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James Yu

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Christine Hendon (Fleming)

Columbia University

Anna M . Czarnecka

Ivana Gadjanski

Columbia University

Olaf L. Müller

Humboldt Universität zu Berlin

Kathirarasi Hasmi

Anna University

North Dakota State University

Thomas Jefferson University

Sahrdaya College OF Engineering and technology

MGH, Harvard

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University of Lausanne

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Papers by James Yu

Historical Trends in the Use of Radiation Therapy for Pediatric Cancers: 1973-2008

International Journal of Radiation Oncology Biology Physics, Mar 1, 2013

Purpose-This study was undertaken to assess historical trends in the use of radiation therapy (RT... more Purpose-This study was undertaken to assess historical trends in the use of radiation therapy (RT) for pediatric cancers over the past 4 decades. Methods-The National Cancer Institute's Surveillance, Epidemiology, and End Results database of the 9 original tumor registries (SEER9) was queried to identify patients aged 0-19 years with acute lympholytic leukemia (ALL), acute myeloid leukemia (AML), bone and joint, brain and other nervous system, Hodgkin's lymphoma (HL), neuroblastoma, non-Hodgkin's lymphoma (NHL), soft tissue, Wilms tumor, or retinoblastoma from 1973 to 2008. Patients were grouped into 4 year time epochs. Number and percentage of patients who received RT as a part of initial treatment were calculated per epoch by each diagnosis group from 1973-2008. Results-RT usage for ALL, NHL, and retinoblastoma declined sharply from 57%, 57%, and 30% in 1973-76 to 11%, 15%, and 2% in 2005-08, respectively. Similarly, smaller declines in RT usage were also seen in brain (70% to 39%), bone (41% to 21%), Wilms tumors (75% to 53%), and neuroblastoma (60% to 25%). RT usage curves for Wilms tumors and neuroblastoma were nonlinear with nadirs in 1993-96 at 39% and 19%, respectively. There were minimal changes in RT use for HL, soft tissue cancers, or AML, roughly stable at 72%, 40%, and 11%, respectively. Almost all patients treated with RT were given exclusively external beam radiation therapy (EBRT). However, from 1985-2008, treatments involving brachytherapy, radioisotopes, or combination therapy increased in frequency, comprising 1.8%, 4.6%, and 11.9% of RT treatments in brain cancer, soft tissue cancer, and retinoblastoma, respectively. Conclusions-The use of RT is declining over time in seven out of ten pediatric cancer categories. A limitation of this study is a potential underascertainment of radiotherapy usage in the SEER9 database including the delayed use of RT.

BRAF V600 Mutation and BRAF Kinase Inhibitors in Conjunction With Stereotactic Radiosurgery for Intracranial Melanoma Metastases: A Multicenter Retrospective Study

Neurosurgery, 2018

BACKGROUND The BRAF mutation has been identified as a potent target for the treatment of metastat... more BACKGROUND The BRAF mutation has been identified as a potent target for the treatment of metastatic melanoma and BRAF inhibitors (BRAFi) have demonstrated promising results against melanoma brain metastases (BM). OBJECTIVE To further investigate the effectiveness of this combined treatment regimen. METHODS In this multicenter retrospective cohort study, 198 patients with known BRAF mutation status and treated with stereotactic radiosurgery (SRS) between 2011 and 2015 were identified. Kaplan–Meier methodology and multivariate regression analysis was then used to compare survival based on each parameter. RESULTS The median survival after the diagnosis of BM in patients with BRAF mutation who received BRAFi was increased compared to survival in patients with wild-type BRAF (BRAF wt). In multivariate analysis, the BRAF mutation was an independent, positive prognostic factor with a hazard ratio of 0.59. BRAF mutated Patients who received BRAFi following SRS had improved survival compared...

Prostate cancer outcomes for men aged younger than 65 years with Medicaid versus private insurance

Cancer, Jan 15, 2018

In the current national debate regarding private insurance versus Medicaid expansion, understandi... more In the current national debate regarding private insurance versus Medicaid expansion, understanding how insurance is associated with racial disparities in prostate cancer (CaP) outcomes has broad policy implications. In the current study, the authors examined the association between insurance status, race, and CaP outcomes. The Surveillance, Epidemiology, and End Results program identified 155,524 men aged < 65 years who were diagnosed with CaP from 2007 through 2014. The association between insurance and stage of disease at the time of presentation was examined. Among men with localized CaP, the associations between insurance and receipt of therapy and prostate cancer-specific mortality (PCSM) were determined. Compared with private insurance, men with Medicaid were more likely to present with metastatic disease (adjusted odds ratio [AOR], 4.27; 95% confidence interval [95% CI], 4.01-4.55), were less likely to receive definitive treatment (AOR, 0.67; 95% CI, 0.62-0.71), and had i...

Demonstration of differential radiosensitivity based upon mutation profile in metastatic melanoma treated with stereotactic radiosurgery

Journal of radiosurgery and SBRT, 2016

Metastatic melanoma often involves the brain. Radiotherapy is an important treatment of melanoma ... more Metastatic melanoma often involves the brain. Radiotherapy is an important treatment of melanoma brain metastases, although melanoma radiosensitivity is considered heterogeneous. Thus, identifying subsets with differential radiosensitivity is essential. Patients with metastatic melanoma were identified in a prospective stereotactic radiosurgery (SRS) database. Tumor were tested for alterations in B-RAF, N-RAS, and c-KIT. Standardized imaging following SRS was reviewed for recurrence. Differences in local and distant failure were determined using modified Cox proportional hazards models. 102 patients and 1,028 brain metastases were included. N-RAS mutated patients were significantly less likely to develop local recurrence after SRS than wild type patients (HR 0.17, 95% CI 0.04-0.72, p=0.017). B-RAF and c-KIT mutations were not associated with altered rates of local recurrence. Lower local recurrence rates for N-RAS mutated tumors persisted on multivariate analysis (HR 0.18, 95% CI 0....

