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The value of hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of cytoreductive surgery (CRS) for epithelial ovarian cancer (EOC) is controversial and its use remains experimental in most national and international guidelines. We wished to systematically evaluate all available evidence.A comprehensive review of data from MEDLINE, EMBASE, and Cochrane Library databases was conducted from the first report on HIPEC in EOC till April 3, 2022. Progression-free survival (PFS) and overall survival (OS) were compared between the HIPEC and control groups. This meta-analysis was registered with PROSPERO (CRD42021265810).Fifteen studies (10 case-control studies and 5 randomized controlled trials [RCTs]) were included in the present meta-analysis. Based on the time interval between the last systemic chemotherapy exposure and timing of CRS +/- HIPEC, all studies and patients' cohorts we classified into recent (6 months; n = 9 studies/patients cohorts) and non-recent (≥6 months, n = 8 studies/patients cohorts) chemotherapy exposure groups. In the recent chemotherapy exposure group, HIPEC was associated with improvement of both PFS (HR, 0.585; 95% CI, 0.422-0.811) and OS (HR, 0.519; 95% CI, 0.346-0.777). On the contrary, in the non-recent chemotherapy exposure group, HIPEC failed to significantly affect PFS (HR, 1.037; 95% CI, 0.684-1.571) or OS (HR, 0.932; 95% CI, 0.607-1.430). Consistent results were observed in subsequent sensitivity analyses.Our present meta-analysis demonstrates that the value of HIPEC at CRS for EOC appears to depend on the timing of the last systemic chemotherapy exposure. Future trials are awaited to define the role of HIPEC in EOC.

Supplementary Figures S1-S4 from Ubiquitin Proteasome System Stress Underlies Synergistic Killing of Ovarian Cancer Cells by Bortezomib and a Novel HDAC6 Inhibitor

Purpose: Elevated metabolic activity of ovarian cancer cells causes increased ubiquitin-proteasome-system (UPS) stress, resulting in their greater sensitivity to the toxic effects of proteasomal inhibition. The proteasomes and a potentially compensatory histone deacetylase 6 (HDAC6)-dependent lysosomal pathway mediate eukaryotic protein turnover. We hypothesized that up-regulation of the HDAC6-dependent lysosomal pathway occurs in response to UPS stress and proteasomal inhibition, and thus, ovarian cancer cell death can be triggered most effectively by coinhibition of both the proteasome- and HDAC6-dependent protein degradation pathways.Experimental Design: To address this hypothesis, we examined HDAC6 expression patterns in normal and cancerous ovarian tissues and used a novel HDAC6-specific inhibitor, NK84, to address HDAC6 function in ovarian cancer.Results: Abnormally high levels of HDAC6 are expressed by ovarian cancer cells in situ and in culture relative to benign epithelium and immortalized ovarian surface epithelium, respectively. Specific HDAC6 inhibition acts in synergy with the proteasome inhibitor Bortezomib (PS-341) to cause selective apoptotic cell death of ovarian cancer cells at doses that do not cause significant toxicity when used individually. Levels of UPS stress regulate the sensitivity of ovarian cancer cells to proteasome/HDAC6 inhibition. Pharmacologic inhibition of HDAC6 also reduces ovarian cancer cell spreading and migration consistent with its known function in regulating microtubule polymerization via deacetylation of α-tubulin.Conclusion: Our results suggest the elevation of both the proteasomal and alternate HDAC6-dependent proteolytic pathways in ovarian cancer and the potential of combined inhibition of proteasome and HDAC6 as a therapy for ovarian cancer.

OBJECTIVE: To examine whether exposure to ambient ozone, particulate matter with diameter less than 2.5 microns (PM(2.5)), nitrogen dioxide (NO(2)), and distance to major roadways (DTR) impact ovarian cancer-specific survival, while considering differences by stage, race/ethnicity, and socioeconomic status. METHODS: Women diagnosed with epithelial ovarian cancer from 1996-2014 were identified through the California Cancer Registry and followed through 2016. Women’s geocoded addresses were linked to pollutant exposure data and averaged over the follow-up period. Pollutants were considered independently and in multi-pollutant models. Cox proportional hazards models assessed hazards of disease-specific death due to environmental exposures, controlling for important covariates, with additional models stratified by stage at diagnosis, race/ethnicity and socioeconomic status. RESULTS: PM(2.5) and NO(2), but not ozone or DTR, were significantly associated with survival in univariate models. In a multi-pollutant model for PM(2.5), ozone, and DTR, an interquartile range increase in PM(2.5) (Hazard Ratio [HR], 1.45; 95% Confidence Interval [CI], 1.41-1.49) was associated with worse prognosis. Similarly, in the multi-pollutant model with NO(2), ozone, and DTR, women with higher NO(2) exposures (HR for 20.0-30.0 ppb, 1.30; 95% CI, 1.25-1.36 and HR for >30.0 ppb, 2.48; 95% CI, 2.32-2.66) had greater mortality compared to the lowest exposed (

Background Research suggests that geographic location may affect ovarian cancer (OC) outcomes. Insurance status often remains an important predictor of outcomes. The Affordable Care Act was enacted in 2010 to expand access to affordable health insurance. Our objective was to examine spatiotemporal trends in OC treatment nonadherence and disease-specific mortality in California (USA) among women diagnosed with OC. Methods Newly diagnosed epithelial OC cases between 1996 and 2017 were identified from the California Cancer Registry. Spatiotemporal trends in adherence to treatment guidelines were examined using generalized additive models and OC-specific mortality using Cox proportional hazards additive models. Prediction grids covering California were used to display the odds ratios (ORs) and hazard ratios of location using the median value for the study area as the referent value. Seven overlapping 5-year periods and 2 larger ones (pre- and post-2013) were assessed. Analyses were stratified according to stage (early vs advanced) and used P = .05 to determine statistical significance. Results Statistically significant spatial patterns in treatment nonadherence were observed for every time period examined (P Conclusions Residential location was statistically significantly associated with treatment received in California, with spatial patterns varying over time but not OC-specific mortality. Changes in insurance status over time were accompanied by shifts in population demographics and increased travel distances to receive care.

