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To evaluate the relationship of patient, hospital, and cancer characteristics with the adoption of hypofractionation in a national sample of patients diagnosed with early-stage breast cancer.We performed a retrospective study of breast cancer patients in the National Cancer Data Base from 2004-2011 who were treated with radiation therapy and met eligibility criteria for hypofractionation. We used logistic regression to identify factors associated with receipt of hypofractionation (vs conventional fractionation).We identified 13,271 women (11.7%) and 99,996 women (88.3%) with early-stage breast cancer who were treated with hypofractionation and conventional fractionation, respectively. The use of hypofractionation increased significantly, with 5.4% of patients receiving it in 2004 compared with 22.8% in 2011 (P.001 for trend). Patients living ≥50 miles from the cancer reporting facility had increased odds of receiving hypofractionation (odds ratio 1.57 [95% confidence interval 1.44-1.72], P.001). Adoption of hypofractionation was associated with treatment at an academic center (P.001) and living in an area with high median income (P.001). Hypofractionation was less likely to be used in patients with high-risk disease, such as increased tumor size (P.001) or poorly differentiated histologic grade (P.001).The use of hypofractionation is rising and is associated with increased travel distance and treatment at an academic center. Further adoption of hypofractionation may be tempered by both clinical and nonclinical concerns.

Objectives Men treated with androgen deprivation therapy (ADT) or radiation therapy (RT) for prostate cancer have an increased risk for fractures. Given uncertainty as to whether specific clinical factors can identify men at increased risk, we sought to develop a prognostic index for risk of fracture in this population. Materials and methods We used the Surveillance, Epidemiology, and End Results-Medicare database to identify men who received ADT or RT after being diagnosed with localized prostate cancer in 2007–2009. Cox proportional hazards models tested the association of potential risk factors with fracture. In a derivation group, hazard ratios were used to assign points for factors independently related to fracture. The prognostic index was then applied to a validation group. Results The sample of 5824 men had a median age of 73.0 years; 82.9% were white and 8.6% had a fracture within 2 years of treatment for prostate cancer. The Cox model identified 8 variables (age, race, hormone treatment, Elixhauser score, anxiety, Parkinson's, fall-inducing medications and disability status) independently associated with fracture. In the derivation cohort, 4.3% of the sample experienced a fracture in the low-risk group, 8.9% in the intermediate group, and 19.2% in the high-risk group (C statistic, 0.749). The index was applied to the validation cohort (C statistic, 0.782). Conclusion The prognostic index can help to identify patients at increased risk for fracture. This underscores the importance of identifying risk factors for fracture, given the substantial variation in fracture risk in men treated with ADT or RT.

Ambulatory surgery centers now report immediate hospital transfer rates as a measure of quality. For patients undergoing colonoscopy, this measure may fail to capture adverse events, which occur after discharge yet still require a hospital-based acute care encounter. We conducted this study to estimate rates of immediate hospital transfer and hospital-based acute care following outpatient colonoscopy performed in ambulatory surgery centers. Using state ambulatory surgery databases from the 2009-2010 Healthcare Cost and Utilization Project, we identified adult patients who underwent colonoscopy. Immediate hospital transfer and overall acute health care utilization in the 14 days following colonoscopy was determined from corresponding inpatient, ambulatory surgery, and emergency department databases. To compare rates across centers while accounting for differences in patient populations, we calculated risk-standardized rates using hierarchical generalized linear modeling. The final sample included 1,137,381 colonoscopy discharges from 1019 centers. At the ambulatory surgery center level, the median risk-standardized hospital transfer rate was 0.0% (interquartile range=0.0%), whereas the hospital-based acute care rate was 2.1% (interquartile range=0.6%), with few centers (N=36) having no observed encounters. No correlation was noted between the risk-standardized hospital transfer and hospital-based acute care rates (volume weighted correlation coefficient=0.04, P=0.16). Patients more frequently experience hospital-based acute care encounters after colonoscopy than the need for immediate hospital transfer. Broadening existing quality measures to include hospital-based acute care in the postdischarge period may provide a more complete measure of quality.

By the year 2030 older adults will account for 20% of the U.S. population1, almost doubled from 20052. Cancer is a disease of aging; over half of all cancer diagnoses and almost three quarters of cancer deaths occur in patients older than 653. The development and progression of comorbid conditions and the accelerating loss of spouses, friends and loved ones may make older adults with cancer more vulnerable to anxiety and depression4. The rate of anxiety in older oncology patients has been cited to be as high as 23%5, while depression in older oncology patients ranges from 17–26%6. Despite the various challenges faced by geriatric oncology patients, recent studies have suggested that age may actually serve as a protective factor against cancer-related psychological distress7. Distress is an umbrella term encompassing factors such as quality of life, anxiety, and depression. When teasing apart distress, age may not buffer against all facets of distress. For example, in a study of older men (age 50 and older) with prostate cancer, while increased age was associated with reduced anxiety (p < 0.01), increased age was also associated with greater depressive symptoms (p < .01)8. The percentage of men scoring above the cut-off for depression consistently increased with age. Despite the burgeoning geriatric oncology population and the importance of understanding how age may be related to constructs such as anxiety and depression, there has been limited further exploration of changes in anxiety and depression related to age within an older population of patients. Depression and anxiety are associated with poorer treatment outcomes9, reduced ability to make treatment decisions, decreased adherence to lengthy treatment and longer hospital stays10–14, and suicide1,15. Given the serious consequences of unrecognized and untreated depression and anxiety, it is important for clinicians to know if older adults are more vulnerable, and which variables might serve as signals to screen for depression and anxiety among this population. The current study seeks to explore the relationship between age, anxiety and depression within an older oncology population. Based on the literature, we hypothesized that anxiety would decrease with age while depression would increase with age.

To evaluate the contributions of patient and treatment factors to overall expenditures and regional variation for initial treatment of localized prostate cancer (CaP) in the Medicare program.Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 47,517 beneficiaries with localized CaP during 2005-2009 and matched noncancer controls. We employed hierarchical generalized linear models to estimate risk-standardized cancer-related expenditures for each hospital referral region. To identify key contributors to the variation, we sequentially added patient characteristics, treatment intensity (the percentage of patients receiving curative treatments), ancillary procedures (biopsy, hormone therapy, and imaging), and specific treatment modalities into the model. We categorized the expenditures according to the type of services to identify their relative impact on the expenditure variations.The mean expenditure on CaP-related care per CaP beneficiary was $15,900, including $1800 on surgery, $11,200 on radiotherapy, and $1900 on ancillary procedures. The expenditure difference between quintiles 5 and 1 was $6200. Patient characteristics explained 8.4% of this difference. Treatment intensity and treatment modalities accounted for an additional 21.2% and 31.2% of the variation, respectively. Between the highest and lowest expenditure quintiles, the difference in radiotherapy expenditure was $5000, whereas that in surgery or ancillary procedures was$200.There is substantial geographic variation in CaP expenditures, and the specific modality of radiotherapy is the most important contributor to this variation. Efforts to address the CaP care costs, such as bundled payment development, require targeting both treatment intensity and use of costly modalities.

Objective To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot-assisted surgery from a population-based cohort in the USA. Methods After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN. Results We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [OR] 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)-designated cancer centres (OR: 1.10; P < 0.05) compared with non-academic, rural and non-ACOS-designated cancer centre hospitals, respectively. Robot-assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001). Conclusions Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot-assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN.

