scholarly journals Spending for Advanced Cancer Diagnoses: Comparing Recurrent Versus De Novo Stage IV Disease

2019 ◽  
Vol 15 (7) ◽  
pp. e616-e627 ◽  
Author(s):  
Michael J. Hassett ◽  
Matthew Banegas ◽  
Hajime Uno ◽  
Shicheng Weng ◽  
Angel M. Cronin ◽  
...  
Keyword(s):  
Advanced Cancer ◽  
Cancer Diagnosis ◽  
De Novo ◽  
Stage Iv ◽  
Absolute Difference ◽  
Medicare Data ◽  
Stage Iv Disease ◽  
De Novo Cancer ◽  
Payment Models ◽  
Diagnosis Age

PURPOSE: Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending. METHODS: Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors. RESULTS: We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all P < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all P < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]). CONCLUSION: Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.

The impact of socioeconomic status (SES) on stage of cancer at time of diagnosis: A population-based study in Ontario, Canada

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 6505-6505
Author(s):  
C. M. Booth ◽  
G. Li ◽  
W. J. Mackillop
Keyword(s):  
Overall Survival ◽  
Cox Model ◽  
Stage Iv ◽  
Stage I ◽  
Absolute Difference ◽  
Stage At Diagnosis ◽  
Stage Iv Disease ◽  
Incident Cases ◽  
The Impact ◽  
Universal Health

6505 Background: Lower SES is known to be associated with worsened cancer survival. Here we evaluate the impact of SES on stage of cancer at diagnosis in Ontario which has universal health insurance. Methods: All incident cases of breast, colon, rectal, non-small cell lung, cervical and larynx cancer diagnosed in Ontario 2003–2005 were identified using the Ontario Cancer Registry. Stage information is only captured routinely for patients seen at Ontario's 8 Regional Cancer Centers (RCCs). This represents approximately 68% of the population and forms the basis for all analyses. Using a best stage grouping approach, cases were assigned stage based on pathologic TNM if available and clinical TNM otherwise. The population of Ontario was divided into quintiles based on community median household income reported in the 2001 Canadian census. Using postal code at time of diagnosis cases were assigned to quintiles (Q); Q1 represents the communities where the poorest 20% of the Ontario population resided. Comparisons between Q1 and Q2–5 were made using the chi-square test. A Cox model was used to evaluate overall survival, SES, stage, and age. Results: Stage at diagnosis was available for 19,239/23,254 (83%) of cases seen at RCCs. Among cases with breast cancer, those in Q1 were less likely to have stage I disease (43 vs 47%, p = 0.004) and more likely to have stage IV disease (5 vs 4%, 0.008) than Q2–5. With lung cancer, cases in Q1 were more likely to have stage I disease compared to Q2–5 (16 vs 13%, p = 0.015). Distribution of stage I and stage IV disease did not differ by SES across other individual diseases. However, for all 6 cancers combined, cases in Q1 were less likely than Q2–5 to have stage I disease (27 vs 30%, p = 0.001) and more likely to have stage IV disease (21 vs 18%, p < 0.0001). We found significant gradients in 3-year overall survival across Q1-Q5 for breast (5% absolute difference in survival, p < 0.001), colon (4%, p = 0.049), and cervical (18%, p = 0.031) cancers. Adjustment for stage and age only slightly diminished these survival gradients. Conclusions: Despite universal health care, SES remains associated with survival among patients with cancer in Ontario. These data suggest that the difference in outcome is only partially explained by differences in stage at diagnosis. No significant financial relationships to disclose.

