opioid prescribing policies for patients with cancer.[Table: see text]

Key Points Question Is prostate-specific antigen velocity associated with clinical progression in patients with low-risk prostate cancer treated with active surveillance, and are there differences between African American and non-Hispanic White patients? Findings In this population-based cohort study of 5296 patients with low-risk prostate cancer, prostate-specific antigen velocity was associated with clinical progression to more advanced disease. Compared with non-Hispanic White patients, African American patients were more likely to experience disease progression at lower prostate-specific antigen velocity thresholds. Meaning This study suggests that prostate-specific antigen velocity is a useful clinical tool for all patients treated with active surveillance, and African Americans may require closer attention to follow-up., Importance The association of prostate-specific antigen velocity (PSAV) with clinical progression in patients with localized prostate cancer managed with active surveillance remains unclear and, to our knowledge, has not been studied in African American patients. Objectives To test the hypothesis that PSAV is associated with clinical progression in patients with low-risk prostate cancer treated with active surveillance and to identify differences between African American and non-Hispanic White patients. Design, Setting, and Participants This was a retrospective population-based cohort study using patient records from the Veterans Heath Administration Informatics and Computing Infrastructure on 5296 patients with a diagnosis of localized prostate cancer from January 1, 2001, to December 31, 2015, who were managed with active surveillance. Follow-up extended through March 31, 2020. Low-risk prostate cancer was defined as International Society of Urologic Pathology grade group (GG) 1 clinical tumor stage 2A or lower, PSA level of 10 ng/dL or lower, active surveillance, and no definitive treatment within the first year after diagnosis with at least 1 additional staging biopsy after diagnostic biopsy. Exposures Prostate-specific antigen testing. Main Outcomes and Measures The primary outcome was GG progression detected after repeated biopsy or prostatectomy, defined as GG2 or higher or GG3 or higher. The secondary outcome was incident metastases. Cumulative incidence functions and multivariable Cox proportional hazards regression models were used to test associations between PSAV and outcomes. Results The final cohort (n = 5296) included 3919 non-Hispanic White men (74.0%; mean [SD] age, 65.7 [5.8] years) and 1377 African American men (26.0%; mean [SD] age, 62.8 [6.6] years). Compared with African American patients, non-Hispanic White patients were older (mean [SD] age, 65.7 [5.8] years vs 62.8 [6.6] years; P, This cohort study evaluates whether prostate-specific antigen velocity is associated with clinical progression in patients with low-risk prostate cancer treated with active surveillance and identifies differences between African American and non-Hispanic White patients.

Key Points Question Is nivolumab-ipilimumab combination therapy cost-effective as first-line treatment for patients with advanced non–small cell lung cancer compared with platinum-doublet chemotherapy? Findings In this economic evaluation of the cost-effectiveness of nivolumab-ipilimumab combination therapy, a Markov model was designed to simulate patients with advanced non–small cell lung cancer who were receiving either nivolumab-ipilimumab combination therapy or platinum-doublet chemotherapy. In this model, nivolumab-ipilimumab combination therapy was not found to be cost-effective at a willingness-to-pay threshold of $100 000 per quality-adjusted life-year, with an incremental cost-effectiveness ratio of $401 700 per quality-adjusted life-year compared with chemotherapy. Meaning The findings suggest that first-line treatment with nivolumab-ipilimumab combination therapy is not cost-effective at current prices despite clinical trial data indicating that this therapy increases overall survival among patients with advanced non–small cell lung cancer., Importance Treatment with nivolumab-ipilimumab combination therapy was found to improve overall survival compared with chemotherapy among patients with advanced non–small cell lung cancer (NSCLC) in the CheckMate 227 clinical trial. However, these drugs are substantially more expensive than chemotherapy and, given the high incidence of advanced NSCLC, the incorporation of dual immune checkpoint inhibitors into the standard of care could have substantial economic consequences. Objective To assess whether nivolumab-ipilimumab combination therapy is a cost-effective first-line treatment for patients with advanced NSCLC. Design, Setting, and Participants This economic evaluation designed a Markov model to compare the cost-effectiveness of nivolumab-ipilimumab combination therapy with platinum-doublet chemotherapy as first-line treatment for patients with advanced NSCLC. The Markov model was created to simulate patients with advanced NSCLC who were receiving either nivolumab-ipilimumab combination therapy or platinum-doublet chemotherapy. Transition probabilities, including disease progression, survival, and treatment toxic effects, were derived using data from the CheckMate 227 clinical trial. Costs and health utilities were obtained from published literature. Data analyses were conducted from November 2019 to September 2020. Exposures Nivolumab-ipilimumab combination therapy. Main Outcomes and Measures The primary study outcomes were quality-adjusted life-years (QALYs) and cost in 2020 US dollars. Cost-effectiveness was measured using an incremental cost-effectiveness ratio (ICER), with an ICER less than $100 000 per QALY considered cost-effective. Model uncertainty was assessed with 1-way and probabilistic sensitivity analyses. Results Treatment with nivolumab-ipilimumab combination therapy was associated with an increase in overall cost of $201 900 and improved effectiveness of 0.50 QALYs compared with chemotherapy, yielding an ICER of $401 700 per QALY. The study model was sensitive to the cost and duration of immunotherapy. Treatment with nivolumab-ipilimumab combination therapy became cost-effective when monthly treatment costs were reduced from $26 425 to $5058 (80.9% reduction) or when the maximum duration of immunotherapy was reduced from 24.0 months to 1.4 months. The model was not sensitive to assumptions about survival or programmed cell death 1 ligand 1 status. A probabilistic sensitivity analysis indicated that, at a willingness-to-pay threshold of $100 000 per QALY, nivolumab-ipilimumab combination therapy was less cost-effective than chemotherapy 99.9% of the time. Conclusions and Relevance In this study, first-line treatment with nivolumab-ipilimumab combination therapy was not found to be cost-effective at current prices despite clinical trial data indicating that this regimen increases overall survival among patients with advanced NSCLC., This economic evaluation uses data from the CheckMate 227 clinical trial and a Markov model to examine the cost-effectiveness of nivolumab-ipilimumab combination therapy vs platinum-doublet chemotherapy as first-line treatment for patients with advanced non–small cell lung cancer.