Risk of myeloid neoplasms after radiotherapy among older women with localized breast cancer: A population-based study

PLOS ONE, 2017

Background There are inconsistent and limited data regarding the risk of myeloid neoplasms (MN) a... more Background There are inconsistent and limited data regarding the risk of myeloid neoplasms (MN) among breast cancer survivors who received radiotherapy (RT) in the absence of chemotherapy. Concern about subsequent MN might influence the decision to use adjuvant RT for women with localized disease. As patients with therapy-related MN have generally poor outcomes, the presumption of subsequent MN being therapy-related could affect treatment recommendations. Methods We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to study older women with in-situ or stage 1-3 breast cancer diagnosed 2001-2009 who received surgery. Chemotherapy and RT were ascertained using Medicare claims, and new MN diagnoses were captured using both SEER registry and Medicare claims. We excluded women who received chemotherapy for initial treatment, and censored at receipt of subsequent chemotherapy. Competing-risk survival analysis was used to assess the association between RT and risk of subsequent MN adjusting for relevant characteristics. Results Median follow-up for 60,426 eligible patients was 68 months (interquartile range, 46 to 92 months), with 47.6% receiving RT. In total, 316 patients (0.52%) were diagnosed with MN; the cumulative incidence per 10,000 person-years was 10.6 vs 9.0 among RT-treated vs non-RT-treated women, respectively (p = .004); the increased risk of subsequent MN

Weighing Risk of Cardiovascular Mortality Against Potential Benefit of Hormonal Therapy in Intermediate-Risk Prostate Cancer

Journal of the National Cancer Institute, Jun 1, 2017

The purpose of this study is to determine the optimal strategy for men with newly diagnosed inter... more The purpose of this study is to determine the optimal strategy for men with newly diagnosed intermediate-risk prostate cancer by age and cardiac risk. A Markov model was calibrated to the EORTC 22991 trial, which randomly assigned men with intermediate-risk prostate cancer to radiation therapy (RT) with or without six months of hormonal therapy (HT). We compared quality-adjusted life-years (QALYs) in men age 50, 60, and 70 years by age decile and cardiac risk group. Competing risks of cardiovascular mortality were estimated from the published literature. Sensitivity analyses were used to assess the impact of varying model assumptions. HT was associated with a net decrease of 0.3 to 0.4 QALYs in men with a history of myocardial infarction. However, for all other men, HT improved QALYs (range = 0.4-2.6 QALYs). Younger men with fewer cardiac risk factors experienced the largest benefit from HT. In sensitivity analyses, the model was only found to be sensitive to the probability of bioc...

Promoting the Appropriate Use of Advanced Radiation Technologies in Oncology: Summary of a National Cancer Policy Forum Workshop

International journal of radiation oncology, biology, physics, Mar 8, 2016

Leaders in the oncology community are sounding a clarion call to promote "value" in can... more Leaders in the oncology community are sounding a clarion call to promote "value" in cancer care decisions. Value in cancer care considers the clinical effectiveness, along with the costs, when selecting a treatment. To discuss possible solutions to the current obstacles to achieving value in the use of advanced technologies in oncology, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop, "Appropriate Use of Advanced Technologies for Radiation Therapy and Surgery in Oncology" in July 2015. The present report summarizes the discussions related to radiation oncology. The workshop convened stakeholders, including oncologists, researchers, payers, policymakers, and patients. Speakers presented on key themes, including the rationale for a value discussion on advanced technology use in radiation oncology, the generation of scientific evidence for value of advanced radiation technologies, the effect of both s...

Spine Stereotactic Body Radiotherapy Outcomes in Patients with Concurrent Brain Metastases

Curēus, Jan 11, 2016

Stereotactic body radiotherapy (SBRT) is an emerging technique for maximizing tumor and pain con... more Stereotactic body radiotherapy (SBRT) is an emerging technique for maximizing tumor and pain control in selected patients with spinal metastases. Outcomes for those with concurrent brain metastases (CBM) have not been well-described previously. The goal of this study was to compare outcomes for patients with or without CBM treated with spine SBRT. Records of all patients treated with SBRT for spine metastases at our institution from January 2008 to January 2014 were reviewed. Chi-square analyses and the Mann-Whitney test were used to assess the association of CBM (defined as brain metastasis present prior to or at the time of spinal SBRT) with potential covariates. The log-rank test and Cox proportional hazards regression were used to evaluate the impact of CBM on overall survival and local control from the time of the first course of spine SBRT. Seventy-eight patients and a total of 86 SBRT lesions were treated. Median patient age was 60 years (range: 38-84 years); 28.2% had rad...

Concurrent chemoradiotherapy versus radiotherapy alone for “biopsy‐only” glioblastoma multiforme

Cancer, 2016

BACKGROUNDCombined temozolomide and radiotherapy (RT) is the standard postoperative therapy for g... more BACKGROUNDCombined temozolomide and radiotherapy (RT) is the standard postoperative therapy for glioblastoma multiforme (GBM). However, the clearest benefit of concurrent chemoradiotherapy (CRT) observed in clinical trials has been among patients who undergo surgical resection. Whether the improved survival with CRT extends to patients who undergo “biopsy only” is less certain. The authors compared overall survival (OS) in a national cohort of patients with GBM who underwent biopsy and received either RT alone or CRT during the temozolomide era.METHODSThe US National Cancer Data Base was used to identify patients with histologically confirmed, biopsy‐only GBM who received either RT alone or CRT from 2006 through 2011. Demographic and clinicopathologic predictors of treatment were analyzed using the chi‐square test, the t test, and multivariable logistic regression. OS was evaluated using the log‐rank test, multivariable Cox proportional hazard regression, and propensity score‐matche...