Survival benefit of nephrectomy prior to immunotherapy-based combinations in patients with metastatic renal cell carcinoma: An FDA pooled analysis.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 4516-4516
Author(s):  
Jaleh Fallah ◽  
Haley Gittleman ◽  
Chana Weinstock ◽  
Erik Bloomquist ◽  
Elaine Chang ◽  
...  
Keyword(s):  
Kinase Inhibitor ◽  
De Novo ◽  
Risk Group ◽  
Stage Iv ◽  
Standard Of Care ◽  
Pooled Analysis ◽  
Tumor Pathology ◽  
Kaplan Meier ◽  
Metastatic Setting ◽  
Stage Iv Disease

4516 Background: Immunotherapy-based combination therapies (IO-X) are standard of care for metastatic RCC (mRCC) in the frontline setting. Limited data is available on the role of cytoreductive nephrectomy prior to IO-X in patients (pts) with mRCC (Bakouny, et al. GU ASCO 2020). We assessed the correlation between nephrectomy prior to IO-X and overall survival (OS) in pts with de novo mRCC. Methods: We pooled data from trials submitted for FDA review of a checkpoint inhibitor combination as first-line treatment for pts with mRCC. We only included trials with available data for stage at initial diagnosis (dx) to identify pts with stage IV disease at initial dx and to exclude those with nephrectomy in the non-metastatic setting. Kaplan-Meier method was used to estimate median OS in pts with de novo mRCC with and without nephrectomy prior to IO-X. Results: Five trials met inclusion criteria, all of which evaluated IO in combination with a kinase inhibitor. Data for stage at initial dx was available in 1708 pts who received IO-X. The majority of pts were male (72%) and White (80%). Among the 849 pts (50%) with stage IV RCC at initial dx, 523 pts (62%) had nephrectomy prior to IO-X. All pts had clear cell histology; Sarcomatoid differentiation was present in tumor pathology of 25% and 10% of pts with and without prior nephrectomy, respectively. Proportion of pts with favorable, intermediate and poor risk disease was 10%, 70% and 20%, respectively. OS appeared better in those with stage IV disease at dx who had prior nephrectomy compared to pts without nephrectomy (Hazard ratio (HR) = 0.53, 95% CI: 0.42, 0.68), even after adjusting for age and prognostic risk group (HR = 0.59, 95% CI: 0.46, 0.75) (see table). Conclusions: In this retrospective exploratory analysis, nephrectomy prior to IO-X in pts with new dx of stage IV RCC appeared to be associated with improved OS, even when controlling for age and prognostic risk group. The decision for nephrectomy is affected by factors such as medical comorbidities which could not be completely controlled. Results should be considered hypothesis generating.[Table: see text]

Factors affecting survival of patients with Masaoka stage IV thymic epithelial tumors (TET).

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 7107-7107
Author(s):  
Yaman Suleiman ◽  
Milan Radovich ◽  
Luis Rojas ◽  
Ryan Frederick Porter ◽  
Madison Conces ◽  
...  
Keyword(s):  
De Novo ◽  
Residual Disease ◽  
Stage Iv ◽  
Progression Free Survival ◽  
Primary Treatment ◽  
Lung Nodules ◽  
Thymic Epithelial Tumors ◽  
Masaoka Stage ◽  
Pleural Metastasis ◽  
Stage Iv Disease

7107 Background: Thymoma and thymic carcinoma (TC) are rare tumors, but represent the most common neoplasms of the anterior mediastinum. The vast majority of TET present in early stages with little data existing on factors influencing survival in patients with advanced or stage IV disease. Methods: A retrospective analysis was performed on patients with confirmed TET (histology and with tissue blocks) seen at IUSCC diagnosed between 1976 and 2011. Patient demographics including Masaoka stage, histology, and sites of metastasis were linked with progression free survival (PFS) and overall survival (OS). Results: Our analysis included 102 patients with stage IV TET: 50 presented de novo and 52 developed stage IV disease following primary treatment. When stratified by tumor histology (thymoma or TC), patients with TC had considerably poorer PFS (p=1.87x10-7) and OS (p=7.72x10-8). The median PFS for TC was 13 months (range 4 to 39) and the MST was 36 months (range 4 to 115). PFS at 5-years was 21% and 0% but the five-year OS was 84% and 29% for thymoma and TC, respectively. Ten year OS was 55% for patients with thymoma and 0% for those with TC. Pleural (>3 vs. <3) metastases were significantly associated with a better PFS (p=0.036) and OS (p=0.0003). The PFS and OS of patients with lung nodules trended with those with pleural metastasis. Patients with pleural metastasis and lung nodules sites did considerably better than those with visceral disease (PFS, p=0.004, OS, p=2.09x10-5). Conclusions: Patients with TC have significantly poorer PFS and OS when compared to thymoma confirming that TC is a distinct clinical entity from thymoma. Patients with thymoma may have prolonged survival, despite having residual disease. Although current staging places patients with pleural metastasis (Masaoka stage IVA) and those with lung nodules (stage IVB) as separate categories, our data would suggest that those with lung nodules have similar survival with those who have pleural metastasis.