With the growing concerns about overtreatment in prostate cancer, the extent to which radiation oncologists and urologists perceive active surveillance (AS) as effective and recommend it to patients are unknown.To assess opinions of radiation oncologists and urologists about their perceptions of AS and treatment recommendations for low-risk prostate cancer.National survey of specialists.Radiation oncologists and urologists practicing in the United States.A total of 1366 respondents were asked whether AS was effective and whether it was underused nationally, whether their patients were interested in AS, and treatment recommendations for low-risk prostate cancer. Pearson's χ test and multivariate logistic regression were used to test for differences in physician perceptions on AS and treatment recommendations.Overall, 717 (52.5%) of physicians completed the survey with minimal differences between specialties (P=0.92). Although most physicians reported that AS is effective (71.9%) and underused in the United States (80.0%), 71.0% stated that their patients were not interested in AS. For low-risk prostate cancer, more physicians recommended radical prostatectomy (44.9%) or brachytherapy (35.4%); fewer endorsed AS (22.1%). On multivariable analysis, urologists were more likely to recommend surgery [odds ratio (OR): 4.19; P0.001] and AS (OR: 2.55; P0.001), but less likely to recommend brachytherapy (OR: 0.13; P0.001) and external beam radiation therapy (OR: 0.11; P0.001) compared with radiation oncologists.Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

BACKGROUND Ideally, screening detects cancer at a more curable stage and, as a result, decreases the rate of subsequent diagnosis at a late stage. Although it is suggested that some cancer screening tests have led to substantial increases in early-stage incidence with only marginal reductions in late-stage incidence (eg mammography), the association between temporal trends in colorectal cancer screening and its cumulative impact on colorectal cancer incidence is unknown. METHODS Colorectal cancer incidence data spanning over 3 decades (1976-2009) were collected from the Surveillance, Epidemiology, and End Results database. Data on screening use spanning the period from 1986 to 2010 were collected from the National Cancer Institute Cancer Trends Progress Report, and trends in the incidence of early-stage (in situ, local) and late-stage (regional, distant) colorectal cancer were examined among adults aged ≥50 years. RESULTS From 1987 to 2010—the years for which screening data were available—the percentage of adults aged ≥50 years who underwent screening rose from 34.8% to 66.1% (which included increases in colonoscopy). During that time, the incidence of late-stage colorectal cancer decreased from 118 to 74 cases per 100,000 population (P

Background As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers. Methods Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix. Results We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1–1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6–32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th–75th percentile = 1.0–2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0–39.0]). Conclusion Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality.

6511 Background: Because the benefits of adjuvant radiation therapy (RT) for breast cancer decrease with increasing age, the use of newer and more expensive RT modalities such as brachytherapy in the treatment of older women has been questioned. In particular, patients and policy makers may be concerned that for-profit hospitals might be more likely to use therapies with higher reimbursements. Among both younger and older Medicare beneficiaries with breast cancer, we examined whether hospital ownership status is associated with use of adjuvant brachytherapy. Methods: Using the Centers for Medicare and Medicaid Services Chronic Condition Warehouse database, we conducted a retrospective study of female Medicare beneficiaries aged 66-94 years old receiving breast-conserving surgery for invasive breast cancer in 2008 and 2009. We assessed the relationship between hospital ownership and receipt of brachytherapy, as well as overall RT (i.e. brachytherapy or whole breast irradiation) using hierarchical generalized linear models. Results: The sample consisted of 35,118 women, 8.0% of whom had undergone surgery at for-profit hospitals.Among patients who received RT, those who underwent surgery at for-profit hospitals were significantly more likely to receive brachytherapy (20.2%) than patients treated at not-for-profit hospitals (15.2%; OR for profit vs. not-for profit: 1.50; 95% CI: 1.23-1.84; p

Purpose Stereotactic body radiation therapy (SBRT) is a technically demanding prostate cancer treatment that may be less expensive than intensity-modulated radiation therapy (IMRT). Because SBRT may deliver a greater biologic dose of radiation than IMRT, toxicity could be increased. Studies comparing treatment cost to the Medicare program and toxicity are needed. Methods We performed a retrospective study by using a national sample of Medicare beneficiaries age ≥ 66 years who received SBRT or IMRT as primary treatment for prostate cancer from 2008 to 2011. Each SBRT patient was matched to two IMRT patients with similar follow-up (6, 12, or 24 months). We calculated the cost of radiation therapy treatment to the Medicare program and toxicity as measured by Medicare claims; we used a random effects model to compare genitourinary (GU), GI, and other toxicity between matched patients. Results The study sample consisted of 1,335 SBRT patients matched to 2,670 IMRT patients. The mean treatment cost was $13,645 for SBRT versus $21,023 for IMRT. In the 6 months after treatment initiation, 15.6% of SBRT versus 12.6% of IMRT patients experienced GU toxicity (odds ratio [OR], 1.29; 95% CI, 1.05 to 1.53; P = .009). At 24 months after treatment initiation, 43.9% of SBRT versus 36.3% of IMRT patients had GU toxicity (OR, 1.38; 95% CI, 1.12 to 1.63; P = .001). The increase in GU toxicity was due to claims indicative of urethritis, urinary incontinence, and/or obstruction. Conclusion Although SBRT was associated with lower treatment costs, there appears to be a greater rate of GU toxicity for patients undergoing SBRT compared with IMRT, and prospective correlation with randomized trials is needed.

Objective To assess recommendations for prostate-specific antigen (PSA) screening in a national survey of radiation oncologists and urologists following the recent USA Preventive Services Task Force (USPSTF) grade D recommendation. Methods A random sample of 1366 radiation oncologists and urologists were identified from the American Medical Association Physician Masterfile. From November 2011 to April 2012, a mail survey was sent to query PSA screening recommendations for men at average risk of prostate cancer for the following age groups: 40–49, 50–59, 60–69, 70–74, 75–79 and ≥80 years. Multivariable logistic regression was used to test for differences in PSA-based screening recommendations by physician characteristics. Results Response rates were similar at 52% for radiation oncologists and urologists (P = 0.92). Overall, 51.5% of respondents recommended PSA-based screening for men aged 40–49 years, while nearly all endorsed it for those aged 50–74 years (96.1% for 50–59, 97.3% for 60–69, and 87.7% for 70–74 years). However, screening recommendations decreased to 43.9% and 12.8% for men aged 75–79 and ≥80 years, respectively. On multivariable analysis, urologists were more likely to recommend screening for men aged 40–49 (odds ratio [OR] 3.09; P < 0.001) and 50–59 years (OR 3.81; P = 0.01), but less likely for men aged 75–79 (OR 0.66; P = 0.01) and ≥80 years (OR 0.45; P = 0.002) compared with radiation oncologists. Conclusion While radiation oncologists and urologists recommended PSA screening for men aged 50–69 years, there was less agreement about screening for younger (40–49 years old) and older (≥70 years) men at average risk for prostate cancer.