ReCAP: Radiation Oncology Practice: Adjusting to a New Reimbursement Model

Journal of oncology practice / American Society of Clinical Oncology, May 22, 2016

How will the increasing use of hypofractionation (use of a fewer number of fractions) affect reim... more How will the increasing use of hypofractionation (use of a fewer number of fractions) affect reimbursement and staffing in a hospital-based radiation oncology department? From a 40% use rate of hypofractionation, a department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 operating hours per day. We modeled the effects on reimbursement on a typical average-sized hospital-based radiation oncology department of moving to hypofractionation for the most common cancers that make up the bulk of a typical hospital-based practice using 2015 Centers for Medicare and Medicaid Services reimbursement rates and relative value unit values. A radiotherapy department treating 40% with hypofractionation would experience an approximate $540,663 decrease in global revenue with a per-case marginal reduction of $9,498, $4,297, $9,040, and $1,777 for lung, breast, and prostate cancers and palliative care, respec...

Role of Chemoradiotherapy in Elderly Patients With Limited-Stage Small-Cell Lung Cancer

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 19, 2015

To investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemorad... more To investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemoradiotherapy (CRT) in the modern era by using a large national database. Elderly patients (age ≥ 70 years) with limited-stage small-cell lung cancer clinical stage I to III who received CT or CRT were identified in the National Cancer Data Base between 2003 and 2011. Hierarchical mixed-effects logistic regression with clustering by reporting facility was performed to identify factors associated with treatment selection. Overall survival (OS) of patients receiving CT versus CRT was compared by using the log-rank test, Cox proportional hazards regression, and propensity score matching. A total of 8,637 patients were identified, among whom 3,775 (43.7%) received CT and 4,862 (56.3%) received CRT. The odds of receiving CRT decreased with increasing age, clinical stage III disease, female sex, and the presence of medical comorbidities (all P < .01). Use of CRT was associated with increased OS...

Extended Survival and Prognostic Factors for Patients With ALK-Rearranged Non-Small-Cell Lung Cancer and Brain Metastasis

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 5, 2015

We performed a multi-institutional study to identify prognostic factors and determine outcomes fo... more We performed a multi-institutional study to identify prognostic factors and determine outcomes for patients with ALK-rearranged non-small-cell lung cancer (NSCLC) and brain metastasis. A total of 90 patients with brain metastases from ALK-rearranged NSCLC were identified from six institutions; 84 of 90 patients received radiotherapy to the brain (stereotactic radiosurgery [SRS] or whole-brain radiotherapy [WBRT]), and 86 of 90 received tyrosine kinase inhibitor (TKI) therapy. Estimates for overall (OS) and intracranial progression-free survival were determined and clinical prognostic factors were identified by Cox proportional hazards modeling. Median OS after development of brain metastases was 49.5 months (95% CI, 29.0 months to not reached), and median intracranial progression-free survival was 11.9 months (95% CI, 10.1 to 18.2 months). Forty-five percent of patients with follow-up had progressive brain metastases at death, and repeated interventions for brain metastases were com...

Gleason score 5 + 3 = 8 prostate cancer: much more like Gleason score 9?

BJU International, 2015

To determine whether patients with Gleason score 5+3=8 prostate cancer have outcomes more similar... more To determine whether patients with Gleason score 5+3=8 prostate cancer have outcomes more similar to other patients with Gleason 8 disease or to patients with Gleason 9 disease. The SEER database was used to study 40,533 men diagnosed with N0M0 Gleason 8 or 9 prostate cancer from 2004 - 2011. Using Gleason 4+4=8 as the referent, Fine and Gray competing risks regression analyses modeled the association between Gleason score and prostate cancer-specific mortality (PCSM). Five-year PCSM rates for patients with Gleason 4+4=8, Gleason 3+5=8, Gleason 5+3=8, and Gleason 9 disease were 6.3%, 6.6%, 13.5%, and 13.9%, respectively (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Patients with Gleason 5+3=8 or Gleason 9 disease had up to a two-fold increased risk for PCSM ([Adjusted Hazard Ratio (AHR) 1.89; 95% CI 1.50 - 2.38; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001] and [AHR 2.17; 95% CI 1.99 - 2.36; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001], respectively) compared to the referent group of patients (Gleason 4+4=8). There was no difference in PCSM between patients with Gleason 5+3=8 versus 9 disease (P=0.25). Gleason 8 disease represents a heterogeneous entity with PCSM outcomes distinguishable by the primary Gleason pattern. The PCSM of Gleason 3+5=8 and Gleason 4+4=8 disease are similar, but patients with Gleason 5+3=8 have a risk of PCSM that is twice as high as other patients with Gleason 8 disease and should be considered to have similar poor prognosis as patients with Gleason 9 disease. Such patients should be allowed onto trials seeking the highest-risk patients in which to test novel aggressive treatment strategies. This article is protected by copyright. All rights reserved.

Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non-Small-Cell Lung Cancer

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 22, 2015

To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletel... more To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletely resected non-small-cell lung cancer (NSCLC) and evaluate the association between PORT and survival in such patients. We identified patients with pathologic stage N0-2, overall American Joint Committee on Cancer stage II or III NSCLC within the National Cancer Data Base who had undergone a lobectomy or pneumonectomy with positive surgical margins. Only patients coded as receiving external-beam PORT at 50 to 74 Gy or observation were included. To account for perioperative mortality, we excluded patients who survived less than 4 months after diagnosis. Multivariable logistic regression was used to determine factors associated with PORT receipt. Cox proportional hazards regression was performed for multivariable analyses of overall survival. Among 3,395 included patients, 1,207 (35.6%) received PORT. Predictors for the use of PORT among this patient population included age less than 60 yea...