OBJECTIVE To evaluate the association of race-ethnicity and neighborhood socioeconomic status with adherence to National Comprehensive Cancer Network guidelines for endometrial carcinoma. METHODS Data are from the SEER (Surveillance, Epidemiology, and End Results) cancer registry of women diagnosed with endometrial carcinoma for the years 2006-2015. The sample included 83,883 women after inclusion and exclusion criteria were applied. Descriptive statistics, bivariate analyses, univariate, and multivariate logistic regression models were performed to evaluate the association between race-ethnicity and neighborhood socioeconomic status with adherence to treatment guidelines. RESULTS After controlling for demographic and clinical covariates, Black (odds ratio [OR] 0.89, P

Background Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. Methods The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. Results Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. Conclusion The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.

National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance.Determine independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence.This was a retrospective study.Study was conducted utilizing the California Cancer Registry.Patients aged 18-79 years diagnosed with rectal adenocarcinoma between January 1, 2004 and December 31, 2017 with follow-up through November 30, 2018. Investigators determined whether patients received care with guideline adherence.Odds ratios and 95% confidence intervals were used for logistic regression to analyze patients receiving care with guideline adherence. Disease-specific survival analysis was calculated using Cox regression models.A total of 30,118 patients were analyzed. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians and Hispanics had better disease-specific survival in the non-adherent group HR 0.80 (95% CI 0.72 - 0.88, p0.001) and HR 0.91 (95% CI 0.83 - 0.99, p = 0.0279). Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the non-adherent group HR 1.56 (95% CI 1.40 - 1.73, p0.0001) and guideline adherent group HR 1.18 (95% CI 1.08 - 1.30, p = 0.0005). Lowest socioeconomic status' disease-specific survival was worse in both non-adherent group HR 1.42 (95% CI 1.27 - 1.59) guideline adherent group HR 1.20 (95% CI 1.08 - 1.34).Limitations included unmeasured confounders and retrospective nature of review.Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease specific survival in the guideline adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline non-adherent group and adherent groups. See Video Abstract at http://links.lww.com/DCR/B954.

Ovarian cancer has the highest mortality rate among gynecologic malignant tumors. Data are lacking on the survival benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) in women with ovarian cancer who underwent primary or interval cytoreductive surgery.To assess the clinical benefit of HIPEC after primary or interval maximal cytoreductive surgery in women with stage III or IV primary advanced ovarian cancer.In this single-blind randomized clinical trial performed at 2 institutions in South Korea from March 2, 2010, to January 22, 2016, a total of 184 patients with stage III or IV ovarian cancer with residual tumor size less than 1 cm were randomized (1:1) to a HIPEC (41.5 °C, 75 mg/m2 of cisplatin, 90 minutes) or control group. The primary end point was progression-free survival. Overall survival and adverse events were key secondary end points. The date of the last follow-up was January 10, 2020, and the data were locked on February 17, 2020.Hyperthermic intraperitoneal chemotherapy after cytoreductive surgery.Progression-free and overall survival.Of the 184 Korean women who underwent randomization, 92 were randomized to the HIPEC group (median age, 52.0 years; IQR, 46.0-59.5 years) and 92 to the control group (median age, 53.5 years; IQR, 47.5-61.0 years). After a median follow-up of 69.4 months (IQR, 54.4-86.3 months), median progression-free survival was 18.8 months (IQR, 13.0-43.2 months) in the control group and 19.8 months (IQR, 13.7-55.4 months) in the HIPEC group (P = .43), and median overall survival was 61.3 months (IQR, 34.3 months to not reported) in the control group and 69.5 months (IQR, 45.6 months to not reported) in the HIPEC group (P = .52). In the subgroup of interval cytoreductive surgery after neoadjuvant chemotherapy, the median progression-free survival was 15.4 months (IQR, 10.6-21.1 months) in the control group and 17.4 months (IQR, 13.8-31.5 months) in the HIPEC group (hazard ratio for disease progression or death, 0.60; 95% CI, 0.37-0.99; P = .04), and the median overall survival was 48.2 months (IQR, 33.8-61.3 months) in the control group and 61.8 months (IQR, 46.7 months to not reported) in the HIPEC group (hazard ratio, 0.53; 95% CI, 0.29-0.96; P = .04). In the subgroup of primary cytoreductive surgery, median progression-free survival was 29.7 (IQR, 17.2-90.1 months) in the control group and 23.9 months (IQR, 12.3-71.5 months) in the HIPEC group, and the median overall survival was not reached in the control group and 71.3 months (IQR, 45.6 months to not reported) in the HIPEC group.The addition of HIPEC to cytoreductive surgery did not improve progression-free and overall survival in patients with advanced epithelial ovarian cancer. Although the results are from a subgroup analysis, the addition of HIPEC to interval cytoreductive surgery provided an improvement of progression-free and overall survival.ClinicalTrials.gov Identifier: NCT01091636.