Acoustic neuroma (AN) management involves surgery, radiation, or observation. Previous studies have demonstrated that patient race and insurance status impact in-hospital morbidity/mortality following surgery; however the nationwide impact of these demographics on the receipt of each treatment modality has not been examined. The National Cancer Data Base (NCDB) from 2004 to 2013 identified AN patients. Multivariate analysis adjusted for several variables within each treatment modality, including patient age, race, sex, income, primary payer for care, tumor size, and medical comorbidities. Patients who were African-American (OR=0.7; 95%CI=0.5-0.9; p=0.01), elderly (minimum age 65) (OR=0.4; 95%CI=0.4-0.6; p

Purpose The delivery of safe and effective radiation therapy relies on accurate target delineation, particularly in the era of highly conformal treatment techniques. Current contouring resources are fragmented and can be cumbersome to use. The present study reports on the efficacy and usability of a web-based contouring atlas compared with those of existing contouring resources in a randomized trial. Methods and Materials We enrolled radiation oncology residents into a 2-phase contouring study. All residents contoured a T1N1 nasopharyngeal cancer case using the currently available resources. The participants were then randomized to recontour the case with access to existing resources or an interactive web-based contouring atlas (eContour.org). Contour analysis was performed using conformation number and simultaneous truth and performance level estimation. At completion of the second contouring session, the residents completed a multiple choice question knowledge test and a 10-item System Usability Scale. Results Twenty-four residents from 5 institutions completed the study. Compared with the residents using currently available resources, the residents using eContour had improved contour agreement with both the consensus (0.63 vs 0.52; P =.02) and the expert (0.58 vs 0.50; P =.01) contours for the high-risk clinical target volume and greater agreement with the expert contour for the contralateral parotid gland (0.44 ± 0.12 vs 0.56 ± 0.08; P =.003). The residents using eContour demonstrated greater knowledge of contour delineation and radiographic anatomy on a multiple-choice knowledge-based test (89% vs 77%; P =.03). Usability (89 vs 66; P P =.002) were greater for eContour than for the existing resources. Conclusions This study demonstrates the capacity of an interactive 3-dimensional contouring atlas to improve quality of resident target delineation in radiation oncology. Further research is needed to define the utility of easily accessible interactive educational reference tool to improve adherence to contouring-based guidelines and quality of care in routine clinical practice.

Background: Patient-controlled analgesia (PCA) is an effective approach to treat pain. However, data regarding patterns of PCA use for cancer pain are limited. The purpose of this study was to define the patterns of PCA use and related outcomes in hospitalized patients with cancer. Methods: We identified 90 patients with cancer admitted to a single academic center who received PCA for nonsurgical, cancer-related pain and survived to discharge between January 2013 and January 2014. Data collected included patient demographics, cancer diagnosis, type of cancer-related pain, PCA use, opioid-specific adverse events, and 30-day readmission rates for pain. Univariable and multivariable linear regression models were used to analyze the association between patient and clinical variables with PCA duration. Logistic regression models were used to evaluate the relationship between patient and clinical variables and 30-day readmission rates. Results: The median length of hospitalization was 10.2 days with a median PCA duration of 4.4 days. Hematologic malignancies were associated with longer PCA use (P=.0001), as was younger age (P=.032). A trend was seen toward decreased 30-day readmission rates with longer PCA use (P=.054). No correlation was found between 30-day readmission and any covariate studied, including age, sex, cancer type (solid vs hematologic), pain type, palliative care consult, or time from PCA discontinuation to discharge. Conclusions: This study suggests that there is longer PCA use in younger patients and those with hematologic malignancies admitted with cancer-related pain, with a trend toward decreased 30-day readmission rates in those with longer PCA use.