Comparative effectiveness of surgery and radiosurgery for stage I non-small cell lung cancer

Cancer, Jan 6, 2015

Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), st... more Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), stereotactic body radiotherapy (SBRT) has been disseminated as an alternative therapy. The comparative mortalities and toxicities of these treatments for patients of different life expectancies are unknown. The Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify patients who were 67 years old or older and underwent SBRT or surgery for stage I NSCLC from 2007 to 2009. Matched patients were stratified into short life expectancies (<5 years) and long life expectancies (≥5 years). Mortality and complication rates were compared with Poisson regression. Overall, 367 SBRT patients and 711 surgery patients were matched. Acute toxicity (0-1 month) was lower from SBRT versus surgery (7.9% vs 54.9%, P < .001). At 24 months after treatment, there was no difference (69.7% vs 73.9%, P = .31). The incidence rate ratio (IRR) for toxicity from SBRT versus surgery...

Poorer prognosis of African-American patients with Mycosis fungoides: an analysis of the SEER dataset, 1988 to 2008

Clinical lymphoma, myeloma & leukemia, 2014

The aims of this study were: (1) to determine whether AA patients with MF have a worse prognosis ... more The aims of this study were: (1) to determine whether AA patients with MF have a worse prognosis despite accounting for varying clinical factors at presentation, and (2) to assess whether a racial disparity exists regarding utilization of radiation therapy (RT) as an initial treatment modality. The SEER 1988-2008 public use database was investigated. Univariate and multivariate analysis was used to assess for factors significantly associated with disease-specific survival (DSS), overall survival (OS), and RT utilization survival. A total of 4892 patients with MF were identified with a median follow-up of 58 months. On multivariate analysis including tumor registry, age, sex, marital status, and tumor stage, AA race was significantly correlated with a worse OS (hazard ratio [HR], 1.58; P < .001) and DSS (HR, 1.78; P < .001). With regard to RT utilization, more advanced age (odds ratio [OR], 1.005; P < .001) and higher stage (OR, 3.03; P < .001) were associated with a high...

Considerations for Observational Research Using Large Data Sets in Radiation Oncology

International Journal of Radiation Oncology*Biology*Physics, 2014

The radiation oncology community has witnessed growing interest in observational research conduct... more

Variation in Receipt of Radiation Therapy After Breast-conserving Surgery

Medical Care, 2013

Background-Among older women with early stage breast cancer, patients with a short life expectanc... more Background-Among older women with early stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups. Objective-To determine the relative contribution of patient, physician and regional factors on the use of RT. Design-Retrospective cohort. Subjects-Women age 67-94 diagnosed with stage I breast cancer between 1998-2007 receiving breast-conserving surgery. Measures-We evaluated patient, physician and regional factors for their association with RT across strata of LE using a three-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.

Surveillance Epidemiology and End Results Evaluation of the Role of Surgery for Stage I Small Cell Lung Cancer

Journal of Thoracic Oncology, 2010

Introduction: This study was performed to evaluate the clinical outcomes of surgery for stage I s... more Introduction: This study was performed to evaluate the clinical outcomes of surgery for stage I small cell lung cancer (SCLC). Methods: The National Cancer Institute Surveillance Epidemiology and End Results (SEER) database was analyzed to evaluate outcomes for patients with SCLC treated from 1988 to 2004. Patients with stage I disease were selected. Kaplan-Meier survival curves were constructed for overall survival (OS) and cause-specific survival for patient strata based on type of surgery and radiation use or nonuse. Although SEER does not provide chemotherapy details, it is assumed that most, if not all, of these patients received systemic therapy. Results: A total of 1560 patients were identified as having stage I SCLC. Median age was 70 years (range 27-94 years). Two hundred forty-seven patients underwent lobectomy, 121 had local tumor excision/ablation, 10 had a pneumonectomy, and surgery was unknown in 21. One thousand one hundred sixty-one did not have any cancer-directed surgery. Of those who had lobectomy, 205 (83%) did not receive radiation therapy (RT), 38 (15%) did receive RT, and use of RT was unknown in 4 (2%). For those who had lobectomy without RT (n ϭ 205), 3-and 5-year OS was 58.1% (95% confidence interval [CI] 51.1-64.5%) and 50.3% (95% CI 43.1-57.1%), respectively. For those patients who had a lobectomy with RT (n ϭ 38), 3-and 5-year OS was 64.9% (95% CI 45.5-78.9%) and 57.1% (95% CI 37.4-72.7%), respectively. Conclusions: Surgery without RT seems to offer reasonable OS outcomes in a cohort of stage I patients who undergo lobectomy. These results should be considered with the understanding that systemic therapy information and margin status are not available from the SEER database.

The influence of regional health system characteristics on the surgical management and receipt of post operative radiation therapy for glioblastoma multiforme

Journal of Neuro-Oncology, 2013

Despite a known optimal treatment protocol for the management of glioblastoma multiforme (GBM), m... more Despite a known optimal treatment protocol for the management of glioblastoma multiforme (GBM), many patients fail to receive complete surgical resection or postoperative radiation therapy (PORT). The underlying reasons behind this disparity are unclear. Our study investigates the influence of regional health system resources on the surgical management and PORT receipt in patients with GBM. Surgical intervention, PORT receipt and patient data for patients diagnosed with GBM were obtained from the years 2004 to 2008 from the NCI Surveillance, Epidemiology, and End Results database and combined with the health system data from the Area Resource File. Four logistic models were constructed to test the effect of health system characteristics on surgical treatment choice and PORT receipt among health service areas (HSAs). We found that younger, married patients in HSAs with higher median incomes were significantly more likely to receive both gross total resection (p < 0.001, p < 0.001, p = 0.002) and PORT (p < 0.001, p < 0.001, p = 0.008). The density of radiation oncology equipped hospitals was also a significant predictor of PORT receipt (p = 0.002). Our findings suggest regional variations in of neuro-oncology services and income may have impact on GBM management. Policies aimed at narrowing disparities in treatment may need to focus on addressing regional variations in oncology resources.