INTRODUCTION:To inform proper surgical planning and policy discussion regarding uterine power morcellation, this study estimated the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications.METHODS:Women who underwent a h

Introduction: Ibrutinib, an orally and continuously administered Bruton tyrosine kinase inhibitor, allows for targeted, non-chemotherapy based treatment for chronic lymphocytic leukemia (CLL). While the initial US marketing approval for ibrutinib in CLL was for relapsed disease (February 2014), several trials have since shown favorable efficacy in the first-line setting. Ibrutinib was well tolerated in these pivotal studies, with discontinuation occurring in less than 9% at 12 months (O'Brien et al., Am J Hemato. 2019). Most early ibrutinib discontinuations in the first-line setting are due to adverse events (Tedeschi et al., EHA 2019), and optimal strategies to manage ibrutinib-related toxicities are not well defined. We hypothesized that ibrutinib is increasingly utilized for first-line treatment of CLL during routine management in the US, but that ibrutinib discontinuation rates for the real-world population are greater than those reported in clinical trials. Further, we expected to find greater odds of discontinuation in older adults and those with poor performance status, two groups underrepresented in clinical trials. Methods: We conducted a retrospective cohort study of CLL patients treated at community oncology practices using the nationwide Flatiron Health database. The Flatiron Health database is a longitudinal, demographically and geographically diverse database derived from de-identified electronic health record data from over 280 cancer clinics in the US. All patients initiated CLL therapy in the first-line setting between March 1, 2014 and February 28, 2019. We first assessed trends in the use of first-line ibrutinib (i.e., ibrutinib with/without an anti-CD20 antibody). We then focused on patients who received ibrutinib and had at least 180 days of available follow up or had died within this period. We used multivariable logistic regression to assess the association of patient characteristics with early discontinuation (defined as stopping within 180 days of initiation). Covariates included in our model were patient age, sex, race, insurance type, ECOG performance status, year of treatment, time from CLL diagnosis to ibrutinib initiation, chromosome 17p status, and geographical region. Results: We identified 5,634 individuals initiating first-line treatment for CLL, of whom 1,639 (29.1%) received an ibrutinib-based regimen. Use of ibrutinib in the first-line setting increased over time (Cochrane-Armitage test for trend, p Conclusion: While ibrutinib was increasingly utilized in the first-line setting for CLL within our large representative US community patient cohort, early discontinuation was more common than reported in pivotal trials. Given the complexity of the rapidly changing CLL treatment landscape, clinical decision support tools and other modern cancer care delivery approaches should be explored to improve administration of novel CLL therapies in the real-world setting. Disclosures Huntington: Genentech: Consultancy; Bayer: Consultancy, Honoraria; AbbVie: Consultancy; Celgene: Consultancy, Research Funding; DTRM Biopharm: Research Funding; Pharmacyclics: Honoraria. Barr:Merck: Consultancy; Janssen: Consultancy; AbbVie: Consultancy; Pharmacyclics LLC, an AbbVie company: Consultancy, Research Funding; TG Therapeutics: Consultancy, Research Funding; Seattle Genetics: Consultancy; Celgene: Consultancy; Genentech: Consultancy; Verastem: Consultancy; Gilead: Consultancy; Astra Zeneca: Consultancy, Research Funding. Jacobs:Genentech: Speakers Bureau; AstraZeneca: Speakers Bureau; Pharmacyclics LLC, an AbbVie Company: Research Funding, Speakers Bureau; TG Therapeutics: Honoraria, Research Funding; AbbVie: Consultancy, Speakers Bureau; JUNO: Consultancy; Gilead: Consultancy. Davidoff:PhRMA: Research Funding; Celgene: Research Funding. Gross:Johnson and Johnson: Research Funding; 21st Century Cancer: Research Funding; Pfizer: Research Funding.

Background Risk models for NSCLC have identified age as a prognostic factor, but the relevance of molecular biomarkers to age-related outcomes is undefined. We explored the prevalence of biomarkers by age group and the impact of biomarker status on age-related differences in OS among aNSCLC patients (pts) in a real-world population. Methods Pts with stage IIIB, IV or recurrent metastatic NSCLC (diagnosed 1/1/11 to 11/30/18) were identified in a US-based, EHR-derived, deidentified database (Flatiron Health). Cox proportional hazard regressions evaluated OS by age at aNSCLC diagnosis (dx) ( Results Our sample included 41,024 pts (median age 69 years); median OS was 11 months. Pts Conclusions Young aNSCLC pts have longer OS than older pts; this benefit is significantly mediated through biomarker status. Pts with mutations had similar OS regardless of age group. As older pts are tested less often and have a lower prevalence of mutations, future work should explore whether increased testing in older pts may mitigate the age-related OS disparity. Table . 1558P Baseline characteristics by age at aNSCLC Dx * All, n (%) N = 41,024 ≥50 y, n (%) n = 39,643 Female 19,301 (47) 716 (52) 18,585 (47) Non-squamous histology 28,203 (69) 1092 (79) 27,111 (68) Non-smoker 4723 (12) 323 (23) 4400 (11) ALK tested 23,618 (58) 948 (69) 22,670 (57) ALK+ † 625 (2.6) 106 (11) 519 (2.3) EGFR tested 25,276 (62) 1000 (72) 24,276 (61) EGFR+ † 3009 (12) 162 (16) 2847 (12) ROS1 tested 12,310 (30) 514 (37) 11,796 (30) ROS1+ † 113 (0.92) 12 (2.3) 101 (0.86) * All age comparisons p † among tested Legal entity responsible for the study Flatiron Health. Funding Flatiron Health. Disclosure A.B. Cohen: Shareholder / Stockholder / Stock options, Full / Part-time employment: Flatiron Health, an independent subsidiary of Roche; Shareholder / Stockholder / Stock options: Roche. B.D.A.P. Neri: Shareholder / Stockholder / Stock options, Full / Part-time employment: Flatiron Health, an independent subsidiary of the Roche group. B.J.S. Adamson: Full / Part-time employment, Provisional patent filed: Flatiron Health, an independent subsidiary of Roche; Non-remunerated activity/ies, Provisional patent filed: University of Washington; Research grant / Funding (self): American Foundation for Pharmaceutical Education; Research grant / Funding (institution): PhRMA Foundation; Leadership role: International Society for Pharmacoeconomics and Outcomes Research; Advisory / Consultancy: Salutis Consulting; Advisory / Consultancy: Fred Hutchinson Cancer Research Center; Advisory / Consultancy: Institute for Disease Modeling, Intellectual Ventures; Advisory / Consultancy: Boston Scientific; Shareholder / Stockholder / Stock options: Roche. C.M. Scanlon: Shareholder / Stockholder / Stock options, Full / Part-time employment: Flatiron Health, an independent subsidiary of Roche. C. Gross: Honoraria (self), Travel / Accommodation / Expenses: Flatiron Health, Inc., which is an independent subsidiary of the Roche Group; Research grant / Funding (institution): Pfizer; Research grant / Funding (institution): Johnson & Johnson. N.J. Meropol: Shareholder / Stockholder / Stock options, Full / Part-time employment: Flatiron Health, Inc., which is an independent subsidiary of the Roche Group; Shareholder / Stockholder / Stock options: Roche. R.A. Miksad: Shareholder / Stockholder / Stock options, Full / Part-time employment: Flatiron Health, Inc., which is an independent subsidiary of the Roche Group; Shareholder / Stockholder / Stock options: Roche; Advisory / Consultancy: De Luca Foundation.