Purpose Our goal was to determine the impact of pathologic response after neoadjuvant chemotherapy in triple negative breast cancer (TNBC) on the subsequent risk of locoregional recurrence (LRR) and disease-free survival (DFS) in the setting of adjuvant radiation therapy. Methods and materials This was an institutional review board–approved retrospective chart review of patients with clinical stage I-III breast cancer treated with neoadjuvant chemotherapy, local surgery (breast conservation or mastectomy), and adjuvant radiation therapy between 1997 and 2015. Medical records were reviewed for clinical stage, tumor grade and subtype, neoadjuvant chemotherapy regimen, type of surgery, pathologic stage, use of radiation therapy, date and location of recurrence, and date of death. Molecular subtypes were defined using immunohistochemistry and histologic grade. ypT0 and ypN0 were defined as no residual invasive disease in breast or nodes, respectively. LRR was defined as any failure within the breast, chest wall, or regional lymph nodes. Statistical analysis was performed; LRR and DFS rates over 30 months were determined from Kaplan-Meier plots. Results Ninety-four patients with TNBC were analyzed, of whom 72 received radiation therapy. This subgroup was isolated for further investigation. Median follow-up was 32.5 months in this group. The pathologic complete response (pCR) rate was 36%, and presence or absence of disease in breast and/or nodes was significantly predictive of LRR. In TNBC patients who received radiation therapy, 30-month LRR was 22% in 41 patients with ypT+ versus 0% in 31 patients with ypT0 (P = .003), 23% in 31 patients with ypN+ versus 5% in 41 patients with ypN0 (P = .016), and 20% in 46 patients with residual disease in breast or nodes versus 0% in 26 patients with pCR (P = .015). The difference in the rate of LRR between those who underwent lumpectomy versus mastectomy did not reach significance (8% vs 17%, respectively). Furthermore, patients with residual disease had a higher rate of DFS events (hazard ratio, 3.58; 95% confidence interval, 1.37-9.41; P = .006). The difference in DFS was not significantly associated with the type of surgery received. Conclusions Patients with TNBC treated with neoadjuvant chemotherapy who have residual disease in the breast or lymph nodes at the time of surgery have significantly higher rates of locoregional failure and lower DFS compared with those with a pCR despite the use of adjuvant radiation therapy. Strategies to intensify therapy for patients with residual disease warrant further investigation.

Tongue-tie can cause many serious breastfeeding problems and even lead to breastfeeding cessation. As the mothers’ stories listed in “When Tongue-Ties Were Missed: Mothers’ Stories” attest, healthcare providers often do not correctly identify when a baby has a tongue-tie. Assessing tongue-tie is essential. What should clinicians look for? Which professionals should be the ones identifying and identifying tongue-tie? Assessing tongue-tie is the focus of this article.

Do parents have any alternatives to surgery for addressing tongue-tie? Our panelists agree that latch issues should be assessed first. Other modalities include physical therapy, speech therapy, chiropractic, and craniosacral therapy. In addition, infants should be assessed for other issues, such as torticollis, that may co-occur with tongue-tie. For some parents, complementary techniques may be all that they need to address tongue-tie–related issues. For other parents, surgical release will still be necessary.

What is the prevalence of tongue-tie (the proportion of total cases in a population)? Is the incidence (occurrence of new cases) increasing or are clinicians simply identifying it more often? The most reliable way to estimate incidence and prevalence is through population-based epidemiological studies. So far, these are limited. However, there has been some research that allows us to approximate rates. Our expert panel offers their judgment on two questions: What is the approximate percentage of babies with tongue-tie? And is incidence increasing?

If a tongue-tie is to be revised, what is the best technique for accomplishing that? There is some debate in the field about whether scissors or laser is most effective. Both techniques seem efficacious. This section also addresses which professionals should be performing the revision. Our panelists represent a wide range of disciplines, so some refer, and others perform the revisions themselves.

INTRODUCTION AND OBJECTIVE:Utility of lymph node dissection (LND) in localized renal cell carcinoma (RCC) is controversial. We sought to assess the impact of LND in non metastatic pT2-3 RCC patient...

The in-hospital mortality rate of surgery for acoustic neuroma (AN) is 0.5% and increases exponentially with age. There have been no studies examining the nationwide distribution of nonoperative management (radiation or observation) in the geriatric (≥ age 65) AN population. The National Cancer Database (NCDB) from 2004 to 2013 identified geriatric AN patients. Multivariable logistic regression adjusted for patient age, race, sex, income, geographic region, primary payer for care, tumor size, and comorbidities. Of the 11,614 AN patients, 1725 (14.9%) were geriatric; median tumor size was 2.1 cm. Solitary treatment was administered as radiation (13%), observation (8.5%), and surgery (74.5%). Men (OR = 1.3, p = 0.03) and comprehensive cancer center (CCC) treatment (OR = 1.4, p = 0.02) were more likely to receive radiation. African-American race (OR = 1.5, p = 0.03) was associated with increased observation, while comorbidities (OR = 0.7, p = 0.03) were associated with decreased observation. Fifteen percent of the AN population is ≥ age 65, with surgery the most commonly used treatment modality. Male gender and CCC treatment independently predict receipt of radiation, while African-American race independently predicts receipt of observation. Given the proven impact of radiation on local control in AN, there is fertile ground for dissemination of radiation treatment for geriatric AN patients.