Historical Trends in the Use of Radiation Therapy for Pediatric Cancers: 1973-2008

International Journal of Radiation Oncology Biology Physics, Mar 1, 2013

Purpose-This study was undertaken to assess historical trends in the use of radiation therapy (RT... more Purpose-This study was undertaken to assess historical trends in the use of radiation therapy (RT) for pediatric cancers over the past 4 decades. Methods-The National Cancer Institute's Surveillance, Epidemiology, and End Results database of the 9 original tumor registries (SEER9) was queried to identify patients aged 0-19 years with acute lympholytic leukemia (ALL), acute myeloid leukemia (AML), bone and joint, brain and other nervous system, Hodgkin's lymphoma (HL), neuroblastoma, non-Hodgkin's lymphoma (NHL), soft tissue, Wilms tumor, or retinoblastoma from 1973 to 2008. Patients were grouped into 4 year time epochs. Number and percentage of patients who received RT as a part of initial treatment were calculated per epoch by each diagnosis group from 1973-2008. Results-RT usage for ALL, NHL, and retinoblastoma declined sharply from 57%, 57%, and 30% in 1973-76 to 11%, 15%, and 2% in 2005-08, respectively. Similarly, smaller declines in RT usage were also seen in brain (70% to 39%), bone (41% to 21%), Wilms tumors (75% to 53%), and neuroblastoma (60% to 25%). RT usage curves for Wilms tumors and neuroblastoma were nonlinear with nadirs in 1993-96 at 39% and 19%, respectively. There were minimal changes in RT use for HL, soft tissue cancers, or AML, roughly stable at 72%, 40%, and 11%, respectively. Almost all patients treated with RT were given exclusively external beam radiation therapy (EBRT). However, from 1985-2008, treatments involving brachytherapy, radioisotopes, or combination therapy increased in frequency, comprising 1.8%, 4.6%, and 11.9% of RT treatments in brain cancer, soft tissue cancer, and retinoblastoma, respectively. Conclusions-The use of RT is declining over time in seven out of ten pediatric cancer categories. A limitation of this study is a potential underascertainment of radiotherapy usage in the SEER9 database including the delayed use of RT.

BRAF V600 Mutation and BRAF Kinase Inhibitors in Conjunction With Stereotactic Radiosurgery for Intracranial Melanoma Metastases: A Multicenter Retrospective Study

Neurosurgery, 2018

BACKGROUND The BRAF mutation has been identified as a potent target for the treatment of metastat... more BACKGROUND The BRAF mutation has been identified as a potent target for the treatment of metastatic melanoma and BRAF inhibitors (BRAFi) have demonstrated promising results against melanoma brain metastases (BM). OBJECTIVE To further investigate the effectiveness of this combined treatment regimen. METHODS In this multicenter retrospective cohort study, 198 patients with known BRAF mutation status and treated with stereotactic radiosurgery (SRS) between 2011 and 2015 were identified. Kaplan–Meier methodology and multivariate regression analysis was then used to compare survival based on each parameter. RESULTS The median survival after the diagnosis of BM in patients with BRAF mutation who received BRAFi was increased compared to survival in patients with wild-type BRAF (BRAF wt). In multivariate analysis, the BRAF mutation was an independent, positive prognostic factor with a hazard ratio of 0.59. BRAF mutated Patients who received BRAFi following SRS had improved survival compared...

Prostate cancer outcomes for men aged younger than 65 years with Medicaid versus private insurance

Cancer, Jan 15, 2018

In the current national debate regarding private insurance versus Medicaid expansion, understandi... more In the current national debate regarding private insurance versus Medicaid expansion, understanding how insurance is associated with racial disparities in prostate cancer (CaP) outcomes has broad policy implications. In the current study, the authors examined the association between insurance status, race, and CaP outcomes. The Surveillance, Epidemiology, and End Results program identified 155,524 men aged < 65 years who were diagnosed with CaP from 2007 through 2014. The association between insurance and stage of disease at the time of presentation was examined. Among men with localized CaP, the associations between insurance and receipt of therapy and prostate cancer-specific mortality (PCSM) were determined. Compared with private insurance, men with Medicaid were more likely to present with metastatic disease (adjusted odds ratio [AOR], 4.27; 95% confidence interval [95% CI], 4.01-4.55), were less likely to receive definitive treatment (AOR, 0.67; 95% CI, 0.62-0.71), and had i...

Demonstration of differential radiosensitivity based upon mutation profile in metastatic melanoma treated with stereotactic radiosurgery

Journal of radiosurgery and SBRT, 2016

Metastatic melanoma often involves the brain. Radiotherapy is an important treatment of melanoma ... more Metastatic melanoma often involves the brain. Radiotherapy is an important treatment of melanoma brain metastases, although melanoma radiosensitivity is considered heterogeneous. Thus, identifying subsets with differential radiosensitivity is essential. Patients with metastatic melanoma were identified in a prospective stereotactic radiosurgery (SRS) database. Tumor were tested for alterations in B-RAF, N-RAS, and c-KIT. Standardized imaging following SRS was reviewed for recurrence. Differences in local and distant failure were determined using modified Cox proportional hazards models. 102 patients and 1,028 brain metastases were included. N-RAS mutated patients were significantly less likely to develop local recurrence after SRS than wild type patients (HR 0.17, 95% CI 0.04-0.72, p=0.017). B-RAF and c-KIT mutations were not associated with altered rates of local recurrence. Lower local recurrence rates for N-RAS mutated tumors persisted on multivariate analysis (HR 0.18, 95% CI 0....