PURPOSE The survival impact of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer was studied. METHODS We identified published studies from 1983 to 2021 following our inclusion criteria from MEDLINE, EMBASE, and Cochrane library. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% CI. The publication bias was evaluated with the funnel plot and Egger's test, and sensitivity analysis was performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival (OS) time using study size as a weight. RESULTS Thirty-six studies with 2,805 patients reporting death rates were used for this meta-analysis of the 80 eligible studies. There was strong heterogeneity, with the P value of the Cochrane Q test of < 0.0001 and Higgins's I2 statistics of 86%; thus, we considered a random effect model. The pooled death rate was 44.2% (95% CI, 39.0 to 49.5), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model ( P < .001 and P = .005, respectively). Although 14 studies were located outside the funnel plot, Egger's test indicated no publication bias ( P = .327). A sensitivity analysis excluding 14 studies showed similar results. In the linear regression model on the basis of 57 studies, the median OS time increased by 8.97% and 7.04% when the complete and optimal cytoreduction proportion increased by 10%, respectively, after adjusting other variables. CONCLUSION Secondary cytoreductive surgery, resulting in maximal tumor resection, significantly prolongs OS in platinum-sensitive recurrent ovarian cancer.

1 Background: Oncology-specific evidence-based treatment guidelines aim to improve cancer care. Our study analyzed adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival. Methods: Patients aged 18 to 79 years diagnosed with anal squamous cell carcinoma (SCC) between January 1, 2004 and December 31, 2017 with follow-up through November 30, 2018 were identified in the California Cancer Registry. Patient demographics, socioeconomic status (SES) and tumor stage were identified. We determined whether patients received NCCN guideline-adherent care (AdC) by pre-defined criteria. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression for receiving AdC. Overall survival (OS) and disease specific-survival (DSS) were calculated using Cox regression models. Results: Of 4,740 patients with a diagnosis of anal SCC in California, 926 (19.5%) did not receive AdC (non-AdC). Non-AdC had worse DSS (HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001) and worse OS (HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). Females were more likely to receive AdC (OR 1.38, 95% CI = 1.18, 1.62, p < 0.0001). Medicaid patients were less likely to receive AdC (OR 0.75, 95% CI = 0.57, 1.00, p = 0.0476). Patients with the lowest SES were less likely to receive AdC (OR 0.65, 95% CI = 0.50, 0.83, p = 0.0007). Characteristics associated with DSS and OS included female gender, black race, Medicare/Medicaid, and SES (particularly, lower-middle SES). Conclusions: NCCN guideline-adherent care was associated with improved disease-specific and overall survival in anal SCC patients in California.

Purpose of review To summarize the most recent evidence on gynecologic cancer disparities and to describe studies investigating the social determinants of health and receipt of evidence-based care and potential interventions to address inequities in care. Recent findings Significant disparities in disease-specific survival by race/ethnicity, socioeconomic status, and payer status have persisted in women with gynecologic cancers. Compared with white women, black women have an increased likelihood of disease-specific mortality for endometrial cancer and are less likely to receive guideline-adherent care for ovarian cancer. The Covid-19 pandemic has brought significant attention to the structural barriers that contribute to persistent health disparities and how community-based partnerships with a focus on policy interventions are needed for equitable gynecologic cancer outcomes. Summary In this review, we discuss structural barriers contributing to racial inequities, the role of Medicaid payer status and receipt of quality cancer care, gender, and racial workforce diversity, and community-based partnerships to create evidence-based interventions to address disparities.

OBJECTIVE: Rural residence has been related to health disparities and greater mortality risk in cancer patients, including gynecologic cancer patients. Lower survival rates for rural cancer survivors have been attributed to limited access to specialized healthcare, including surgery. Here, we examined whether a rural/urban survival gap existed in ovarian cancer patients receiving surgery at tertiary-care facilities, and potential causes for this gap, including educational attainment. METHODS: Rural and urban patients with high grade invasive ovarian cancer (n=342) seeking treatment at two midwestern tertiary-care university hospitals were recruited pre-surgery and followed until death or censoring date. Rural/urban residence was categorized using the USDA Rural-Urban Continuum Codes. Stratified Cox proportional hazards regression analyses, with clinical site as strata, adjusting for clinical and demographic covariates, were used to examine the effect of rurality on survival. RESULTS: Despite specialized surgical care, rural cancer survivors showed a higher likelihood of death compared to their urban counterparts, HR=1.39 (95%CI: 1.04,1.85) p=0.026, adjusted for covariates. A rurality by education interaction was observed (p=0.027), indicating significantly poorer survival in rural vs. urban patients among those with trade school/some college education, adjusted HR=2.49 (95% CI: 1.44, 4.30), p=0.001; there was no rurality survival disparity for the other 2 levels of education. CONCLUSIONS: Differences in ovarian cancer survival are impacted by rurality, which is moderated by educational attainment even in patients receiving initial care in tertiary settings. Clinicians should be aware of rurality and education as potential risk factors for adverse outcomes and develop approaches to address these possible risks.

Objective Platinum resistance, defined as the lack of response or relapse within six months of platinum-based chemotherapy, is an important determinant of survival in gynecologic cancer. We used quantitative Mass Spectrometry to identify metabolic signatures that predict platinum resistance in patients receiving chemotherapy for gynecologic cancers. Methods In this study 47 patients with adenocarcinoma of the ovary or uterus who were candidates for carboplatin plus paclitaxel submitted blood for quantitation of metabolites and surgical specimens for the isolation 3-dimensional organoids used to measure individual patient platinum resistance, ex vivo. Results were correlated with response, time to progression and survival. Results Of 47 patients, 27 (64.3%) achieved complete remission with a mean time to progression of 1.9 years (± 1.5), disease-free survival of 1.7 years (± 1.4) and overall survival of 2.6 years (± 1.6) and a mean cisplatin lethal concentration 50% (LC50) = 1.15 μg/ml (range 0.4–3.1). Cisplatin LC50's correlated with a non-significant decrease in complete remission (RR [95% CI] =0.76 [0.46–1.27]), diminished disease-free survival (median: 1.15 vs. 2.99 years, p = 0.038) and with biochemical signatures of 186 metabolites. Receiver operating curves (ROC) of lipid ratios, branched chain amino acids and the tryptophan to kynurenine ratio identified patients at the highest risk of relapse and death (AUC = 0.933) with a sensitivity of 92.0% and specificity of 86.0% (p Conclusions Metabolic signatures in gynecologic cancer identify patients at the highest risk of relapse and death offering new diagnostic and prognostic tools for management of the advanced gynecologic tumors.