Cardiac mortality in breast cancer patients treated with radiotherapy (RT) has been addressed in the literature and prompted changes in clinical practice [1]. The Quantitative Analysis of Normal Ti...

Cancer (CA) care delivery fragmentation persists for patients across the cancer continuum. Racial and ethnic disparities are one of the primary factors attributable for variation in treatment outcomes, in addition to language and patient-provider communication barriers. Latino and African-American communities also bear a greater burden of Alzheimer’s Disease (AD) risk than White making patients experiencing AD+CA at risk for poor quality and treatment disparities. This study aims to characterize AD+CA in a population-based sample. Using 2004-2013 SEER-Medicare data we identified multiple cancers and the prevalence of concurrent AD+CA in the database (N=273,349). Patients selected for a first primary, histologically confirmed, any stage, not diagnosed in death certificate or autopsy and had at least 24 months of data prior to diagnosis to calculate a comorbidity index. All analyses were conducted in SAS 9.4 (Cary, N.C.). Across lung (LC), colorectal, head and neck (HNC), prostate (PC), and cervical cancer (CC) we found 5890 cases of AD+CA or 2.15%. While lung represented the largest sample, colorectal (CRC) cancer was responsible for the largest proportion of concurrent AD+CA cases at 3.52% of all CRC. Black and Latino CRC, HNC patients had higher than overall prevalence of AD+CC. Black CRC patients had 6.13% AD+CA vs White 3.27 and Latino HNC patients reported 5.06% vs 3.25 White. Earlier stage patients had higher AD+CA vs later stages for CRC, HNC, and CC. The opposite was true for LC. Finally, women had slightly higher prevalence of AD+LC but significantly higher AD+CRC and AD+HNC compared to men.

Sleep disturbances are associated with cognitive decline but it is not clear if initiation of sleep treatments mitigates decline. We used the 2006-2014 Health and Retirement Study. At each wave, participants were administered cognitive assessments and scores were summed (values=0-35; higher=better cognition). All participants also reported if, in the past two weeks, they had taken medications or used other treatments to improve sleep. Our sample (N=4,650) included individuals who at baseline were cognitively normal and untreated for sleep, and at any wave reported some sleep disturbance. We characterized cognitive performance over study period with comparisons before and after sleep treatment initiation. Between 2006-2014, participants exhibited declines in cognitive performance (B=-2.40; 95% CI=-2.73, -2.06; p

Increasing evidence indicates an association between statins and reduced prostate cancer-specific mortality (PCSM). However, significant bias may exist in these studies. One particularly challenging bias to assess is the healthy user effect, which may be quantified by screening patterns. We aimed to evaluate the association between statin use, screening, and PCSM in a dataset with detailed longitudinal information.We used the Veterans Affairs Informatics and Computing Infrastructure to assemble a cohort of patients diagnosed with prostate cancer (PC) between 2000 and 2015. We collected patient-level demographic, comorbidity, and tumor data. We also assessed markers of preventive care utilization including cholesterol and prostate specific antigen (PSA) screening rates. Patients were considered prediagnosis statin users if they had at least one prescription one or more years prior to PC diagnosis. We evaluated PCSM using hierarchical Fine-Gray regression models and all-cause mortality (ACM) using a cox regression model.The final cohort contained 68,432 men including 40,772 (59.6%) prediagnosis statin users and 27,660 (40.4%) nonusers. Prediagnosis statin users had higher screening rates than nonusers for cholesterol (90 vs. 69%, p 0.001) and PSA (76 vs. 67%, p 0.001). In the model which excluded screening, prediagnosis statin users had improved PCSM (SHR 0.90, 95% CI 0.84-0.97; p = 0.004) and ACM (HR 0.96, 95% CI 0.93-0.99; p = 0.02). However, after including cholesterol and PSA screening rates, prediagnosis statin users and nonusers showed no differences in PCSM (SHR 0.98, 95% CI 0.91-1.06; p = 0.59) or ACM (HR 1.02, 95% CI 0.98-1.05; p = 0.25).We found that statin users tend to have more screening than nonusers. When we considered screening utilization, we observed no relationship between statin use before a prostate cancer diagnosis and prostate cancer mortality.

Evidence supporting radical prostatectomy (RP) for men with clinically node-positive (cN+) prostate cancer (PC) is limited. In a US national database, we identified 741 men with cN+ nonmetastatic PC diagnosed during 2000–2015 who underwent definitive local therapy with RP (n = 78), radiotherapy (RT) with neoadjuvant androgen deprivation therapy (ADT) (n = 193), or nondefinitive therapy with ADT alone (n = 445) or observation (n=25). We compared PC-specific mortality (PCSM) and all-cause mortality (ACM) using multivariable Fine-Gray competing risk regression and Cox regression, respectively. Compared to nondefinitive therapy, RP was associated with significantly better PCSM (subdistribution hazard ratio [SHR] 0.32, 95% confidence interval [CI] 0.16–0.66; p = 0.002) and ACM (HR 0.36, 95% CI 0.21–0.61; p < 0.001). Compared to RT, RP was not associated with a significant difference in PCSM (SHR 0.47, 95% CI 0.19–1.17; p = 0.1) or ACM (HR 0.88, 95% CI 0.46–1.70; p = 0.71). These data suggest that RP is associated with favorable survival outcomes that appear to be superior to those for patients who did not receive definitive therapy and comparable to those for patients receiving definitive ADT/RT. Randomized trials of surgery with multimodal therapy are needed. PATIENT SUMMARY: We found that in clinically node-positive prostate cancer, radical prostatectomy was associated with a cancer-specific and overall survival benefit compared to nondefinitive therapy. Randomized clinical trials are required to determine the best treatment approach in this patient population.