Risk of myeloid neoplasms after radiotherapy among older women with localized breast cancer: A population-based study

PLOS ONE, 2017

Background There are inconsistent and limited data regarding the risk of myeloid neoplasms (MN) a... more Background There are inconsistent and limited data regarding the risk of myeloid neoplasms (MN) among breast cancer survivors who received radiotherapy (RT) in the absence of chemotherapy. Concern about subsequent MN might influence the decision to use adjuvant RT for women with localized disease. As patients with therapy-related MN have generally poor outcomes, the presumption of subsequent MN being therapy-related could affect treatment recommendations. Methods We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to study older women with in-situ or stage 1-3 breast cancer diagnosed 2001-2009 who received surgery. Chemotherapy and RT were ascertained using Medicare claims, and new MN diagnoses were captured using both SEER registry and Medicare claims. We excluded women who received chemotherapy for initial treatment, and censored at receipt of subsequent chemotherapy. Competing-risk survival analysis was used to assess the association between RT and risk of subsequent MN adjusting for relevant characteristics. Results Median follow-up for 60,426 eligible patients was 68 months (interquartile range, 46 to 92 months), with 47.6% receiving RT. In total, 316 patients (0.52%) were diagnosed with MN; the cumulative incidence per 10,000 person-years was 10.6 vs 9.0 among RT-treated vs non-RT-treated women, respectively (p = .004); the increased risk of subsequent MN

Weighing Risk of Cardiovascular Mortality Against Potential Benefit of Hormonal Therapy in Intermediate-Risk Prostate Cancer

Journal of the National Cancer Institute, Jun 1, 2017

The purpose of this study is to determine the optimal strategy for men with newly diagnosed inter... more The purpose of this study is to determine the optimal strategy for men with newly diagnosed intermediate-risk prostate cancer by age and cardiac risk. A Markov model was calibrated to the EORTC 22991 trial, which randomly assigned men with intermediate-risk prostate cancer to radiation therapy (RT) with or without six months of hormonal therapy (HT). We compared quality-adjusted life-years (QALYs) in men age 50, 60, and 70 years by age decile and cardiac risk group. Competing risks of cardiovascular mortality were estimated from the published literature. Sensitivity analyses were used to assess the impact of varying model assumptions. HT was associated with a net decrease of 0.3 to 0.4 QALYs in men with a history of myocardial infarction. However, for all other men, HT improved QALYs (range = 0.4-2.6 QALYs). Younger men with fewer cardiac risk factors experienced the largest benefit from HT. In sensitivity analyses, the model was only found to be sensitive to the probability of bioc...

Promoting the Appropriate Use of Advanced Radiation Technologies in Oncology: Summary of a National Cancer Policy Forum Workshop

International journal of radiation oncology, biology, physics, Mar 8, 2016

Leaders in the oncology community are sounding a clarion call to promote "value" in can... more Leaders in the oncology community are sounding a clarion call to promote "value" in cancer care decisions. Value in cancer care considers the clinical effectiveness, along with the costs, when selecting a treatment. To discuss possible solutions to the current obstacles to achieving value in the use of advanced technologies in oncology, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop, "Appropriate Use of Advanced Technologies for Radiation Therapy and Surgery in Oncology" in July 2015. The present report summarizes the discussions related to radiation oncology. The workshop convened stakeholders, including oncologists, researchers, payers, policymakers, and patients. Speakers presented on key themes, including the rationale for a value discussion on advanced technology use in radiation oncology, the generation of scientific evidence for value of advanced radiation technologies, the effect of both s...

Spine Stereotactic Body Radiotherapy Outcomes in Patients with Concurrent Brain Metastases

Curēus, Jan 11, 2016

Stereotactic body radiotherapy (SBRT) is an emerging technique for maximizing tumor and pain con... more Stereotactic body radiotherapy (SBRT) is an emerging technique for maximizing tumor and pain control in selected patients with spinal metastases. Outcomes for those with concurrent brain metastases (CBM) have not been well-described previously. The goal of this study was to compare outcomes for patients with or without CBM treated with spine SBRT. Records of all patients treated with SBRT for spine metastases at our institution from January 2008 to January 2014 were reviewed. Chi-square analyses and the Mann-Whitney test were used to assess the association of CBM (defined as brain metastasis present prior to or at the time of spinal SBRT) with potential covariates. The log-rank test and Cox proportional hazards regression were used to evaluate the impact of CBM on overall survival and local control from the time of the first course of spine SBRT. Seventy-eight patients and a total of 86 SBRT lesions were treated. Median patient age was 60 years (range: 38-84 years); 28.2% had rad...

Concurrent chemoradiotherapy versus radiotherapy alone for “biopsy‐only” glioblastoma multiforme

Cancer, 2016

BACKGROUNDCombined temozolomide and radiotherapy (RT) is the standard postoperative therapy for g... more BACKGROUNDCombined temozolomide and radiotherapy (RT) is the standard postoperative therapy for glioblastoma multiforme (GBM). However, the clearest benefit of concurrent chemoradiotherapy (CRT) observed in clinical trials has been among patients who undergo surgical resection. Whether the improved survival with CRT extends to patients who undergo “biopsy only” is less certain. The authors compared overall survival (OS) in a national cohort of patients with GBM who underwent biopsy and received either RT alone or CRT during the temozolomide era.METHODSThe US National Cancer Data Base was used to identify patients with histologically confirmed, biopsy‐only GBM who received either RT alone or CRT from 2006 through 2011. Demographic and clinicopathologic predictors of treatment were analyzed using the chi‐square test, the t test, and multivariable logistic regression. OS was evaluated using the log‐rank test, multivariable Cox proportional hazard regression, and propensity score‐matche...