BACKGROUND Adherence to National Comprehensive Cancer Network guidelines have been adopted as the standard of care for various cancers and have been cited to have survival benefits. Few studies have examined the association of adherent treatment and endometrial cancer survival among various racial/ethnic groups and socioeconomic statuses. METHODS Between January 1, 2006 and December 31, 2015, 83,673 women diagnosed with endometrial carcinomas were identified from the Surveillance, Epidemiology, and End Results database. Descriptive statistics of demographic and clinical characteristics were performed. Cox-proportional hazards models were used to examine the effect on cause-specific survival for adherence to guidelines across racial/ethnic and socioeconomic groups. RESULTS Within our sample, 59.5% were treated according to guidelines. Nonadherence to treatment guidelines was significantly associated with decreased survival compared with adherent care (adjusted hazard ratio [HR], 1.59; 95% CI, 1.52-1.67). Being of Black (adjusted HR, 1.41; 95% CI, 1.32-1.51) or Native Hawaiian/Pacific Islander (adjusted HR, 1.44; 95% CI, 1.19-1.73) race/ethnicity compared with White women was significantly associated with worse survival. Being of Asian race/ethnicity (adjusted HR, 0.86, 95% CI, 0.78-0.94) was significantly associated with improved survival compared with White women. Lower neighborhood socioeconomic status was associated with a negative effect on survival relative to women in the highest socioeconomic status category. CONCLUSIONS Findings from this study suggest treatment adherence is an independent predictor of improved survival; however, improved survival was not observed equally among all racial/ethnic and socioeconomic status groups. LAY SUMMARY The National Comprehensive Cancer Network (NCCN) has developed guidelines for physicians to follow in treating various cancers. Within this study of 83,673 women with endometrial cancer, 59.5% of women were treated according to the NCCN guidelines. The findings suggest following NCCN guidelines for treatment of endometrial cancer improves survival. Black or Native Hawaiian/Pacific Islander race and lower neighborhood socioeconomic status has worse survival rates compared with other groups, indicating the importance of exploring other factors that may shape treatment across racial/ethnic and socioeconomic status groups.

Background: The survival impact of secondary cytoreductive surgery in platinum-sensitive recurrent ovarian cancer patients was studied. Methods: Published studies from 1983 to 2020 that were in accordance with our inclusion criteria from MEDLINE, EMBASE, and Cochrane library were identified. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% confidence interval (CI). The publication bias was evaluated with the funnel plot and egger’s test, and sensitivity analysis were performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival time using the study size as a weight. Findings: Of the 75 eligible studies that satisfied the inclusion criteria, 33 studies that reported death rates with 2,261 patients were used for meta-analysis. Following a heterogeneity test, we considered a random effect model because the p-value of Cochrane Q test was less than 0·001, and Higgins’s I 2 statistics was 91%, indicating considerable heterogeneity. The pooled death rate was 0·440 (95% CI, 0·374-0·505), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model (p

The objective of this study was to examine the rate of and indications for readmission in patients with advanced staged ovarian cancer undergoing rectosigmoid resection and primary anastomosis, an important quality metric. A retrospective review was conducted of patients with primary ovarian cancer who underwent rectosigmoid resection as part of cytoreductive surgery between July 2003 and July 2014. Univariate analysis identified rates and predictors of readmission. Fifty patients were eligible for analysis. The unanticipated 30-day readmission rate was 18% (

This article addresses the role of surgery in the management of gynecologic cancers with liver metastases. The authors review the short-term and long-term outcomes of aggressive resection through retrospective and randomized studies. Although the data supporting aggressive resection of liver metastasis are largely retrospective and case based, the randomized control data to address neoadjuvant versus chemotherapy have been widely criticized. Residual disease remains an important predictor for survival in ovarian cancer. If a patient cannot achieve near optimal cytoreduction, radical cytoreductive procedures, such as hepatic resection, should be considered for palliation only.

To evaluate the association of race-ethnicity and neighborhood socioeconomic status with adherence to National Comprehensive Cancer Network guidelines for endometrial carcinoma.Data are from the SEER (Surveillance, Epidemiology, and End Results) cancer registry of women diagnosed with endometrial carcinoma for the years 2006-2015. The sample included 83,883 women after inclusion and exclusion criteria were applied. Descriptive statistics, bivariate analyses, univariate, and multivariate logistic regression models were performed to evaluate the association between race-ethnicity and neighborhood socioeconomic status with adherence to treatment guidelines.After controlling for demographic and clinical covariates, Black (odds ratio [OR] 0.89, P.001), Latina (OR .92, P.001), and American Indian or Alaska Native (OR 0.82, P=.034) women had lower odds of receiving adherent treatment and Asian (OR 1.14, P.001) and Native Hawaiian or Pacific Islander (OR 1.19 P=.012) women had higher odds of receiving adherent treatment compared with White women. After controlling for covariates, there was a gradient by neighborhood socioeconomic status: women in the high-middle (OR 0.89, P.001), middle (OR 0.84, P.001), low-middle (OR 0.80, P.001), and lowest (OR 0.73, P.001) neighborhood socioeconomic status categories had lower odds of receiving adherent treatment than the those in the highest neighborhood socioeconomic status group.Findings from this study suggest there are racial-ethnic and neighborhood socioeconomic disparities in National Comprehensive Cancer Network treatment adherence for endometrial cancer. Standard treatment therapies should not differ based on sociodemographics. Interventions are needed to ensure that equitable cancer treatment practices are available for all individuals, regardless of racial-ethnic or socioeconomic background.