BACKGROUND African American (AA) men in the general US population are more than twice as likely to die of prostate cancer (PC) compared with non-Hispanic white (NHW) men. The authors hypothesized that receiving care through the Veterans Affairs (VA) health system, an equal-access medical system, would attenuate this disparity. METHODS A longitudinal, centralized database of >20 million veterans was used to assemble a cohort of 60,035 men (18,201 AA men [30.3%] and 41,834 NHW men [69.7%]) who were diagnosed with PC between 2000 and 2015. RESULTS AA men were more likely to live in regions with a lower median income ($40,871 for AA men vs $48,125 for NHW men; P

ObjectiveTo conduct an anatomic site-specific case–control study of candidate colorectal cancer (CRC) risk factors.DesignCase–control study of US veterans with >1 colonoscopy during 1999–2011. Cases had cancer registry-identified CRC at colonoscopy, while controls were CRC free at colonoscopy and within 3 years of colonoscopy. Primary outcome was CRC, stratified by anatomic site: proximal, distal, or rectal. Candidate risk factors included age, sex, race/ethnicity, body mass index, height, diabetes, smoking status, and aspirin exposure summarised by adjusted ORs and 95% CIs.Results21 744 CRC cases (n=7017 rectal; n=7039 distal; n=7688 proximal) and 612 646 controls were included. Males had significantly higher odds relative to females for rectal cancer (OR=2.84, 95% CI 2.25 to 3.58) than distal cancer (OR=1.84, 95% CI 1.50 to 2.24). Relative to whites, blacks had significantly lower rectal cancer odds (OR=0.88, 95% CI 0.82 to 0.95), but increased distal (OR=1.27, 95% CI 1.19 to 1.37) and proximal odds (OR=1.62, 95% CI 1.52 to 1.72). Diabetes prevalence was more strongly associated with proximal (OR=1.29, 95% CI 1.22 to 1.36) than distal (OR=1.15, 95% CI 1.08 to 1.22) or rectal cancer (OR=1.12, 95% CI 1.06 to 1.19). Current smoking was more strongly associated with rectal cancer (OR=1.81, 95% CI 1.68 to 1.95) than proximal cancer (OR=1.53, 95% CI 1.43 to 1.65) or distal cancer (OR=1.46, 95% CI 1.35 to 1.57) compared with never smoking. Aspirin use was significantly more strongly associated with reduced rectal cancer odds (OR=0.71, 95% CI 0.67 to 0.76) than distal (OR=0.85, 95% CI 0.81 to 0.90) or proximal (OR=0.91, 95% CI 0.86 to 0.95).ConclusionCandidate CRC risk factor associations vary significantly by anatomic site. Accounting for site may enable better insights into CRC pathogenesis and cancer control strategies.

Background We assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status. Methods The study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger ( Results Risk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interactionP-interaction Conclusion Our results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age.

Background:Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer.Patients and Methods:We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors.Results:In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%;PPPP=.1029).Conclusions:Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.

To evaluate whether automated knowledge-based planning (KBP) (a) is noninferior to human-driven planning across multiple disease sites and (b) systematically affects dosimetric plan quality and variability.Clinical KBP automated planning routines were developed for prostate, prostatic fossa, hypofractionated lung, and head and neck. Clinical implementation consisted of independent generation of human-generated and KBP plans (145 cases across all sites), followed by blinded plan selection. Reviewing physicians were prompted to select a single plan; when plan equivalence was volunteered, this scored as KBP selection. Plan selection analysis used a noninferiority framework testing the hypothesis that KBP is not worse than human-driven planning (threshold: lower 95% confidence interval [CI]0.45 = noninferiority;0.5 = superiority). Target and organ-at-risk metrics were compared by dose differencing: ΔDx = Dx, human-Dx, KBP (2-tailed paired t test, Bonferroni-corrected P.05 significance threshold). To evaluate the aggregated effect of KBP on planning performance, we examined post-KBP dosimetric parameters against 183 plans generated just before KBP implementation (2-tailed unpaired t test, Bonferroni-corrected P.05).Across all disease sites, the KBP success rate (physician preferred + equivalent) was noninferior compared with human-driven planning (83 of 145 = 57.2%; range, 49.2%-65.3%) but did not cross the threshold for superiority. The KBP success rate in respective disease sites was superior with head and neck ([22 + 2]/36 = 66.7%; 95% CI, 51%-82%) and noninferior for lung stereotactic body radiation therapy ([21 + 2]/36 = 63.9%; 95% CI, 48%-80%) but did not meet noninferiority criteria with prostate ([16 + 3]/41 = 46.3%; 95% CI, 31%-62%) or prostatic fossa ([17 + 0]/32 = 53.1%; 95% CI, 36%-70%). Prostate, prostatic fossa, and head and neck showed significant differences in KBP-selected plans versus human-selected plans, with KBP generally exhibiting greater organ-at-risk sparing and human plans exhibiting better target homogeneity. Analysis of plan quality pre- and post-KBP showed some reductions in organ doses and quality metric variability in prostate and head and neck.Fully automated KBP was noninferior to human-driven plan optimization across multiple disease sites. Dosimetric analysis of treatment plans before and after KBP implementation showed a systematic shift to higher plan quality and lower variability with the introduction of KBP.