Contemporary multi-modal management of colorectal cancer: Evolving patterns of care in an Irish cohort.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 827-827
Author(s):  
Megan Greally ◽  
Emily Harrold ◽  
Helen M Fenlon ◽  
Donna Eaton ◽  
Jim McCarthy ◽  
...  
Keyword(s):  
De Novo ◽  
Stage Iv ◽  
Best Supportive Care ◽  
Kaplan Meier ◽  
Pet Ct ◽  
Symptomatic Relapse ◽  
Stage Iv Disease ◽  
The Impact ◽  
Term Benefit

827 Background: The last 15 years have seen significant improvements in the outcomes of patients (pts) with CRC. More effective systemic therapy (Rx) and wider use of surgery (Sx) in stage IV disease (Dx) are key drivers of this. We evaluated the impact of intense surveillance in concert with greater use of metastasectomy and improved systemic Rx on CRC outcomes. Methods: This is a retrospective review of the clinical, radiologic and histological records for consecutive pts with CRC who were referred to the multi-disciplinary CRC team from 2003-2016. Pts with stage I/II Dx were included when referred for adjuvant Rx for high-risk features. We recorded pt characteristics, Rx received and outcomes. Survival was assessed using Kaplan-Meier analysis. Results: We identified 600 pts. Median age was 65 (22-97 years). 71.2% (n=427) of pts had left sided CRC and 25.7% (n=154) had right sided Dx. 211 pts (35.2%) had de novo metastatic Dx. 163 of 389 pts (41.9%) with stage II/III disease relapsed. Median Dx-free interval was 16 months. Of 163 relapses, 121 (74%) were detected by radiologic surveillance and 14 (9%) by rise in CEA. Symptomatic relapse occurred in 20 pts (12%). Median overall survival (OS) was significantly improved in pts with relapse detected by CT, PET/CT or CEA rise (54, 53 and 54 months respectively) vs pts with symptomatic relapse (4 months, p<0.001). Metastasectomy rates were higher in pts with image-detected relapse ( p=0.017). Median OS for pts with stage IV CRC who received any Rx was 27 months. Pts with right sided Dx had shorter median OS vs pts with left sided Dx (24 months vs 40 months, p=0.002). 195 pts (52.8%) underwent metastasectomy; median OS was 71 months vs 16 months in those who did not undergo Sx. 84 pts (14%) with stage IV CRC are currently Dx-free after Sx. Median OS was improved with increasing lines of Rx. Survival in pts receiving best supportive care was 5 months vs 17, 25, 34, 38 and 42 months for pts receiving 2, 3, 4 and 5 lines of Rx respectively ( p<0.001). Conclusions: CRC outcomes are improving with effective multi-disciplinary care, close surveillance, sequencing of systemic Rx and judicious use of salvage Sx following relapse. Our findings support long-term benefit for surgical metatastectomy in stage IV CRC.

Disparities in HER2 testing in breast cancer.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e13084-e13084
Author(s):  
Vijay Paryani ◽  
Mary Chen Schroeder ◽  
Heidi D. Klepin ◽  
Susan Anitra Melin ◽  
Greg B. Russell ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Multivariate Analysis ◽  
De Novo ◽  
Stage Iv ◽  
Population Based ◽  
Her2 Testing ◽  
Breast Cancer Outcomes ◽  
Stage Iv Disease ◽  
Seer Data ◽  
Appropriate Therapy