2 Background: Value-based payment programs like the Oncology Care Model (OCM) have focused efforts to reduce costly acute care use through improvements in access and coordination rather than targeting the exponential rise in pharmaceutical pricing. We assessed how participation in OCM affected total cost of cancer care at a large academic cancer center. Methods: Using Medicare claims for Yale-Smilow Cancer Hospital, an NCI-designated cancer center with an academic hub and 10 community practices, we identified episodes for chemotherapy initiated during a historical period (pre-OCM, 2012-2015) and performance period (post-OCM, 2016-2017) following OCM criteria to identify total cost of care. We reported frequency of utilization categories, the mean cost per episode, the proportion of total cost attributed to each utilization category and compared pre- and post-participation periods. Results: There were 8,843 episodes during the historical period and 6,679 episodes during the performance period. The mean total cost per episode increased from $28,645 to $32,666, but this was less than the Medicare-defined expected increase (target price). Between the two periods, the percentage of total episodes decreased for emergency department (ED) use from 36% to 33%, inpatient care from 33% to 29%, and post-acute care from 28% to 25% (p < 0.01). Mean costs of drugs per episode increased by 27% between periods, and from 52% to 58% of total cost of care (p < 0.01). While mean cost per episode for ED, inpatient, and post-acute care remained stable, the mean cost per episode for antineoplastics increased 39% from $10,676 to $14,843. Conclusions: After implementing OCM, we beat the Medicare target largely by decreasing acute care use and stabilizing the cost of hospitalizations and ED; however, actual cost increased largely due to pharmaceutical spending. Because drug costs were the largest proportion of overall cost of care, future value-based models must address the rising cost of pharmaceuticals. [Table: see text]

105 Background: Despite ongoing debate about the effectiveness of initiating breast cancer screening at age 40, there is less attention paid to costs implications associated with the alternative screening starting ages. We assessed the annual costs of different screening strategies for privately insured women aged 40-49, as well as regional cost variation. Methods: We used a limited data set from Blue Cross Blue Shield (BCBS) Axis, the largest source of commercial US claims data. We identified the unit costs and frequencies of screening and subsequent evaluation for beneficiaries with continuous coverage through 2017. A Monte Carlo simulation model was developed to evaluate the annual costs of three alternate screening strategies: 1) current clinical practice, 2) annual screening beginning at age 40, or 3) annual screening beginning at age 45. The following procedures were included: screening (2-D and 3-D mammogram), supplementary ultrasound, recall (diagnostic 2-D and 3-D mammogram and ultrasound), MRI, and biopsy. We examined variability in screening-related costs across hospital referral regions (HRRs), and identified the main contributors to regional variation. Results: Overall, 69% of women in their 40s received a mammogram in 2017, resulting in an annual cost of $200 per beneficiary. This cost varied nine-fold across HRRs (range: $60-550 per beneficiary). The median cost of mammograms varied substantially across regions (2-D median cost: $206; range: $100-463; 3-D median: $271; range: $104-676). Variability in the cost of 2-D and 3-D mammogram was the main contributor to the variation in annual screening-related costs across HRRs, explaining 37% and 27% of the total variation, respectively. Screening all women beginning at age 40 would be associated with an annual cost of $309 per beneficiary (range: $127-664). Initiating screening at age 45 would cost $153 per beneficiary (range: $61-319). Conclusions: In current practice, breast cancer screening in women ages 40-49 is common, and costs $200 per eligible female beneficiary annually. Screening all women beginning at age 40 would increase the median screening-related costs by over 50%, although the cost implications vary substantially across regions.

Background Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes. Objectives To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors. Study Design Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach. Results Overall, 0.96% (95% confidence interval: 0.92–1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71–0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20–0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13–0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18–29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value. Conclusions In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification.

LBA1 Background: Racial disparities in cancer outcomes remain a societal challenge. The ACA sought to improve equity in healthcare access and outcomes by permitting states to expand Medicaid and providing subsidies for purchase of private insurance. We assessed the impact of Medicaid expansions on racial disparities in time to treatment among patients (pts) with advanced cancer. Methods: We selected pts ages 18-64 years with advanced or metastatic cancer (NSCLC, breast, urothelial, gastric, colorectal, renal cell, prostate, and melanoma), diagnosed between Jan 1, 2011 and Dec 31, 2018, from the nationwide Flatiron Health electronic health record-derived database. We assigned expansion status based on whether the pts’ state of residence had expanded Medicaid as of the diagnosis date. We estimated Medicaid expansion-related changes in the rate of “timely treatment,” an outcome defined as first-line treatment start within 30 days of advanced or metastatic diagnosis. Regression model covariates included race (White, African American, Asian, and Other race), age, sex, practice type, cancer type, stage, and unemployment rate, using time and state fixed-effects. Regression results present predictive margins. Results: The study included 34,067 pts (median age 57 years; 12% African American). Racial disparities were observed pre-expansion: African American pts were 4.9 percentage points (%pt) less likely to receive timely treatment (Table). Regardless of race, Medicaid expansion trended toward an increase in timely treatment overall (p = 0.05). Expansion was associated with a differential benefit for African American vs white pts (6.9 %pt and 1.8 %pt). Prior racial disparities were no longer observed after Medicaid expansion. Conclusions: Implementation of Medicaid expansions as part of the ACA differentially improved African American cancer pts’ receipt of timely treatment, reducing racial disparities in access to care.[Table: see text]

1567 Background: In the setting of decreased PSA screening, the incidence of metastatic prostate cancer has been increasing in the United States. This was chronologically proceeded by decreasing localized prostate cancer incidence. While decreased detection of localized disease is hypothesized to increase likelihood of metastatic disease at diagnosis, it is unclear whether the two are geographically connected. Methods: Prostate cancer incidence was obtained from the of Surveillance, Epidemiology, and End Results (SEER) database for men 70 years or older. SEER Summary Stage 2000 was used to classify localized (local) and metastatic (distant) prostate cancers. Changes in incidence rates were calculated by health services areas (HSA), which each represents a relatively self-contained region of hospital care. We chose a priori to examine most recent years 2012-2015 for changes in metastatic disease, and proceeding years 2008-2011 for changes in localized disease. Population-weighted linear regression that was robust to outliers was performed. Results: A total of over 66,600 cases of localized and 6,400 cases of metastatic prostate cancer from 200 HSAs were included for analysis. From 2008 to 2011, localized incidence decreased from 613.6 to 534.2 per 100,000 men overall, and for each HSA on average decreased by 30.3 per 100,000 men for each year. From 2012 to 2015, metastatic incidence increased from 54.7 to 62.1 per 100,000 men overall, and for each HSA on average increased by 2.1 per 100,000 men for each year. Linear regression between HSA-level changes in localized and metastatic disease revealed a correlation coefficient of -0.023 (SE = 0.017, p = 0.16, 95% CI -0.056 to 0.009), representing lack of a statistically significant relationship between decreases in localized disease and later increases in metastatic disease within each health services region. Conclusions: Despite concerns of increasing metastatic prostate cancer incidence coinciding with decreases in PSA screening and localized cancer incidence, we do not observe a statistically significant geographic and temporal relationship between metastatic and localized disease at the HSA level. Our study is limited by short lead time and thus this trend warrants continued surveillance.