Highlights • Cure rates are high for choriocarcinoma, however chemoresistant disease often leads to death. • High expression of PD-L1 suggests a role for checkpoint inhibitors in choriocarcinoma. • Pembrolizumab should be considered for salvage therapy for chemoresistant choriocarcinoma.

Background Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations. Methods The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. Results Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma. Conclusion The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

Background: Evidence suggests that geographic location may independently contribute to ovarian cancer survival. We aimed to investigate how the association between residential location and ovarian cancer-specific survival in California varies by race/ethnicity and socioeconomic status. Methods: Additive Cox proportional hazard models were used to predict hazard ratios (HRs) and 95% confidence intervals (CI) for the association between geographic location throughout California and survival among 29,844 women diagnosed with epithelial ovarian cancer between 1996 and 2014. We conducted permutation tests to determine a global P-value for significance of location. Adjusted analyses considered distance traveled for care, distance to closest high-quality-of-care hospital, and receipt of National Comprehensive Cancer Network guideline care. Models were also stratified by stage, race/ethnicity, and socioeconomic status. Results: Location was significant in unadjusted models (P = 0.009 among all stages) but not in adjusted models (P = 0.20). HRs ranged from 0.81 (95% CI: 0.70, 0.93) in Southern Central Valley to 1.41 (95% CI: 1.15, 1.73) in Northern California but were attenuated after adjustment (maximum HR = 1.17, 95% CI: 1.08, 1.27). Better survival was generally observed for patients traveling longer distances for care. Associations between survival and proximity to closest high-quality-of-care hospitals were null except for women of lowest socioeconomic status living furthest away (HR = 1.22, 95% CI: 1.03, 1.43). Conclusions:Overall, geographic variations observed in ovarian cancer-specific survival were due to important predictors such as receiving guideline-adherent care. Improving access to expert care and ensuring receipt of guideline-adherent treatment should be priorities in optimizing ovarian cancer survival.

INTRODUCTION AND OBJECTIVE:It is unclear whether current evidence-based guidelines for high-risk prostate cancer are congruent with clinical practice. In this study, we evaluate the association of ...

Introduction Despite an increasing number of female service members, incidence rates of gynecologic cancers (other than cervical cancer) have not been previously documented in the U.S. active duty military population. This study sought to determine the incidence rates of all gynecologic, including peritoneal, malignancies in the U.S. Active Duty population compared to the general US population as reported in the Surveillance, Epidemiology, and End Results Program database. Materials and Methods Gynecologic cancers diagnosed in U.S. Active Duty women aged 20–59 between 2004 and 2013 were retrospectively ascertained. Cancer cases were identified in both the Automated Central Tumor Registry and the Military Health System Data Repository. All cases in Automated Central Tumor Registry plus cases recorded in Military Health System Data Repository, but not duplicative of Automated Central Tumor Registry cases, were included. Age-specific and age-adjusted incidence rates were calculated in military and Surveillance, Epidemiology, and End Results cases. Results In U.S. Active Duty women, 327 incident cases of gynecologic cancer were identified. There were 110 cases of cervical cancer, 40 cases of endometrial cancer, 152 cases of ovarian cancer, and 25 other gynecologic malignancies. Of the 327 cases, 154 were ascertained from the Automated Central Tumor Registry database and the remainder from Military Health System Data Repository claims data. The age-adjusted rate of all gynecologic cancers for U.S. Active Duty women was 49.17 per 105 (95%CI 37.58, 65.12), while the age-adjusted rate for Surveillance, Epidemiology, and End Results −18 was 42.09 per 105 (95%CI 41.83, 42.35). The kappa coefficient assessing the overlap between the data sources was −0.1937. Though insufficient in numbers for statistical analysis, the observed proportion of ovarian to cervical cancer cases in active duty women Conclusions U.S. Active Duty women exhibited a similar age-adjusted rate of gynecologic cancer as the general US population. There was suboptimal overlap between the Automated Central Tumor Registry and Military Health System Data Repository databases, indicating the necessity of using both databases in order to obtain reliable data in the active duty population. This study is the current best estimate of a baseline rate of gynecologic cancer in U.S. active duty military women. This rate might change over time as women’s roles and exposures in recent and future military conflicts evolve.