IMPORTANCE: 5α-Reductase inhibitors (5-ARIs), commonly used to treat benign prostatic hyperplasia, reduce serum prostate-specific antigen (PSA) concentrations by 50%. The association of 5-ARIs with detection of prostate cancer in a PSA-screened population remains unclear. OBJECTIVE: To test the hypothesis that prediagnostic 5-ARI use is associated with a delayed diagnosis, more advanced disease at diagnosis, and higher risk of prostate cancer–specific mortality and all-cause mortality than use of other or no PSA-decreasing drugs. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study linked the Veterans Affairs Informatics and Computing Infrastructure with the National Death Index to obtain patient records for 80 875 men with American Joint Committee on Cancer stage I-IV prostate cancer diagnosed from January 1, 2001, to December 31, 2015. Patients were followed up until death or December 31, 2017. Data analysis was performed from March 2018 to May 2018. EXPOSURES: Prediagnostic 5-ARI use. MAIN OUTCOMES AND MEASURES: The primary outcome was prostate cancer–specific mortality (PCSM). Secondary outcomes included time from first elevated PSA (defined as PSA≥4 ng/mL) to diagnostic prostate biopsy, cancer grade and stage at time of diagnosis, and all-cause mortality (ACM). Prostate-specific antigen levels for 5-ARI users were adjusted by doubling the value, consistent with previous clinical trials. RESULTS: Median (interquartile range [IQR]) age at diagnosis was 66 (61-72) years; median [IQR] follow-up was 5.90 (3.50-8.80) years. Median time from first adjusted elevated PSA to diagnosis was significantly greater for 5-ARI users than 5-ARI nonusers (3.60 [95% CI, 1.79-6.09] years vs 1.40 [95% CI, 0.38-3.27] years; P

OBJECTIVE:This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer. SUMMARY OF BACKGROUND DATA:Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process. METHODS:A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution. RESULTS:Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05). CONCLUSION:The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.

INTRODUCTION AND OBJECTIVES:The safety of testosterone replacement therapy in men who have undergone radical prostatectomy (RP) for localized prostate cancer remains undefined.METHODS:In a large na...

INTRODUCTION AND OBJECTIVES:5α-Reductase inhibitors (5-ARIs), commonly used to treat benign prostatic hyperplasia, reduce serum prostate-specific antigen (PSA) concentrations by 50%. The effect of 5-ARIs on prostate cancer detection in a PSA-screened population remains unclear. We tested the hypothesis that pre-diagnostic 5-ARI use is associated with a delayed diagnosis, more advanced disease, and higher risk of prostate cancer-specific mortality and all-cause mortality.METHODS:We linked the Veterans Affairs Informatics and Computing Infrastructure with the National Death Index to obtain patient records. The cohort included 80,875 men with American Joint Committee on Cancer stage I-IV prostate cancer diagnosed from 2001-2015. The exposure was pre-diagnostic 5-ARI use. The main outcomes were time from initial PSA elevation (defined as PSA ≥ 4 ng/mL) to diagnostic prostate biopsy, cancer grade and stage at time of diagnosis, and prostate cancer-specific and all-cause mortality. PSA was adjusted by doubling ...

INTRODUCTION AND OBJECTIVES:The safety of testosterone replacement therapy in men who have undergone radiation therapy (RT) for localized prostate cancer remains undefined.METHODS:In a large nation...

Background Intraoperative MRI has been shown to improve gross-total resection of high-grade glioma. However, to the knowledge of the authors, the cost-effectiveness of intraoperative MRI has not been established. Purpose To construct a clinical decision analysis model for assessing intraoperative MRI in the treatment of high-grade glioma. Materials and Methods An integrated five-state microsimulation model was constructed to follow patients with high-grade glioma. One-hundred-thousand patients treated with intraoperative MRI were compared with 100 000 patients who were treated without intraoperative MRI from initial resection and debulking until death (median age at initial resection, 55 years). After the operation and treatment of complications, patients existed in one of three health states: progression-free survival (PFS), progressive disease, or dead. Patients with recurrence were offered up to two repeated resections. PFS, valuation of health states (utility values), probabilities, and costs were obtained from randomized controlled trials whenever possible. Otherwise, national databases, registries, and nonrandomized trials were used. Uncertainty in model inputs was assessed by using deterministic and probabilistic sensitivity analyses. A health care perspective was used for this analysis. A willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained was used to determine cost efficacy. Results Intraoperative MRI yielded an incremental benefit of 0.18 QALYs (1.34 QALYs with intraoperative MRI vs 1.16 QALYs without) at an incremental cost of $13 447 ($176 460 with intraoperative MRI vs $163 013 without) in microsimulation modeling, resulting in an incremental cost-effectiveness ratio of $76 442 per QALY. Because of parameter distributions, probabilistic sensitivity analysis demonstrated that intraoperative MRI had a 99.5% chance of cost-effectiveness at a willingness-to-pay threshold of $100 000 per QALY. Conclusion Intraoperative MRI is likely to be a cost-effective modality in the treatment of high-grade glioma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Bettmann in this issue.