8044 Background: Abnormalities of chromosome 1 (C1A) are common genetic mutations in patients (pts) with Multiple Myeloma (MM). While several small studies have reported worse outcomes for C1A, the prevalence, real-world treatment and outcomes for pts with C1A are unknown. Methods: We used the Flatiron Health Electronic Health Record (EHR)-derived database to identify pts with newly diagnosed MM from 01/2011 to 03/2018 with Fluorescence In situ Hybridization (FISH) testing within 90 days of diagnosis and defined lines of therapy. We identified pts with C1A and other high-risk mutations (HRM; 17p deletion, t14;16 and t4;14). Pts were followed until 3/31/2018 or death. The primary outcome was overall survival (OS). We used Kaplan Meier methods and compared OS for pts with/without C1A using log-rank tests stratified for HRM. We used Cox regression analysis to compare OS across groups, adjusting for age, gender, performance status, stage, HRM and treatment (triple regimen vs other). Results: The total sample included 3,578 pts: median age at diagnosis was 69 yrs (IQR 31-85), with 54% males and 60% whites. IgG(57%) and IgA(22%) were the most common M-protein subtypes. At baseline, 844 (24%) had C1A. Pts with C1A had higher stage (ISS III 35% vs 26%; p < 0.01) and other HRM (27% vs 14%, p < 0.01). Common first line-therapies included bortezomib(V), lenalidomide(R) and dexamethasone (D) (35%), RD (20%) followed by VD(15%). Use of VRD was higher with C1A vs without (40% vs 33% respectively, p < 0.01). Median OS was 66.9 months for the entire cohort and was lower for pts with C1A vs without (median OS 46.6 vs 70.1 months; log rank p < 0.01). Multivariable Cox survival analysis showed that C1A was independently associated with worse OS (adjusted HR 1.64; 95% CI 1.23-2.19); p < 0.01). Other predictors of worse survival included older age, black ethnicity, higher ISS stage, poor performance status and HRM. Conclusions: In this large study of real-world practice, C1A was associated with inferior OS independent of other HRM, despite higher use of VRD. Future studies are needed to assess whether specific regimens improve outcomes for C1A compared to patients without HRM.

531 Background: Hypofractionated radiotherapy is the recommended approach for adjuvant breast cancer care. Yet physicians have been slow to abandon conventionally fractionated radiotherapy (CFRT). We examined distinct trajectories of abandoning CFRT among physician patient-sharing peer groups and the associated cost implications. Methods: Using 2011-2014 national Medicare claims, we constructed peer groups of physicians (radiation and medical oncologists, surgeons, and primary care physicians) who cared for women with breast cancer. Women ≥66 years of age who underwent lumpectomy plus adjuvant radiotherapy were included. Peer groups represented physicians who frequently shared patients with one another. For each peer group, we calculated risk-adjusted rate of CFRT use in 2011-2012 (T1) and 2013-2014 (T2) after accounting for patient risk factors. Based on these utilization rates and a latent growth curve analysis, we identified distinct trajectories of abandoning CFRT among peer groups and estimated their cost implications from the Medicare perspective. Results: The 215 physician peer groups (caring for 16,988 patients) exhibited four distinct trajectories of CFRT use: 1) persistent high use (mean adjusted utilization: T1 = 94.3%, T2 = 90.6%); 2) decreased high use (T1 = 81.3%, T2 = 65.3%); 3) decreased medium use (T1 = 60.1%, T2 = 44.0%); and 4) decreased low use (T1 = 31.6%, T2 = 23.6%). They accounted for 33.0%, 35.3%, 25.6% and 6.0% of the peer groups, respectively. Compared to “persistent high use” of CFRT, peer groups with “decreased high use” and “decreased medium use” of CFRT had a smaller proportion of patients receiving radiotherapy at free-standing (vs. hospital-based) facilities (adjusted odds ratio = 0.89, p = 0.01; and 0.78, p < 0.01; respectively). Accelerating abandonment of CFRT in the three higher utilization trajectories to “decreased low use” for the 2011-2014 patient cohort could save Medicare $342.7 million (95% confidence interval: $232.2-$457.6 million). Conclusions: Physician peer groups had distinct trajectories in abandoning CFRT exhibiting different baseline levels and rates of change in utilization. Efforts to reduce overuse of CFRT could generate substantial savings.

6615 Background: Oncology-specific urgent care clinics (UCC) may play a key role in reducing unscheduled emergency department (ED) visits among patients with cancer. We sought to determine if establishment of an Oncology UCC was associated with lower ED utilization among patients receiving cancer care at Yale’s Smilow Cancer Hospital (SCH) and two nearby, integrated community practices. Methods: SCH opened its UCC in April 2017 to provide supportive care and symptom management for patients with cancer who need acute medical attention outside of regular clinic visits. We identified patients who had at least one visit with an oncology provider during the Pre-UCC period (9/1/16 – 12/31/16) or Post-UCC period (9/1/17 – 12/31/17) and received chemotherapy within a year preceding their provider visit. For each patient, we captured all ED visits in a four-month window starting from their last provider visit in each study period. The ED visit rate for both periods was defined as the total number of ED visits divided by the total number of unique patients in the period. To determine the impact of the UCC on ED utilization, we evaluated the absolute difference in the ED visit rate between the Pre- and Post-UCC period using a two-sample t test. Results: There were 3,754 patients in the Pre-UCC period and 4,734 patients in the Post-UCC period. In the full study sample, the mean age was 62.9 and most common cancer types were Hematologic, Gastrointestinal, and Breast. Prior to opening the UCC, the ED visit rate was 0.27 per unique patient. After opening the UCC, we found a 13.9% relative decrease in the overall ED visit rate from 0.27 to 0.23 (p = 0.02). The SCH patient ED visit rate declined by 12.5% (p = 0.03) and the community practice rate declined by 37.1%; however, the latter decline was not statistically significant, potentially due to a small sample size (p = 0.19). Conclusions: Our study found a decrease in the ED visit rate after the opening of an Oncology UCC. An urgent care strategy for cancer centers may serve as an efficient way to manage patients while minimizing ED use. [Table: see text]

e18310 Background: Cancer care is complex, requiring multidisciplinary care over time and settings. Our implementation strategy for participation in CMS’ Oncology Care Model included the development of a new care management program to provide elderly patients with cancer support and continuity between inpatient and outpatient care with the goal of reducing acute care utilization. With no published models of care coordination in cancer, we launched this program using nurses experience to risk stratify and manage the needs of nearly 2500 patients. To optimize their work, we sought to understand the activity breakdown of their working time and to identify areas that can be managed more efficiently. Methods: Care coordinators are nurses responsible for completing the Institute of Medicine (IOM) care plan, stratifying patients by risk and comorbidity and administering weekly symptom assessment scales to those at high risk for disease and treatment complications. We created, pilot tested and refined a data collection tool that care coordinators could self-report the time they spent in activities of direct and indirect patient care. We performed a desk audit to measure the amount of time that oncology care coordinators spend on various activities and to explore differences in academic center versus care center care coordinators. A total of seven care coordinators self-reported activity specific time for 5 working days. Data were analyzed to assess variation in the proportion of activity time by care coordinator, site of care and day of the week using anova and t-test for the difference in mean activity time. Results: Care coordinators spent the majority of their time in indirect patient care (58%) with the highest percentage of their time specifically on charting/documentation (28%) while only 42% of their time included activities that were direct patient care. We observed no significant difference in the proportion of time spent in direct versus indirect patient care across care coordinators (p = 0.47, day of the week (p = 0.35) or by location of care (p = 0.68). Conclusions: A minority of care coordinators time is spent on providing direct patient care and substantial time is spent on indirect activities including charting and documentation. The efficiency of the care coordination model may be improved by transferring tasks that do not require the clinical expertise of these nurses.

