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Nicholas Faris



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    MA06 - Challenges in the Treatment of Early Stage NSCLC (ID 124)

    • Event: WCLC 2019
    • Type: Mini Oral Session
    • Track: Treatment of Early Stage/Localized Disease
    • Presentations: 1
    • Now Available
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      MA06.01 - Mediastinal Lymph Node Dissection (MLND) v Systematic Sampling (SS) v Neither (NN) in Population-Based Cohort (Now Available) (ID 2974)

      13:30 - 15:00  |  Author(s): Nicholas Faris

      • Abstract
      • Presentation
      • Slides

      Background

      American College of Surgeons’ Oncology Group (ACOSOG) Z0030 revealed similar survival after MLND v SS for early-stage non-small cell lung cancer (NSCLC), but a recent meta-analysis of 1,980 patients in 5 randomized controlled trials from 1989-2007 suggested superior survival after MLND, raising doubts about Z0030 findings. We compared survival of patients with MLND v SS v NN in a population-based cohort.

      Method

      All resections for NSCLC in all institutions within 4 contiguous United States Hospital Referral Regions from 2009-2018 stratified by ACOSOG Z0030 nodal examination criteria into MLND (stations 2R,4R, 7, 8, 9 and 10R for right-side resections; 4L, 5, 6, 7, 8, 9, and 10L for left-sided), SS (minimum of 4R, 7, and 10R on the right and 5,6,7 and 10L on the left, but MLND definition not met), and NN (neither MLND nor SS ).

      Using appropriate statistical tests, we compared demographic and clinical characteristics, perioperative complication rates and survival, adjusting survival for extent of resection, histology, age, race, sex and insurance.

      Result

      2118 patients met Z0030 eligibility criteria (clinical T1/2,N0/non-hilar N1,M0): 15% had MLND, 15% SS, 69% NN. The distribution of age, race, insurance was similar, but 54% v 51% v 43% of MLND v SS v NN, were female (p=.0002). Use of preoperative PET-CT scans was similar (p=.5797), but invasive staging was used in 21% v 19% v 28% (p<.01), Although the distribution of clinical T,N and aggregate stage was similar (p>.05), 10% of the patients who met neither MLND nor SS criteria had no lymph nodes examined (pathologic NX). The median (interquartile range) number of mediastinal lymph nodes examined was 8(6-12), 5(4-8), 2 (0-5) (p<.001); hilar/intrapulmonary nodes 5(2-9), 6(3-10), 3(1-7) (p<.001). Postoperative complication rates were similar, including rates of cardiac arrhythmia, chylothorax and ICU re-admission. ICU length of stay (LOS) was 1(1-2) days in all groups, hospital LOS was 5(3-7), 5(3-8), 6(4-10) days. The 30-day mortality rate was 4% for all groups. Unadjusted hazard ratio (HR) was 0.80 (0.56-1.10, p=1.664) between MLND and SS; adjusted (a)HR 0.81 (0.58-1.138, p=0.2273). Survival of MLND and SS patients was significantly better than NN (Figure): aHR 0.62(0.48-0.81, p=0.0004) for MLND v NN; aHR 0.76 (0.60-0.98, p=0.0304) for SS v NN.

      figure acosog.png

      Conclusion

      ACOSOG systematic nodal dissection was achievable and safe in a ‘real-world,’ population-based cohort. SS was associated with similar survival to MLND in early-stage NSCLC, corroborating Z0030 findings. However, the majority of resections did not attain either criteria, with significantly worse survival.

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    MA19 - Looking at PROs in Greater Detail - What Patients Actually Want and Expect (ID 147)

    • Event: WCLC 2019
    • Type: Mini Oral Session
    • Track: Treatment in the Real World - Support, Survivorship, Systems Research
    • Presentations: 1
    • Now Available
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      MA19.07 - Testing an Optimal Care Coordination Model (OCCM) for Lung Cancer in a Multi-Site Study (Now Available) (ID 2659)

      11:30 - 13:00  |  Author(s): Nicholas Faris

      • Abstract
      • Presentation
      • Slides

      Background

      Medicaid-insured lung cancer patients have worse outcomes than others. To address barriers to optimal care in the US Medicaid population, the Association of Community Cancer Centers (ACCC) created and tested the OCCM.

      Method

      The OCCM included 13 assessment areas: Patient Access to Care, Prospective Multidisciplinary Case Planning, Financial/Transportation/Housing, Care Coordination, Electronic Health Records, Survivorship Care, Supportive Care, Tobacco Cessation, and Clinical Trials. Each area had 5 defined levels of quality care delivery. With support from the Bristol-Myers Squibb Foundation, we pilot tested the model in 7 US cancer centers. Sites selected 1-2 assessment areas to evaluate using OCCM, developing relevant data benchmarks. Sites enrolled patients on Medicaid and Non-Medicaid controls. The ACCC team worked with each site to develop quality improvement projects with bi-weekly conference calls and 2 on-site visits. Data were collected and analyzed at a centralized data coordinating center. Statistical analyses were performed with Kruskal Wallis and chi-squared tests.