PURPOSE Treatment decisions about localized prostate cancer depend on accurate estimation of the patient’s life expectancy. Current cancer and noncancer survival models use a limited number of predefined variables, which could restrict their predictive capability. We explored a technique to create more comprehensive survival prediction models using insurance claims data from a large administrative data set. These data contain substantial information about medical diagnoses and procedures, and thus may provide a broader reflection of each patient’s health. METHODS We identified 57,011 Medicare beneficiaries with localized prostate cancer diagnosed between 2004 and 2009. We constructed separate cancer survival and noncancer survival prediction models using a training data set and assessed performance on a test data set. Potential model inputs included clinical and demographic covariates, and 8,971 distinct insurance claim codes describing comorbid diseases, procedures, surgeries, and diagnostic tests. We used a least absolute shrinkage and selection operator technique to identify predictive variables in the final survival models. Each model’s predictive capacity was compared with existing survival models with a metric of explained randomness (ρ2) ranging from 0 to 1, with 1 indicating an ideal prediction. RESULTS Our noncancer survival model included 143 covariates and had improved survival prediction (ρ2 = 0.60) compared with the Charlson comorbidity index (ρ2 = 0.26) and Elixhauser comorbidity index (ρ2 = 0.26). Our cancer-specific survival model included nine covariates, and had similar survival predictions (ρ2 = 0.71) to the Memorial Sloan Kettering prediction model (ρ2 = 0.68). CONCLUSION Survival prediction models using high-dimensional variable selection techniques applied to claims data show promise, particularly with noncancer survival prediction. After further validation, these analyses could inform clinical decisions for men with prostate cancer.

Purpose Inflammatory bowel disease (IBD) is a known risk factor for rectal cancer, and RT is often an important part of therapy for these patients. Previously published studies have raised concerns for increased rates of RT toxicity in patients with IBD. We performed a matched case-control analysis to assess RT-related toxicity in a large sample of U.S. veterans afflicted with IBD and rectal cancer. Methods and Materials We identified 186 veterans with rectal cancer (71 Patients with IBD treated with RT, 71 matched controls without IBD treated with RT, and 44 nonmatched controls with IBD treated without RT) diagnosed between 2000 and 2015. We analyzed short- and long-term toxicity and mortality in multivariable logistic regression, Fine-Gray, and frailty models, adjusting for potential confounders. Results When comparing patients with and without IBD treated with RT there were no differences in RT breaks (adjusted odds ratio [aOR], 1.70; 95% confidence interval [CI], 0.38-4.76; P = .49) or the need for antidiarrheal medication during RT (aOR, 1.53; 95% CI, 0.70-3.35; P = .29). There was a trend toward higher risk of hospital admission during RT for RT + patients with IBD (aOR, 2.69; 95% CI, 0.88-8.22; P = .08). There were higher rates of small bowel obstruction (OR, 15; 95% CI, 1.9-115; P = .009) and a trend toward higher rates of abdominopelvic adhesions (OR, 3.6; 95% CI, 0.98-13; P = .05) in the RT + IBD cohort. However, compared with a nonmatched cohort of patients with IBD treated without RT there were no differences in long-term complications. No differences were found in other acute or long-term toxicities. Rectal cancer-specific mortality appeared similar across all cohorts. Conclusions RT does not appear to increase the rates of acute or long-term toxicity in patients with IBD and should be considered a standard part of therapy when otherwise indicated.

RationaleThe Institute of Medicine emphasizes care in the post-treatment phase of the cancer survivorship continuum. Physical exercise has been shown to be effective in improving physical function and quality of life in cancer survivors; however, its cost-effectiveness in lung cancer survivors is not well established.ObjectiveWe performed a model-based cost-effectiveness analysis of an exercise intervention in lung cancer survivors following curative-intent treatment.MethodsWe constructed a Markov model to simulate the impact of the Lifestyle Interventions and Independence for Elders (LIFE) exercise intervention compared to usual care for stage I-IIIA lung cancer survivors. Costs and utility benefit of exercise were extracted from the LIFE study. Baseline utilities, transition probabilities, and survival were modeled. We calculated and considered incremental cost-effectiveness ratios (ICERs) ResultsOur base-case model found that the LIFE exercise program would increase overall cost by $4,740 and effectiveness by 0.06 QALYs compared to usual care, and have an ICER of $79,504/QALY. The model was most sensitive to the cost of the exercise program, probability of increasing exercise, and utility benefit related to exercise. At a willingness-to-pay threshold of $100,000/QALY, the LIFE exercise program had a 71% probability of being cost-effective compared to 27% for usual care. When we included opportunity costs, the LIFE exercise program had an ICER of $179,774/QALY, exceeding the cost-effectiveness threshold.ConclusionsA simulation of the LIFE exercise program in lung cancer survivors following curative-intent treatment demonstrates cost-effectiveness from an organization but not societal perspective. Strategies to effectively increase exercise remotely may be more cost-effective than in-facility strategies for these patients.