ReCAP: Radiation Oncology Practice: Adjusting to a New Reimbursement Model

Journal of oncology practice / American Society of Clinical Oncology, May 22, 2016

How will the increasing use of hypofractionation (use of a fewer number of fractions) affect reim... more How will the increasing use of hypofractionation (use of a fewer number of fractions) affect reimbursement and staffing in a hospital-based radiation oncology department? From a 40% use rate of hypofractionation, a department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 operating hours per day. We modeled the effects on reimbursement on a typical average-sized hospital-based radiation oncology department of moving to hypofractionation for the most common cancers that make up the bulk of a typical hospital-based practice using 2015 Centers for Medicare and Medicaid Services reimbursement rates and relative value unit values. A radiotherapy department treating 40% with hypofractionation would experience an approximate $540,663 decrease in global revenue with a per-case marginal reduction of $9,498, $4,297, $9,040, and $1,777 for lung, breast, and prostate cancers and palliative care, respec...

Role of Chemoradiotherapy in Elderly Patients With Limited-Stage Small-Cell Lung Cancer

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 19, 2015

To investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemorad... more To investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemoradiotherapy (CRT) in the modern era by using a large national database. Elderly patients (age ≥ 70 years) with limited-stage small-cell lung cancer clinical stage I to III who received CT or CRT were identified in the National Cancer Data Base between 2003 and 2011. Hierarchical mixed-effects logistic regression with clustering by reporting facility was performed to identify factors associated with treatment selection. Overall survival (OS) of patients receiving CT versus CRT was compared by using the log-rank test, Cox proportional hazards regression, and propensity score matching. A total of 8,637 patients were identified, among whom 3,775 (43.7%) received CT and 4,862 (56.3%) received CRT. The odds of receiving CRT decreased with increasing age, clinical stage III disease, female sex, and the presence of medical comorbidities (all P < .01). Use of CRT was associated with increased OS...

Extended Survival and Prognostic Factors for Patients With ALK-Rearranged Non-Small-Cell Lung Cancer and Brain Metastasis

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 5, 2015

We performed a multi-institutional study to identify prognostic factors and determine outcomes fo... more We performed a multi-institutional study to identify prognostic factors and determine outcomes for patients with ALK-rearranged non-small-cell lung cancer (NSCLC) and brain metastasis. A total of 90 patients with brain metastases from ALK-rearranged NSCLC were identified from six institutions; 84 of 90 patients received radiotherapy to the brain (stereotactic radiosurgery [SRS] or whole-brain radiotherapy [WBRT]), and 86 of 90 received tyrosine kinase inhibitor (TKI) therapy. Estimates for overall (OS) and intracranial progression-free survival were determined and clinical prognostic factors were identified by Cox proportional hazards modeling. Median OS after development of brain metastases was 49.5 months (95% CI, 29.0 months to not reached), and median intracranial progression-free survival was 11.9 months (95% CI, 10.1 to 18.2 months). Forty-five percent of patients with follow-up had progressive brain metastases at death, and repeated interventions for brain metastases were com...

Gleason score 5 + 3 = 8 prostate cancer: much more like Gleason score 9?

BJU International, 2015

To determine whether patients with Gleason score 5+3=8 prostate cancer have outcomes more similar... more To determine whether patients with Gleason score 5+3=8 prostate cancer have outcomes more similar to other patients with Gleason 8 disease or to patients with Gleason 9 disease. The SEER database was used to study 40,533 men diagnosed with N0M0 Gleason 8 or 9 prostate cancer from 2004 - 2011. Using Gleason 4+4=8 as the referent, Fine and Gray competing risks regression analyses modeled the association between Gleason score and prostate cancer-specific mortality (PCSM). Five-year PCSM rates for patients with Gleason 4+4=8, Gleason 3+5=8, Gleason 5+3=8, and Gleason 9 disease were 6.3%, 6.6%, 13.5%, and 13.9%, respectively (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Patients with Gleason 5+3=8 or Gleason 9 disease had up to a two-fold increased risk for PCSM ([Adjusted Hazard Ratio (AHR) 1.89; 95% CI 1.50 - 2.38; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001] and [AHR 2.17; 95% CI 1.99 - 2.36; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001], respectively) compared to the referent group of patients (Gleason 4+4=8). There was no difference in PCSM between patients with Gleason 5+3=8 versus 9 disease (P=0.25). Gleason 8 disease represents a heterogeneous entity with PCSM outcomes distinguishable by the primary Gleason pattern. The PCSM of Gleason 3+5=8 and Gleason 4+4=8 disease are similar, but patients with Gleason 5+3=8 have a risk of PCSM that is twice as high as other patients with Gleason 8 disease and should be considered to have similar poor prognosis as patients with Gleason 9 disease. Such patients should be allowed onto trials seeking the highest-risk patients in which to test novel aggressive treatment strategies. This article is protected by copyright. All rights reserved.

Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non-Small-Cell Lung Cancer

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 22, 2015

To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletel... more To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletely resected non-small-cell lung cancer (NSCLC) and evaluate the association between PORT and survival in such patients. We identified patients with pathologic stage N0-2, overall American Joint Committee on Cancer stage II or III NSCLC within the National Cancer Data Base who had undergone a lobectomy or pneumonectomy with positive surgical margins. Only patients coded as receiving external-beam PORT at 50 to 74 Gy or observation were included. To account for perioperative mortality, we excluded patients who survived less than 4 months after diagnosis. Multivariable logistic regression was used to determine factors associated with PORT receipt. Cox proportional hazards regression was performed for multivariable analyses of overall survival. Among 3,395 included patients, 1,207 (35.6%) received PORT. Predictors for the use of PORT among this patient population included age less than 60 yea...