Ovarian cancer care at a high-performing hospital is an independent predictor of improved survival, and barriers to access disproportionately affect patients according to sociodemographic characteristics., OBJECTIVE: To validate the observed/expected ratio for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care, and to identify patient characteristics associated with disparities in access to high-performing hospitals. METHODS: This was a retrospective population-based study of stage I–IV invasive epithelial ovarian cancer reported to the California Cancer Registry between 1996 and 2014. A fit logistic regression model, which was risk-adjusted for patient and disease characteristics, was used to calculate the observed/expected ratio for each hospital, stratified by hospital annual case volume. A Cox proportional hazards model was used for survival analyses, and a multivariable logistic regression model was used to identify independent predictors of access to high-performing hospitals. RESULTS: The study population included 30,051 patients who were treated at 426 hospitals: low observed/expected ratio (n=304) 23.5% of cases; intermediate observed/expected ratio (n=92) 57.8% of cases; and high observed/expected ratio (n=30) 18.7% of cases. Hospitals with high observed/expected ratios were significantly more likely to deliver guideline-adherent care (53.3%), compared with hospitals with intermediate (37.8%) and low (27.5%) observed/expected ratios (P

PURPOSE: We sought to determine the level of concordance among surgeons’ assessment of residual disease (RD) and pre-treatment computed tomography (CT) findings among women who underwent optimal surgical cytoreduction for advanced stage ovarian cancer. METHODS: This is a post-trial ad hoc analysis of a phase 3 randomized clinical trial evaluating the impact of bevacizumab in primary and maintenance therapy for patients with advanced stage ovarian cancer following surgical cytoreduction. All subjects underwent imaging of the chest/abdomen/pelvis to establish a post-surgical baseline prior to the initiation of chemotherapy. Information collected on trial was utilized to compare surgeon’s operative assessment of RD, to pre-treatment imaging. RESULTS: Of 1,873 enrolled patients, surgical outcome was described as optimal (RD ≤ 1 cm) in 639 subjects. Twelve patients were excluded as they did not have a baseline, pretreatment imaging, leaving 627 participants for analysis. The average interval from surgery to baseline scan was 26 days (range: 1–109). In 251 cases (40%), the post-operative scan was discordant with surgeon assessment, demonstrating RD > 1 cm in size. RD > 1 cm was most commonly identified in the right upper quadrant (28.4%), retroperitoneal para-aortic lymph nodes (RD > 1.5 cm; 28.2%) and the left upper quadrant (10.7%). Patients with RD > 1 cm on pre-treatment CT (discordant) exhibited a significantly greater risk of disease progression (HR 1.30; 95% CI 1.08–1.56; p=0.0059). CONCLUSIONS: Among patients reported to have undergone optimal cytoreduction, 40% were found to have lesions > 1 cm on postoperative, pretreatment imaging. Although inflammatory changes and/or rapid tumor regrowth could account for the discordance, the impact on PFS and distribution of RD may suggest underestimation by the operating surgeon.

The aim of this study was to review the surgical and clinical outcomes of intrathoracic and mediastinal surgical cytoreduction in stage IV epithelial ovarian cancer (EOC). Relevant articles were identified from MEDLINE and EMBASE. Only analyses or reports that described actual intrathoracic cytoreduction via pleurectomy and/or resection of cardiophrenic/mediastinal lymph nodes were included. Imaging articles that merely described thoracic tumor patterns were excluded. A total of nine studies were identified, the oldest originating in 2007. Procedures described were transdiaphragmatic resection of cardiophrenic lymph nodes and pleural disease (n = 5) and video-assisted thoracoscopic and mediastinal tumorectomies including pleurectomy (n = 4). The number of operated patients ranged between 1 and 30 with complete cytoreduction rates ranging between 68 and 100%. No surgical deaths directly related to the thoracic cytoreduction were reported and only one patient (1/30) experienced a postoperative complication in terms of a pneumothorax. None of the studies presented a direct comparison of survival to patients with thoracic disease who did not undergo thoracic cytoreduction, and therefore the survival benefit of thoracic cytoreduction could not be quantified. In conclusion, thoracic cytoreduction in advanced EOC seems feasible and with acceptable morbidity while offering a better understanding of the extent of disease and hence allowing the tailoring of intraabdominal resections. Nevertheless, its direct impact on patients' survival by a potential overruling of a more adverse tumor biology remains to be established in larger-scale prospective and ideally randomized trials.

Gynecologic cancers account for ~12% of all new cancer cases in women and ~15% of all female cancer survivors. Current and continued advances within the field have resulted in long-term outcomes and a high rate of survivors. Therefore determining the most cost-effective clinical surveillance for detection of recurrence is critical. Unfortunately, there has been a paucity of research regarding the most effective strategies for surveillance after patients have achieved a complete response. Currently, most recommendations are based on retrospective studies and expert opinion. Taking a thorough history, performing a thorough examination, and educating cancer survivors about concerning symptoms are the most effective methods for the detection of most gynecologic cancer recurrences. There is very little evidence that routine cytology or imaging improves the ability to detect gynecologic cancer recurrence that will impact cure or response rates to salvage therapy. This article provides an update on surveillance for gynecologic cancer recurrence in women who have had a complete response to primary cancer therapy.

ObjectivesWe performed a patterns-of-care study to characterize the types of patients with epithelial ovarian cancer (EOC) who received neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) using the National Cancer Database (NCDB).MethodsWe identified patients with stages IIIC and IV EOC in the NCDB diagnosed from 2003 to 2011. Patients who received chemotherapy (CT) prior to surgery were classified as receiving NACT; if surgery preceded CT, then it was classified as PDS. Data collected from the NCDB included demographics, medical comorbidity index, cancer characteristics and treatment, and hospital characteristics. Univariate and multivariable analyses were performed using χ2 test, logistic regression, log-rank test, and Cox proportional hazards modeling as indicated. Statistical significance was set at P < 0.05.ResultsA total of 62,727 patients with stages IIIC and IV EOC were identified. The sequence of surgery and CT was identified, of which 6922 (11%) had NACT and 31,280 (50%) had PDS. Neoadjuvant CT was more frequently done in stage IV than stage IIIC (13% vs 9%), and its use markedly increased over time. Variables associated with increased likelihood of NACT use were as follows: age older than 50 years and those with higher comorbidities, stage IV, and higher-grade EOC. Neoadjuvant CT use was also associated with hospitals that were adherent to the National Comprehensive Cancer Network guidelines, high-volume facilities, those in the Midwest and West, and academic centers.ConclusionsEvidence suggests that patients with greater adverse risk factors are more likely to receive NACT instead of PDS. Use of NACT has significantly increased over the study period, especially in patients with stage IV ovarian cancer.