e13084 Background: Although targeted therapies directed at human epidermal growth factor-2 (HER2) impact breast cancer outcomes, studies have found geographic variation in testing rates. We report population-based patterns of HER2 testing by patient, tumor and geographic characteristics. Methods: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER) data included women diagnosed 2010-2015 with de novo breast cancer. Women were categorized by age, race, stage, year of diagnosis, and receipt of estrogen receptor (ER), progesterone receptor (PR), and HER2 testing. SEER classified lack of testing with “test ordered, results not in chart” and “test not done.” We report on cases with HER2 “test not done”. Records missing any variables were excluded. County-level measures of socioeconomic status were included for each woman. Univariate and multivariate logistic regressions identified factors associated with testing. Results: Of 281,214 new breast cancer diagnoses, 1.75% had HER2 “test not done”. ER and PR testing were “not done” in 0.57% and 0.74% of cases, respectively. HER2-testing rates improved over time: 2.54% not tested in 2010 and 1.30% in 2015 (p < 0.01). The following characteristics were associated with higher rates of “test not done”: age >70 vs < 50 (OR = 1.33, p < 0.01), blacks vs whites (OR = 1.23, p < 0.01), Stage IV vs I (OR = 2.27, p < 0.01). Regional variation was also seen, with registries reporting HER2 “test not done” ranging from 0.18%-2.89%. On multivariate analysis (Table), HER2 testing was less likely for women age ≥ 70, blacks, Stage IV disease, and those living in counties with high rates of less than high school education. Conclusions: Rates of HER2 testing have increased. However, disparities exist and are associated with age, race, stage, geography, and education. Understanding the cause of these disparities could ultimately enhance access to appropriate therapy and improve disease outcomes. Odds of not having HER2 testing (select results from multivariate analysis). [Table: see text]

Medical oncology referral and systemic therapy of patients with advanced stage urothelial carcinoma

2020 ◽  
Vol 9 (13) ◽  
pp. 945-957
Author(s):  
Abdalla Aly ◽  
Courtney Johnson ◽  
Yunes Doleh ◽  
Rahul Shenolikar ◽  
Marc F Botteman ◽  
...  
Keyword(s):  
Urothelial Carcinoma ◽  
Medical Oncology ◽  
Stage Iv ◽  
Care Physician ◽  
Older Age ◽  
Medical Oncologist ◽  
Negatively Associated ◽  
Medicare Data ◽  
Adjusted Model ◽  
Timely Referral

Aim: To understand physician visit patterns among patients with stage IV (including nonmetastatic [M0] and metastatic [M1] disease) urothelial carcinoma (UC) and understand factors associated with a timely referral to a medical oncologist and systemic treatment. Patients & methods: Retrospective analysis of Surveillance, Epidemiology and End Results-Medicare data. Results: First physician encounter was with a urologist (M0: 69%; M1: 53%) or primary care physician ([PCP]; M0: 19%, M1: 25%) for the majority of patients around UC diagnosis. After the index urologist encounter, most patients had a subsequent medical oncologist visit at a median of 52 days (M0: 69.5 days, M1: 33 days). In an adjusted model, older age, index PCP visit, higher comorbidities and M0 disease were negatively associated with a medical oncologist referral. Among those referred to a medical oncologist, older age, Hispanic or non-Hispanic Black race and not being married were negatively associated with subsequent chemotherapy receipt (p < 0.05). Conclusion: Many patients with advanced UC encounter multiple specialists during their disease course. Older patients or those with a first UC-related encounter with a PCP are less likely to be referred to medical oncology. Once referred to medical oncology, social determinants, including race and marital status, are relevant predictors of receiving chemotherapy.

scholarly journals Laparoscopic Revisional Surgery After Failed Heller Myotomy for Esophageal Achalasia: Long-Term Outcome at a Single Tertiary Center

2021 ◽  
Author(s):  
Giovanni Capovilla ◽  
Renato Salvador ◽  
Luca Provenzano ◽  
Michele Valmasoni ◽  
Lucia Moletta ◽  
...  
Keyword(s):  
Heller Myotomy ◽  
Revisional Surgery ◽  
Stage Iv ◽  
Postoperative Outcomes ◽  
Control Group ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Eckardt Score ◽  
Stage Iv Disease

Abstract Background Laparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10–20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM. Methods Patients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment. Results Forty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003). Conclusions This study reports the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.

Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2018

2021 ◽  
pp. 019459982110328
Author(s):  
Lauren E. Miller ◽  
Neil S. Kondamuri ◽  
Roy Xiao ◽  
Vinay K. Rathi
Keyword(s):  
Pay For Performance ◽  
Payment System ◽  
Incentive Payment ◽  
Cross Sectional ◽  
Medicare Data ◽  
And Performance ◽  
Value Based Care ◽  
Sectional Analysis ◽  
Median Change ◽  
Payment Models

In 2017, the Centers for Medicare and Medicaid Services transitioned clinicians to the Merit-Based Incentive Payment System (MIPS), the largest mandatory pay-for-performance program in health care history. The first full MIPS program year was 2018, during which the Centers for Medicare and Medicaid Services raised participation requirements and performance thresholds. Using publicly available Medicare data, we conducted a retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS in 2017 and 2018. In 2018, otolaryngologists reporting as individuals were less likely ( P < .001) to earn positive payment adjustments (n = 1076/1584, 67.9%) than those participating as groups (n = 2802/2804, 99.9%) or in alternative payment models (n = 1705/1705, 100.0%). Approximately one-third (n = 1286/4472, 28.8%) of otolaryngologists changed reporting affiliations between 2017 and 2018. Otolaryngologists who transitioned from reporting as individuals to participating in alternative payment models (n = 137, 3.1%) achieved the greatest performance score improvements (median change, +23.4 points; interquartile range, 12.0-65.5). These findings have important implications for solo and independent otolaryngology practices in the era of value-based care.

scholarly journals Can artificial intelligence reduce the interval cancer rate in mammography screening?

2021 ◽  
Author(s):  
Kristina Lång ◽  
Solveig Hofvind ◽  
Alejandro Rodríguez-Ruiz ◽  
Ingvar Andersson
Keyword(s):  
Artificial Intelligence ◽  
Risk Score ◽  
Mammography Screening ◽  
False Negative ◽  
Interval Cancer ◽  
Stage Iv ◽  
True Negative ◽  
Stage Iv Disease ◽  
Interval Cancer Rate ◽  
Screening Mammograms

Abstract Objectives To investigate whether artificial intelligence (AI) can reduce interval cancer in mammography screening. Materials and methods Preceding screening mammograms of 429 consecutive women diagnosed with interval cancer in Southern Sweden between 2013 and 2017 were analysed with a deep learning–based AI system. The system assigns a risk score from 1 to 10. Two experienced breast radiologists reviewed and classified the cases in consensus as true negative, minimal signs or false negative and assessed whether the AI system correctly localised the cancer. The potential reduction of interval cancer was calculated at different risk score thresholds corresponding to approximately 10%, 4% and 1% recall rates. Results A statistically significant correlation between interval cancer classification groups and AI risk score was observed (p < .0001). AI scored one in three (143/429) interval cancer with risk score 10, of which 67% (96/143) were either classified as minimal signs or false negative. Of these, 58% (83/143) were correctly located by AI, and could therefore potentially be detected at screening with the aid of AI, resulting in a 19.3% (95% CI 15.9–23.4) reduction of interval cancer. At 4% and 1% recall thresholds, the reduction of interval cancer was 11.2% (95% CI 8.5–14.5) and 4.7% (95% CI 3.0–7.1). The corresponding reduction of interval cancer with grave outcome (women who died or with stage IV disease) at risk score 10 was 23% (8/35; 95% CI 12–39). Conclusion The use of AI in screen reading has the potential to reduce the rate of interval cancer without supplementary screening modalities. Key Points • Retrospective study showed that AI detected 19% of interval cancer at the preceding screening exam that in addition showed at least minimal signs of malignancy. Importantly, these were correctly localised by AI, thus obviating supplementary screening modalities. • AI could potentially reduce a proportion of particularly aggressive interval cancers. • There was a correlation between AI risk score and interval cancer classified as true negative, minimal signs or false negative.

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