There is conflicting evidence regarding the association between androgen deprivation therapy (ADT) for prostate cancer (PC) and the risk of developing stroke and thromboembolic events. Our study evaluated the association between ADT use and development of stroke, transient ischemic attack (TIA), deep vein thrombosis (DVT), and pulmonary embolism (PE) in a homogenous group of men with PC treated with definitive radiation therapy (RT) after controlling for multiple sources of confounding.Observational cohort study of patients diagnosed with PC at the US Department of Veterans Affairs between 1 January 2001 and October 31, 2015 and treated with definitive RT. Exposure was initiation of ADT within 1 year of PC diagnosis. Primary outcomes were development of stroke, TIA, DVT, or PE.44,246 men with median follow-up of 6.8 years. The overall cumulative incidences of stroke, TIA, DVT, and PE at 10 years were 6.0, 3.0, 3.4, and 1.9%, respectively. In the multivariable competing risks model, there was a significant association between ADT and stroke (subdistribution hazard ratio (SHR) = 1.19, 95% CI = 1.09-1.30, p 0.01), TIA (SHR = 1.24, 95% CI = 1.08-1.41, p 0.01), and DVT (SHR = 1.18, 95% CI = 1.04-1.34, p 0.01). ADT was only associated with PE in men receiving ADT for 1 year (SHR = 1.34, 95% CI = 1.06-1.69, p-value = 0.03).We observed an increase in the risk of stroke, TIA, and DVT in men receiving ADT and an increased risk of PE in men receiving long-term ADT. These results highlight concerns regarding long-term risks of ADT on stroke and thromboembolic events in the treatment of PC.

Purpose Generalized competing event (GCE) models improve stratification of patients according to their risk of cancer events relative to competing causes of mortality. The potential impact of such methods on clinical trial power and cost, however, is uncertain. We sought to test the hypothesis that GCE models can reduce estimated clinical trial cost in elderly patients with cancer. Methods Patients with nonmetastatic head and neck (n = 9,677), breast (n = 22,929), or prostate cancer (n = 51,713) were sampled from the SEER-Medicare database. Using multivariable Cox proportional hazards models, we compared risk scores for all-cause mortality (ACM) and cancer-specific mortality (CSM) with GCE-based risk scores for each disease. We applied a cost function to estimate the cost and duration of clinical trials with a primary end point of overall survival in each population and in high-risk subpopulations. We conducted sensitivity analyses to examine model uncertainty. Results For the purpose of enriching subpopulations, GCE models reduced estimated clinical trial cost compared with Cox models of ACM and CSM in all disease sites. The relative cost reductions with GCE models compared with ACM and CSM models, respectively, were −68.4% and −14.4% in prostate cancer, −38.8% and −18.3% in breast cancer, and −17.1% and −4.1% in head and neck cancer. Cost savings in breast and prostate cancers were on the order of millions of dollars. The GCE model also reduced relative clinical trial duration compared with CSM and ACM models for all disease sites. The optimal risk score cutoff for clinical trial enrollment occurred near the top tertile for all disease sites. Conclusion GCE models have significant potential to improve clinical trial efficiency and reduce cost, with a potentially large impact in prostate and breast cancers.

Purpose To determine the cost-effectiveness of multifocal intraocular lenses (IOLs) compared to that of monofocal IOLs from a societal and health care sector perspective. Design Cost-effectiveness analysis. Methods A Markov model was constructed that simulated patients who received either multifocal or monofocal IOLs during cataract surgery. Postoperatively, patients could experience spectacle dependence, glare, and haloes. Cost-effectiveness was determined by measuring the incremental cost-effectiveness ratio (ICER) as the incremental cost in dollars per quality-adjusted life year (QALY) gained. Treatments with an ICER below the standard willingness-to-pay (WTP) threshold of $50,000/QALY were considered cost effective. One-way sensitivity analyses and probabilistic sensitivity analyses were used to evaluate model sensitivity to cost, utilities, and other model inputs. Results Multifocal IOLs were associated with a 0.71 QALY increase at an increased cost of $3,415 compared with monofocal IOLs, leading to an ICER of $4,805/QALY from the societal and health care sector perspectives. The cost-effectiveness model was most sensitive to patient age, probability of spectacle dependence with multifocal IOLs and monofocal IOLs, and the disutility of glasses. Probabilistic sensitivity analysis found multifocal IOLs to be the cost-effective option compared with monofocal IOLs 99.9% of the time at a WTP threshold of $50,000/QALY. Conclusions From a societal and health care perspective, multifocal IOLs would be considered a cost-effective strategy compared to monofocal IOLs for patients who desire a higher chance to be spectacle-free. However, more studies need to be conducted to further evaluate the efficacy of multifocal IOLs.