Comparative effectiveness of surgery and radiosurgery for stage I non-small cell lung cancer

Cancer, Jan 6, 2015

Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), st... more Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), stereotactic body radiotherapy (SBRT) has been disseminated as an alternative therapy. The comparative mortalities and toxicities of these treatments for patients of different life expectancies are unknown. The Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify patients who were 67 years old or older and underwent SBRT or surgery for stage I NSCLC from 2007 to 2009. Matched patients were stratified into short life expectancies (<5 years) and long life expectancies (≥5 years). Mortality and complication rates were compared with Poisson regression. Overall, 367 SBRT patients and 711 surgery patients were matched. Acute toxicity (0-1 month) was lower from SBRT versus surgery (7.9% vs 54.9%, P < .001). At 24 months after treatment, there was no difference (69.7% vs 73.9%, P = .31). The incidence rate ratio (IRR) for toxicity from SBRT versus surgery...

Poorer prognosis of African-American patients with Mycosis fungoides: an analysis of the SEER dataset, 1988 to 2008

Clinical lymphoma, myeloma & leukemia, 2014

The aims of this study were: (1) to determine whether AA patients with MF have a worse prognosis ... more The aims of this study were: (1) to determine whether AA patients with MF have a worse prognosis despite accounting for varying clinical factors at presentation, and (2) to assess whether a racial disparity exists regarding utilization of radiation therapy (RT) as an initial treatment modality. The SEER 1988-2008 public use database was investigated. Univariate and multivariate analysis was used to assess for factors significantly associated with disease-specific survival (DSS), overall survival (OS), and RT utilization survival. A total of 4892 patients with MF were identified with a median follow-up of 58 months. On multivariate analysis including tumor registry, age, sex, marital status, and tumor stage, AA race was significantly correlated with a worse OS (hazard ratio [HR], 1.58; P < .001) and DSS (HR, 1.78; P < .001). With regard to RT utilization, more advanced age (odds ratio [OR], 1.005; P < .001) and higher stage (OR, 3.03; P < .001) were associated with a high...

Considerations for Observational Research Using Large Data Sets in Radiation Oncology

International Journal of Radiation Oncology*Biology*Physics, 2014

The radiation oncology community has witnessed growing interest in observational research conduct... more

Variation in Receipt of Radiation Therapy After Breast-conserving Surgery

Medical Care, 2013

Background-Among older women with early stage breast cancer, patients with a short life expectanc... more Background-Among older women with early stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups. Objective-To determine the relative contribution of patient, physician and regional factors on the use of RT. Design-Retrospective cohort. Subjects-Women age 67-94 diagnosed with stage I breast cancer between 1998-2007 receiving breast-conserving surgery. Measures-We evaluated patient, physician and regional factors for their association with RT across strata of LE using a three-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.

Surveillance Epidemiology and End Results Evaluation of the Role of Surgery for Stage I Small Cell Lung Cancer

Journal of Thoracic Oncology, 2010

Introduction: This study was performed to evaluate the clinical outcomes of surgery for stage I s... more Introduction: This study was performed to evaluate the clinical outcomes of surgery for stage I small cell lung cancer (SCLC). Methods: The National Cancer Institute Surveillance Epidemiology and End Results (SEER) database was analyzed to evaluate outcomes for patients with SCLC treated from 1988 to 2004. Patients with stage I disease were selected. Kaplan-Meier survival curves were constructed for overall survival (OS) and cause-specific survival for patient strata based on type of surgery and radiation use or nonuse. Although SEER does not provide chemotherapy details, it is assumed that most, if not all, of these patients received systemic therapy. Results: A total of 1560 patients were identified as having stage I SCLC. Median age was 70 years (range 27-94 years). Two hundred forty-seven patients underwent lobectomy, 121 had local tumor excision/ablation, 10 had a pneumonectomy, and surgery was unknown in 21. One thousand one hundred sixty-one did not have any cancer-directed surgery. Of those who had lobectomy, 205 (83%) did not receive radiation therapy (RT), 38 (15%) did receive RT, and use of RT was unknown in 4 (2%). For those who had lobectomy without RT (n ϭ 205), 3-and 5-year OS was 58.1% (95% confidence interval [CI] 51.1-64.5%) and 50.3% (95% CI 43.1-57.1%), respectively. For those patients who had a lobectomy with RT (n ϭ 38), 3-and 5-year OS was 64.9% (95% CI 45.5-78.9%) and 57.1% (95% CI 37.4-72.7%), respectively. Conclusions: Surgery without RT seems to offer reasonable OS outcomes in a cohort of stage I patients who undergo lobectomy. These results should be considered with the understanding that systemic therapy information and margin status are not available from the SEER database.

The influence of regional health system characteristics on the surgical management and receipt of post operative radiation therapy for glioblastoma multiforme

Journal of Neuro-Oncology, 2013

Despite a known optimal treatment protocol for the management of glioblastoma multiforme (GBM), m... more Despite a known optimal treatment protocol for the management of glioblastoma multiforme (GBM), many patients fail to receive complete surgical resection or postoperative radiation therapy (PORT). The underlying reasons behind this disparity are unclear. Our study investigates the influence of regional health system resources on the surgical management and PORT receipt in patients with GBM. Surgical intervention, PORT receipt and patient data for patients diagnosed with GBM were obtained from the years 2004 to 2008 from the NCI Surveillance, Epidemiology, and End Results database and combined with the health system data from the Area Resource File. Four logistic models were constructed to test the effect of health system characteristics on surgical treatment choice and PORT receipt among health service areas (HSAs). We found that younger, married patients in HSAs with higher median incomes were significantly more likely to receive both gross total resection (p < 0.001, p < 0.001, p = 0.002) and PORT (p < 0.001, p < 0.001, p = 0.008). The density of radiation oncology equipped hospitals was also a significant predictor of PORT receipt (p = 0.002). Our findings suggest regional variations in of neuro-oncology services and income may have impact on GBM management. Policies aimed at narrowing disparities in treatment may need to focus on addressing regional variations in oncology resources.