9059 Background: Several tests measuring programmed cell death ligand 1 (PD-L1) expression are available to select patients with advanced non-small cell lung cancer (aNSCLC) for PD-1 axis therapy including FDA approved companion diagnostics (CoDx), as well as complementary (CyDx) and laboratory developed tests (LDTs). However, it is unknown how rapidly PD-L1 expression testing has become adopted, which type of tests are used, or whether testing affects first-line therapy. Methods: We retrospectively reviewed the Flatiron Health electronic health record-derived database, reflecting real-world care at community oncology practices in the U.S. We evaluated trends in the use of PD-L1 expression testing within 12 months of diagnosis. Among patients diagnosed after FDA approval of PD-L1 testing prior to first-line therapy (Oct 2016), and without other identifiable driver mutations, we used multivariable logistic regression to examine the association between PD-L1 testing and receipt of first-line PD-1 axis therapy. We further examined the association between PD-L1 expression result (using overall reported status or % staining) and choice of first-line therapy. Results: We identified 49,546 patients with aNSCLC from 2011 through the third quarter of 2018. The use of PD-L1 expression testing increased from 7.0% in 2015 to 70.6% in 2017 (p < 0.01). Among those receiving testing, the proportion of patients receiving CoDx increased from 29.9% in 2015 to 73.0% in 2017 with corresponding reductions in CyDx and LDTs. PD-L1 expression testing was associated with use of PD1-axis therapy in the first-line (OR = 2.92, 95% CI 2.59-3.30). Among 4,942 treated patients diagnosed after Oct 2016, those with ≥50% staining more frequently received first line PD-1 axis therapy (82.9%) than those with intermediate (35.5%) or low (25.8%) positive staining; conversely, patients with ≥50% were less likely to receive chemotherapy alone or combination with PD-1 axis therapy. Conclusions: PD-L1 expression testing was rapidly adopted following FDA approval of companion diagnostic testing for aNSCLC. Although the results of PD-L1 expression testing inform the choice of first-line therapy, a substantial proportion of patients are not tested prior to first line treatment.

395 Background: National guidelines recommend against chemotherapy use at the end of life. Five CPIs are now approved for aUC. We hypothesized that oncologists may have a lower threshold to initiate CPI in patients (pts) at the end of life, particularly among pts with poor performance status (PS), because of the perceived favorable toxicity profile of CPI. Methods: We conducted a secular trend analysis using the Flatiron Health Database, a large real-world electronic medical record-derived dataset. We used nonparametric tests of trend (p values reported as ptrend) to evaluate quarterly proportions of pts initiating CPI, chemotherapy, or no systemic therapy within 30 and 60 days of death, among 2959 pts diagnosed with aUC from 2015 to 2017. Results: 1637 pts died during follow-up and were eligible for analysis. 278 (17.0%) and 488 (29.8%) pts initiated a new line of systemic therapy in the last 30 and 60 days of life, respectively. The quarterly proportion of CPI initiators within 60 days of death increased from 1.0% to 23% during the study period ( ptrend < 0.001), with corresponding decreases in chemotherapy initiation and no systemic therapy. After CPI approval in mid-2016, CPI initiation significantly increased among pts with Eastern Cooperative Oncology Group (ECOG) PS ≥ 2 ( ptrend = 0.02) but did not significantly change among pts with PS 0-1. Initiation of any systemic therapy at the end of life doubled (17.4% to 34.8%) over the study period, driven largely by end-of-life CPI use. Compared to chemotherapy initiators, CPI initiators had slightly worse PS (table). Conclusions: In patients with aUC, there has been a dramatic rise in CPI initiation at the end of life particularly among pts with poor PS. Existing guidelines on systemic therapy initiation near the end of life should account for the increasing use of CPI. [Table: see text]

Background: Older pts with BC receiving adjuvant tx are at increased risk of chemo tox; however, no BC-specific tool exists to quantify this risk. The Cancer and Aging Research Group (CARG) developed/validated a chemo tox score for older pts with all stages of solid tumor. The goals of this study were to: 1) build upon the CARG score by developing/validating CARG-BC (a BC specific adjuvant chemo tox score for older pts) and 2) evaluate its association with dose modifications, reduced relative dose intensity (RDI) and hospitalizations. Methods: 501 pts age ≥65 with stage I-III BC from 16 sites were accrued (300 development; 201 validation cohort). A pre-chemo assessment captured: CARG chemo tox score, BC tumor/tx variables, and additional geriatric assessment (GA) items. Grade 3-5 chemo tox by NCI CTCAE v 4.0 was captured. Univariate analysis identified chemo tox risk factors (p Results: Among 501 pts, 28 received non-standard regimens and were excluded, leaving 473 evaluable pts: 283 development and 190 validation cohort. The development cohort (median age 70; range 65-85) had Stage I (39%), II (41%), & III (20%) BC with 65% hormone positive, 24% triple negative, 27% Her2 positive; and 37% received an anthracycline. Grade 3-5 tox occurred in 46% (36% grade 3, 10% grade 4, 0.4% grade 5). The CARG score was significantly associated with grade 3-5 tox (p Conclusions: We developed and validated a risk score (CARG-BC) which identifies an older pt's risk for adjuvant BC chemo tox and is associated with dose reduction, delay, reduced RDI, and hospitalization. This tool could be considered as a part of adjuvant tx decision-making. Chemo Tox Risk Score for BC (CARG-BC) Grade 3-5 Tox (%)ScoreCARG-Score: age, # of chemo drugs, dose, hemoglobin, creatinine clearance, hearing, falls, ability to walk 1 block and take meds, decreased social activitiesLow360Middle573High613StageI330II/III552Planned Tx Duration≤ 3 mo.330> 3 mo.584AnthracyclineNo380Yes591Liver FunctionNormal450Abnormal623Ability to Walk a MileNot limited370Limited613Someone to Provide AdviceMost of Time440None to Some of Time613 CARG-BC Risk ScoreLow210-5Middle456-9High7910+ Citation Format: Hurria A, Magnuson A, Gross CP, Tew WP, Klepin HD, Wildes TM, Muss HB, Dotan E, Freedman R, O'Connor T, Dale W, Cohen HJ, Katheria V, Arsenyan A, Levi A, Kim H, Sun C-L. Development and validation of a chemotherapy toxicity (Chemo Tox) risk score for older patients (Pts) with breast cancer (BC) receiving adjuvant/neoadjuvant treatment (Adjuvant Tx): A R01 and BCRF funded prospective multicenter study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS6-04.