      Result

      Seven sites spanning 3,081 miles evaluated 10 of the 13 OCCM areas. Total enrollment was 927 patients (257 Medicaid/ 670 Non-Medicaid). The Medicaid population had an average age of 62 years, ranging from 58-68 across sites. The clinical stage distribution was 40% stage I/II and 60% stage III/IV. Medicaid patients were 47% adenocarcinoma histology, 29% squamous cell, 14% small cell, and 10% other. Sites differed by patient age (p=0.0041), race (p<0.0001), and smoking status (p=0.028).

      Three sites evaluated models for prospective multidisciplinary case planning for Medicaid patients including: bi-weekly tumor board (BTB), virtual tumor board (VTB), and multidisciplinary team huddle (MTH). VTB and MTH allowed for presentation of higher percentages of eligible patients (BTB: 23%, VTB: 100%, MTH: 100%, p<0.0001). BTB and MTH discussed all cases prospectively, while VTB achieved 80%. Median days from diagnosis to presentation were 18 (BTB), 14 (VTB), and 9 (MTH, p=0.14).

      Two sites evaluated smoking cessation programs. One, using trained cessation counselors, had 62% (18/29) active smokers, of whom 56% (10/18) expressed readiness to quit. Another site, using the freedom from smoking initiative, had 50% (11/22) active smokers and 55% (6/11) readiness to quit. 83% of those who started the cessation program quit smoking.

      Patient access to care was evaluated with timeliness of care metrics at two sites: one found 13 days (median) from lesion discovery to diagnosis and 21 days from diagnosis to treatment in Medicaid patients, which did not differ from Non-Medicaid controls (p=0.96 and 0.38). 94% met the site goal of treatment initiation within 45 days. Another site found 16 days (median) from discovery to diagnosis and 27 days from diagnosis to treatment (did not differ from Non-Medicaid controls, p=0.68 and 0.83).

      Conclusion

      Sites successfully used the OCCM to identify areas to improve and developed meaningful data benchmarks. The OCCM is a valuable tool for cancer centers to identify specific areas to target to improve lung cancer care delivery.

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    P1.16 - Treatment in the Real World - Support, Survivorship, Systems Research (ID 186)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Treatment in the Real World - Support, Survivorship, Systems Research
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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      P1.16-38 - Racial Disparities in Long-Term Survival After Surgical Resection in the US (Now Available) (ID 1968)

      09:45 - 18:00  |  Author(s): Nicholas Faris

      • Abstract
      • Slides

      Background

      Racial disparities exist in US lung cancer care, including delayed access, lower use of invasive procedures such as curative-intent surgery, and worse surgical outcomes in African-Americans compared to Caucasians. We investigated if racial disparities persist in non-small cell lung cancer (NSCLC) patients who received curative-intent resection in a population-based cohort.

      Method

      We examined all patients from a prospective population-based cohort who underwent curative-intent resections for lung cancer from 12 hospitals across 7 healthcare systems from 2009-2018. We compared overall survival (OS) by race and adjusted for age, sex, smoking status, family history, tumor histology, and clinical stage. We used Chi-square tests, Kaplan-Meier plots, and Cox proportional hazards modeling, reporting unadjusted and adjusted hazard ratios (aHR) with 95% confidence intervals.

      Result

      Of the 3,418 patients, 78% were Caucasian, 22% were African-American; 42% had Medicare,15% Medicaid, 39% commercial insurance, and 3% were uninsured. Caucasians were older (mean age 67.8 vs. 64.1; p=<0.0001). African-Americans were more likely to be active smokers (p=0.0017), have adenocarcinoma histology (p=0.0167), and less likely to be clinical stage I (p=0.0453). Median follow-up time in censored patients was 3.4 years. Overall, we found no differences in OS by race (unadjusted HR: 0.97 [0.88-1.08]; aHR: 0.998 [0.87-1.15]). However, stratified by insurance, we found significant differences (p=0.0251). Among patients with Medicaid insurance, African-Americans had significantly better OS (aHR: 0.73 [0.55-0.97]) than Caucasians but among patients with commercial insurance, African-Americans had significantly worse OS (aHR: 1.26 [1.02-1.57]).

      youmedicaid31_resize.jpg

      youcommercial31_resize.jpg

      Conclusion

      When all patients receive curative-intent surgical resection, racial disparities in NSCLC survival may be reduced, but differences in the impact of race on survival by type of insurance suggest residual and complex disparities in both access and quality of care. Further exploration of the interaction between race, socio-economic factors, and the mechanisms of lung cancer outcome disparities is warranted.

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