Background: More than 14,000 women in the United States die of ovarian cancer (OC) every year. Disparities in survival have been observed by race and socioeconomic status (SES), and vary spatially even after adjusting for treatment received. This study aimed to determine the impact of geographic location on receiving treatment adherent to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for OC, independent of other predictors. Patients and Methods: Women diagnosed with all stages of epithelial OC (1996–2014) were identified through the California Cancer Registry. Generalized additive models, smoothing for residential location, were used to calculate adjusted odds ratios (ORs) and 95% CIs for receiving nonadherent care throughout California. We assessed the impact of distance traveled for care, distance to closest high-quality hospital, race/ethnicity, and SES on receipt of quality care, adjusting for demographic and cancer characteristics and stratifying by disease stage. Results: Of 29,844 patients with OC, 11,419 (38.3%) received guideline-adherent care. ORs for nonadherent care were lower in northern California and higher in Kern and Los Angeles counties. Magnitudes of associations with location varied by stage (OR range, 0.45–2.19). Living farther from a high-quality hospital increased the odds of receiving nonadherent care (OR, 1.18; 95% CI, 1.07–1.29), but travel >32 km to receive care was associated with decreased odds (OR, 0.76; 95% CI, 0.70–0.84). American Indian/other women were more likely to travel greater distances to receive care. Women in the highest SES quintile, those with Medicare insurance, and women of non-Hispanic black race were less likely to travel far. Patients who were Asian/Pacific Islander lived the closest to a high-quality hospital. Conclusions: Among California women diagnosed with OC, living closer to a high-quality center was associated with receiving adherent care. Non-Hispanic black women were less likely to receive adherent care, and women with lower SES lived farthest from high-quality hospitals. Geographic location in California is an independent predictor of adherence to NCCN Guidelines for OC.

OBJECTIVES/HYPOTHESIS To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E

Ovarian cancer is commonly diagnosed at an advanced stage, with disease involving the upper abdomen. The finding of enlarged cardiophrenic lymph nodes (CPLNs) on pre-operative imaging often indicates the presence of malignant spread to the mediastinum. Surgical resection of CPLN through a transdiaphragmatic approach can help to achieve cytoreduction to no gross residual. A retrospective chart review was conducted on all patients who underwent transdiaphragmatic cardiophrenic lymph node resection from 8/1/11 through 2/1/15. All relevant pre-, intra-, and post-operative characteristics and findings were recorded. A brief description of the surgical technique is included for reference. Eleven patients were identified who had undergone transdiaphragmatic resection of cardiophrenic lymph nodes. Malignancy was identified in 18/21 (86%) of total lymph nodes submitted. The median number of post-operative days was 7. The overall post-operative morbidity associated with CPLN resection was low, with the most common finding being a small pleural effusion present on chest x-ray between POD# 3–5 (55%). Transdiaphragmatic CPLN resection is a feasible procedure with relatively minor short-term post-operative morbidities that can be used to achieve cytoreduction to no gross residual disease., Highlights • Pre-operative chest CT can help to identify enlarged cardiophrenic lymph nodes. • The technique of transdiaphragmatic cardiophrenic lymph node resection is described. • Resection of CPLNs aids in achieving cytoreduction to no gross residual disease. • The short-term morbidities associated with the procedure are relatively minor.

Most patients with advanced-stage epithelial ovarian cancer will experience a relapse of disease despite a complete response after surgical cytoreduction and platinum-based chemotherapy. Treatment of recurrent ovarian cancer mainly comprises various combinations of systemic chemotherapy with or without targeted agents. The role of cytoreductive surgery for recurrent ovarian cancer is not well established. Although the literature on survival benefit of cytoreductive surgery for recurrent disease has expanded steadily over the past decade, most studies were retrospective, single-institution series with small numbers of patients. Given the balance between survival benefit and surgery-related morbidity during maximum cytoreductive surgical effort, it is essential to establish the optimal selection criteria for identifying appropriate candidates who will benefit from surgery without worsening quality of life. Three phase III randomized trials for this issue are currently underway. Herein, we present contemporary evidence supporting the positive role of cytoreductive surgery and offer selection criteria for optimal candidates for surgery in the treatment of recurrent ovarian cancer.

OBJECTIVE To identify risk factors associated with refusal of recommended chemotherapy and its impact on patients with epithelial ovarian cancer (EOC). METHODS We identified patients in the National Cancer Data Base diagnosed with EOC from January 1998 to December 2011. Patients who refused chemotherapy were identified and compared with those who received recommended, multiagent chemotherapy. Univariate and multivariable analyses were performed using chi-square test with Bonferroni correction, binary logistic regression, log-rank test, and Cox proportional hazards modeling. The threshold for statistical significance was set at a P value of less than 0.05. RESULTS From a cohort of 147,713 eligible patients, 2,707 refused chemotherapy. These patients were compared with 92,212 patients who received recommended multiagent chemotherapy. Older age, more medical comorbidities, not having insurance, and later year of diagnosis were directly and significantly associated with chemotherapy refusal when analyzed using multivariable logistic regression. In addition, lower-than-expected facility adherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer, treatment at low-volume center, lower grade, and higher stage were all significantly and independently associated with chemotherapy refusal. Median overall survival of patients who received multiagent chemotherapy was significantly longer than that of those who refused chemotherapy (43 vs 4.8 months; P

Introduction: California is home to the largest ethnic/racial diversity in the US, with 39% Latino, 37% White, 15% Asian American, 6% African American, 3% multiracial, Citation Format: Sora P. Tanjasiri, Kiran Clair, Jenny Chang, Argyrios Ziogas, Greg Gin, Kari J. Kansal, Jason Zell, Robert Bristow. Ethnic/racial differences in later stage diagnoses, NCCN adherent care and survival in California [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-149.

Introduction: Orange County (OC) is home to the third-largest population of Asian Americans in the U.S., including the largest population of Vietnamese outside of Vietnam. While breast, lung and colorectal cancers are the top overall causes of cancer incidence and mortality in OC, unique cancers are prevalent among Asian and Pacific Islanders including liver and stomach cancers. The University of California, Irvine Chao Family Comprehensive Cancer Center (UCI CFCCC) adapted a hub-and- spoke model of care (Elrod & Fortenberry, 2017) to increase efficiency among underserved Asian Americans who continue to experience disparities in screening, early detection, and access to cancer treatment. Methods: Our hub-and-spoke model arranges service delivery assets into a network between community organizations through culturally/linguistically competent and trained community health navigators, OC medicaid primary and specialty care providers for low/moderate complexity patients, and UCI CFCCC for high-complexity cancer treatment. UCI CFCCC serves as the anchor establishment (hub) which offers a full array of services. This is complemented by community providers and care coordinators at local Federally Qualified Health Centers (spokes) which offer culturally-tailored primary prevention services. The community patient navigators (rim) located at community-based organizations, routes patients needing more tailored services to the spokes or hub for screening or treatment. Results: Patient Navigators at OC Herald Center, OC Asian Pacific Islander Community Alliance, and Vietnamese American Cancer Foundation have educated 2,246 Korean, Vietnamese, and Chinese individuals on cancer prevention and screening guidelines. Of those, 320 medicaid members have been routed to KCS Health Centers (Korean-serving FQHC lookalike), Southland Integrated Services, Inc (Vietnamese and Chinese-serving FQHC), or Medicaid community providers for cancer screening and/or follow-up. 64 community providers have been trained on NCCN guideline adherent care for Korean, Vietnamese, and Chinese. UCI CFCCC has developed an algorithm/pathway for Medicaid-serving community physicians to easily refer qualified Vietnamese, Chinese, or Korean patients to the hub for complex care or clinical trials. Conclusions: The current COVID-19 pandemic has exacerbated disparities in screening and early detection, and compounds the uncertainty about the importance of optimizing cancer care quality (i.e. access proportion and timeliness, adherence to guidelines, patient satisfaction). Disparities being highlighted in COVID-19 has shown us the power and need of community engagement models to rapidly catalyze and create unique community-based efforts that strengthen capacities and infrastructures, and promote best practices in cancer prevention and early detection designed to decrease cancer incidence and/or mortality in the communities we serve. Citation Format: Cevadne Lee, Ellen Ahn, Mary Anne Foo, Sherry Huang, Becky Nguyen, Tricia Nguyen, Jacqueline Tran, Robert Bristow, Sora Park Tanjasiri. A hub and spoke model to improve cancer care quality: Advancing Cancer Care Together (ACCT) for Asian American Medicaid beneficiaries in Orange County, California [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-021.

Introduction Significant advancements have been made over the last 50 years in the areas of cancer biology, pathology, therapeutics, and surgical planning with only modest improvements in the overall survival of patients. Disparities in survival across different racial/ethnic groups and geography are multifactorial; however, a minimum set of quality indicators would allow us to assess adherence to clinical guideline therapy as a measure of quality care and a therapeutic standard all patients should be provided. The National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines to assist providers in the treatment and surveillance of patients across many primary cancer sites. In this systematic review, we aim to evaluate available literature assessing the relationship of NCCN guideline adherent cancer care and overall survival in gastrointestinal malignancies. Methods We performed a systematic literature search through June 2019. We searched MEDLINE (Pubmed) using a combination of MESH terms, only English language literature was included. Our search query was designed to assess the inclusion of survival data in studies evaluating the receipt of NCCN guideline adherent care in gastrointestinal cancers. Study exclusion criteria included: therapeutic or surgical clinical trial, non-NCCN guideline assessment, symptom-based guidelines, evaluation of tumor board or multidisciplinary team, disease specific practice guidelines. We plan to include additional disease groups: gynecologic, genitourinary, hepatobiliary, and breast cancer in our future analysis. Results The results of our review identified 59 studies, of which 23 studies were excluded based on criteria listed above. Of the 26 studies, 7 studies included overall survival as part of the statistical analysis in relation to compliance with NCCN guidelines. Of the 7 studies, 5 of these studies showed a favorable relationship with improved overall survival associated with increased compliance with NCCN guidelines. One study did not show a difference in overall survival, and one study had mixed results. This observed pattern supports the hypothesis that increased adherence to NCCN guidelines is associated with improved overall survival for patients with gastrointestinal malignancies. Conclusion Despite some limitations, our review has demonstrated that increased compliance with NCCN guidelines is associated with improved overall survival. Additional research is needed to further assess the relationship between NCCN guideline adherence and overall survival across other disease types. Specific parameters of the NCCN guideline should be analyzed to assess which aspects and sequences of treatment are most critical to patient survival. This effort could help assess opportunities for intervention for patients who are most at risk for receiving non-adherent guideline-based cancer care. Citation Format: Kiran Clair, Sora Tanjasiri, Robert Bristow. Does adherence to National Comprehensive Cancer Network (NCCN) practice guidelines improve survival? [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D069.