Background Treatment adherence may influence the therapeutic effect that is observed in a randomized controlled trial (RCT). Adherence may also be an indicator of research quality and treatment acceptance by participants. Despite the importance of adherence in RCT research, little is known about current practices for its measurement and reporting. Purpose The objective of this study was to determine and evaluate adherence measurement and reporting practices in RCTs involving oral pharmacologic interventions published in high impact factor journals. Methods We conducted a systematic review of RCTs involving oral pharmacotherapy published during 2010 in 10 high-impact general medicine and subspecialty journals. Two investigators independently abstracted data regarding trial characteristics, adherence monitoring, and adherence reporting. Differences were reconciled in conference. Descriptive statistics were calculated, statistical comparisons were made using chi-square analysis, and associations assessed using Spearman’s rank correlation coefficient. Results Of 111 RCT manuscripts included in the sample, 51 (45.9%) reported study-drug adherence among participants. Studies that reported adherence results were more likely to report negative findings (i.e., no significant treatment effect in a superiority trial, non-equivalence in an equivalence trial) (p = 0.032). The most common method for adherence monitoring was pill count-back on returned bottles. Among the studies that reported adherence, the median adherence was 88.4% (range: 48%−100%), and trials with longer follow-up time reported lower adherence (r = −0.45; p = 0.0015). A minority of the 51 studies described a strategy for calculating adherence that accounted for participants who were lost to follow-up (11/51 studies; 21.6%), discontinued the study medication temporarily (6/51 studies; 11.8%), or discontinued the study drug permanently (1/51 study; 2%). Limitations This study is limited by the inclusion of a small set of journals with the highest impact factors in specific fields of clinical medicine, including general medicine. Although the analysis pertains to studies published in 2010, no new guidelines in the field since the last Consolidated Standards of Reporting Trials (CONSORT) statement have been issued that would be expected to change practices for adherence monitoring, analysis, and reporting. Conclusions Adherence measurement methodology and results are underreported in published RCTs. In the minority of RCTs that provided adherence information, there was substantial heterogeneity in how adherence was defined, analyzed, and reported. Improved reporting of adherence may enhance the interpretation of study quality and results.

Objective: Oncotype DxTM (ODx) is a gene expression profile test that is rapidly gaining popularity for its ability to stratify breast cancer patients according to risk of distant recurrence and suggest the potential benefit of adjuvant chemotherapy (CTx). Presently, National Comprehensive Cancer Network (NCCN) guidelines suggest use of ODx for all patients with node negative (or micrometastatic node positive disease), hormone receptor positive breast cancer with a primary tumor measuring over 5mm. However, if risk factors predictive of a high recurrence score (RS) were defined, clinicians would be better able to tailor use of ODx. This study was undertaken to identify standard clinicopathologic factors that correlate with a high RS by ODx, and to determine whether these factors or RS most influenced receipt of CTx. We also measured compliance with NCCN guidelines regarding ODx utilization. Methods and Materials: We performed an IRB approved retrospective review of women with invasive breast cancer treated at Yale Cancer Center from 2008-2012 to identify patients that received ODx testing, and abstracted clinical and tumor characteristics including: age, tumor size, grade, histology, lymphovascular invasion (LVI), number of involved nodes, size of nodal metastasis, presence of extracapsular extension, hormone receptor status (including percent positive), HER2 status (by FISH), RS, and receipt of CTx. The RS was categorized into low (30). We assessed the association between these characteristics and both high RS as well as CTx receipt using Chi squared tests and Wilcoxon ranked test as appropriate. Characteristics with a p-value Results: We identified 432 women with a median age of 58 years. RS was low, intermediate, and high in 56%, 37%, and 7%, respectively. Median tumor size was 1.6cm (range 0.1-13.2). Differentiation was rated as well, moderate, or poor in 32%, 60%, and 8%, respectively. Tumors were hormone receptor positive in 99%. ODx was used outside of NCCN guidelines in 12%. CTx was given to 30% of patients. Younger age, HER2-positivity, LVI, poor differentiation, progesterone receptor positivity (PR+) 50% or less, and RS were associated with receipt of CTx (p< = 0.01) in bivariate analyses. High RS remained independently associated with CTx receipt in multivariate analysis. Poor differentiation, PR+ 50% or less, and HER2-positivity were significantly associated with a high RS (p Conclusions: High RS independently influences recommendations for chemotherapy. Poor differentiation, PR+ 50% or less, and HER2-positivity were associated with a high RS. In the absence of any of these three factors, the likelihood of a high RS is minimal. Noncompliance with NCCN guidelines was observed. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-11-22.

BACKGROUND Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. METHODS A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. RESULTS Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). CONCLUSIONS Medicare prostate cancer screening–related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis. Cancer 2014;120:96–102. © 2013 American Cancer Society.

BACKGROUND Laparoscopic colectomy for the treatment of colon cancer has been widely adopted in community practice, in part, because of shorter hospitalizations. The benefits of a shorter hospital stay are only realized if readmissions and emergency department visits, collectively termed revisits, do not increase after discharge. We conducted a population-based analysis to determine whether hospitals with higher laparoscopic colectomy rates have higher revisit rates. OBJECTIVE The aim of this study was to determine whether hospital utilization after discharge is increased for patients undergoing laparoscopic colectomy for cancer. DESIGN This is a retrospective cohort study. SETTINGS Data were gathered from the Healthcare Cost and Utilization Project's inpatient and emergency department databases for California. These databases include data from all nonfederal hospitals in the State of California. PATIENTS Patients who underwent elective colectomy for cancer from 2008 to 2009 were included. INTERVENTIONS The primary intervention was elective colectomy with the use of the open or laparoscopic approach. MAIN OUTCOME MEASURES The correlation between hospital laparoscopy rates and hospital readmission rates, emergency department visit rates, and revisit rates was calculated. RESULTS Overall, 6760 patients were treated at 176 hospitals. For every 100 patients discharged, there were 14.0 readmissions and 9.2 emergency department encounters. At the hospital level, laparoscopy rates varied considerably (median = 45.7%, range = 2.2%-88.9%), as did the risk-standardized readmission (12.1%, 8.6%-16.5%), emergency department encounter (7.8%, 4.1%-18.0%), and revisit rates (17.9%, 13.0%-26.4%). A hospital's laparoscopy rate was not significantly correlated with its risk-standardized readmission (weighted correlation coefficient = 0.05, p = 0.50), emergency department encounter (-0.11, p = 0.16), or revisit (-0.03, p = 0.70) rates. LIMITATIONS There are inherent limitations when using administrative data. CONCLUSIONS Hospitals where a greater proportion of colon resections for cancer are approached laparoscopically do not have higher 30-day, risk-standardized readmission, emergency department encounter, or revisit rates.

While there has been increasing interest in the use of preoperative breast magnetic resonance imaging (MRI) for women with breast cancer, little is known about trends in MRI use, or the association of MRI with surgical approach among older women. Using the Surveillance, Epidemiology and End Results–Medicare database, we identified a cohort of women diagnosed with breast cancer from 2000 to 2009 who underwent surgery. We used Medicare claims to identify preoperative breast MRI and surgical approach. We evaluated temporal trends in MRI use according to age and type of surgery, and identified factors associated with MRI. We assessed the association between MRI and surgical approach: breast-conserving surgery (BCS) versus mastectomy, bilateral versus unilateral mastectomy, and use of contralateral prophylactic mastectomy. Among the 72,461 women in our cohort, 10.1 % underwent breast MRI. Preoperative MRI use increased from 0.8 % in 2000–2001 to 25.2 % in 2008–2009 (p < 0.001). Overall, 43.3 % received mastectomy and 56.7 % received BCS. After adjustment for clinical and demographic factors, MRI was associated with an increased likelihood of having a mastectomy compared to BCS (adjusted odds ratio = 1.21, 95 % CI 1.14–1.28). Among women who underwent mastectomy, MRI was significantly associated with an increased likelihood of having bilateral cancer diagnosed (9.7 %) and undergoing bilateral mastectomy (12.5 %) compared to women without MRI (3.7 and 4.1 %, respectively, p < 0.001 for both). In conclusion, the use of preoperative breast MRI has increased substantially among older women with breast cancer and is associated with an increased likelihood of being diagnosed with bilateral cancer, and more invasive surgery.

Learning Objectives Compare characteristics of older patients that receive bevacizumab plus chemotherapy to those treated with chemotherapy alone for advanced NSCLC and CRC. Compare outcomes between older patients treated with bevacizumab plus chemotherapy to chemotherapy alone for advanced NSCLC and CRC. Describe toxicities in older patients treated with bevacizumab plus chemotherapy for advanced NSCLC and CRC. Background. Bevacizumab leads to improved survival for patients with metastatic colorectal cancer (CRC) or non-small cell lung cancer (NSCLC) when added to chemotherapy. Little is known about factors associated with receipt of bevacizumab, or whether bevacizamab is associated with increased toxicity when added to chemotherapy. Patients and Methods. We conducted a prospective study of patients aged ≥65 years, which evaluated the association between geriatric assessment (GA) metrics and chemotherapy toxicity. We examined differences in characteristics and outcomes of patients with CRC and NSCLC cancers who received bevacizumab with chemotherapy versus chemotherapy alone. Results. From a total of 207 patients, 27 (13%) received bevacizumab plus chemotherapy and 180 (87%) received chemotherapy alone. Groups were similar in sociodemographic and cancer characteristics. There were no baseline differences in GA domains except that patients with heart disease were less likely to receive bevacizumab (4% vs. 26%, p = .01). Seventy-eight percent of patients who had bevacizumab had grade 3–5 toxicity compared to only 57% who received chemotherapy alone (p = .06). Patients receiving bevacizumab were more likely to develop grade 3 hypertension than those who received chemotherapy alone (15% vs. 2%, p < .01). In multivariable analysis, factors associated with grade 3 or more toxicity included: bevacizumab (OR: 2.86, p = .04), CRC (OR: 2.54, p < .01), and baseline anemia (OR: 2.58, p = .03). Conclusion. Heart disease was more common in those who did not receive bevacizumab. Older patients who receive bevacizumab with chemotherapy have a higher odds of developing a grade 3–5 toxicity compared with those who receive chemotherapy alone.

Purpose New radiation therapy modalities have broadened treatment options for older women with breast cancer, but it is unclear how clinical factors, geographic region, and physician preference affect the choice of radiation therapy modality. Methods and Materials We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women diagnosed with stage I-III breast cancer from 1998 to 2007 who underwent breast-conserving surgery. We assessed the temporal trends in, and costs of, the adoption of intensity modulated radiation therapy (IMRT) and brachytherapy. Using hierarchical logistic regression, we evaluated the relationship between the use of these new modalities and patient and regional characteristics. Results Of 35,060 patients, 69.9% received conventional external beam radiation therapy (EBRT). Although overall radiation therapy use remained constant, the use of IMRT increased from 0.0% to 12.6% from 1998 to 2007, and brachytherapy increased from 0.7% to 9.0%. The statistical variation in brachytherapy use attributable to the radiation oncologist and geographic region was 41.4% and 9.5%, respectively (for IMRT: 23.8% and 22.1%, respectively). Women undergoing treatment at a free-standing radiation facility were significantly more likely to receive IMRT than were women treated at a hospital-based facility (odds ratio for IMRT vs EBRT: 3.89 [95% confidence interval, 2.78-5.45]). No such association was seen for brachytherapy. The median radiation therapy cost per treated patient increased from $5389 in 2001 to $8539 in 2007. Conclusions IMRT and brachytherapy use increased substantially from 1998 to 2007; overall, radiation therapy costs increased by more than 50%. Radiation oncologists played an important role in treatment choice for both types of radiation therapy, whereas geographic region played a bigger role in the use of IMRT than brachytherapy.

Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown.We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment.The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0).From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.

PURPOSE Following the acute phase of treatment, national guidelines recommend cancer survivors have routine contact with health care providers and undergo basic ancillary testing while avoiding high-cost imaging (HCI). We conducted this study to determine how frequently breast, prostate, and colorectal cancer survivors received recommended follow-up care and HCI tests during the survivorship period. METHODS Using administrative data from TRICARE beneficiaries, we identified a cohort of patients who were treated for breast, prostate, or colorectal cancer between October 2005 and March 2007. These patients were then followed through September 2010. During the 3 years after initial treatment, we determined how frequently survivors received all minimum recommended survivorship care as defined by national guidelines and underwent HCI tests and if these outcomes varied by geographic region. RESULTS Overall, 3148 patients underwent treatment for breast (n = 1630), prostate (n = 1173), or colorectal (n = 345) cancer. Sixty-five percent received all minimum recommended care over 3 years (breast = 74.1%, prostate = 65.3%, colorectal = 25.5%). During the 3-year period, 74.1% of breast cancer survivors received a mammogram each year, whereas 69.1% of colorectal cancer survivors had at least 1 colonoscopy. Sixty-four percent had at least 1 HCI study during the 3-year period (positron emission tomography = 10.9%, computer tomography = 48.8%, magnetic resonance imaging = 36.6%) at a cost of $3.5 million. Substantial state-level variation was noted for both outcomes. DISCUSSION Some cancer survivors do not receive recommended care following initial treatment while frequently undergoing HCI. The existing geographic variation in quality and imaging utilization suggests that improvements to cancer survivorship care are possible.

Objectives. We decomposed the total effect of coexisting diseases on a timed occurrence of an adverse outcome into additive effects from individual diseases. Methods. In a cohort of older adults enrolled in the Precipitating Events Project in New Haven County, Connecticut, we assessed a longitudinal extension of the average attributable fraction method (LE-AAF) to estimate the additive and order-free contributions of multiple diseases to the timed occurrence of a health outcome, with right censoring, which may be useful when relationships among diseases are complex. We partitioned the contribution to death into additive LE-AAFs for multiple diseases. Results. The onset of heart failure and acute episodes of pneumonia during follow-up contributed the most to death, with the overall LE-AAFs equal to 13.0% and 12.1%, respectively. The contribution of preexisting diseases decreased over the years, with a trend of increasing contribution from new onset of diseases. Conclusions. LE-AAF can be useful for determining the additive and order-free contribution of individual time-varying diseases to a time-to-event outcome.

Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both.Using the SEER-Medicare dataset, we identified men 67–84 years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy10 years; high-benefit as moderate-risk tumors and life expectancy ≥10 years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups.Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR)=0.65; 95% CI, 0.62–0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P=0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR=0.74; 95% CI, 0.67–0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR=0.64; 95% CI, 0.59–0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR=0.57; 95% CI, 0.48–0.68). The interaction between race and clinical benefit was significant (P0.001).Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.

Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit.We used the Surveillance, Epidemiology, and End Results–Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004–2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group.There were 10,686 men in the sample (mean age 74.2 years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with a life expectancy5 years had higher rates of ncADT use than men with a life expectancy≥10 years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving ncADT (odds ratio for men aged 80–84 compared to 67–69=1.93 (95% CI 1.37–2.70); 1.51 (95% CI 1.22–1.87); and 1.71 (95% CI 1.14–2.57) for high-, intermediate-, and low-risk groups, respectively).ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy.