Impact of travel distance on receipt of indicated adjuvant therapy in resected non-small cell lung cancer

Assessing barriers to adjuvant therapy among patients with head and neck cancer in Arkansas

Advanced head and neck cancer (HNC) requires multimodal treatment and in the setting of primary curative intent surgery, adjuvant radiation with pathology-based chemotherapy is necessary for best outcomes. HNC treatment guidelines and best evidence support adjuvant radiation initiated within 6 weeks of surgery [1]. Over half of HNC patients face obstacles delaying adjuvant therapy, especially in rural areas [2]. This study assesses barriers to timely adjuvant therapy, specifically radiation in a rural tertiary setting. The study conducted was a retrospective mixed-methods analysis. The initial cohort consists of patients referred for adjuvant radiation therapy after curative intent head and neck surgery at a tertiary referral center, University of Arkansas for Medical Sciences, between 2020 and 2022. Demographic and socioeconomic data were collected and analyzed. Inclusion criteria for the study: patients referred for adjuvant therapy facing delays in treatment (> than 6 weeks) or deferring adjuvant treatment altogether. These patients and/or proxies were surveyed via telephone. Contact was made with 28 of the 46 patients meeting inclusion. 7 declined participation; 21 patients completed the survey personally, by proxy, or via family member. Among the respondents, the primary reasons for delaying adjuvant therapy include travel requirements/distance, general medical health, and financial constraints, with travel requirements/distance rated as the highest concern. Numerous obstacles to timely adjuvant therapy exist within our patient population. Understanding these barriers is crucial for improving timely access to adjuvant therapy and ultimately enhancing patient survivorship. Through individualized risk assessment, patient education, and resource management, we anticipate mitigating barriers to adjuvant therapy.

Geographic Access to Cancer Care and Treatment and Outcomes of Early-Stage Non-Small Cell Lung Cancer

Importance

Data on the impact of geographic access to cancer care on early-stage non-small cell lung cancer (NSCLC) treatment and outcomes are limited.

Objective

To examine the associations of geographic access to cancer care with guideline-recommended treatment and outcomes in patients with early-stage NSCLC.

Design, Setting, and Participants

This population-based cohort study included patients with early-stage NSCLC newly diagnosed between January 1, 2007, and December 31, 2015, followed up through December 31, 2016, and identified from the Surveillance, Epidemiology, and End Results dataset. Data analysis was performed from March to November 2024.

Exposures

Geographic access to thoracic surgeons and radiation oncologists was quantified using the 2-step floating catchment area algorithm and categorized into quintile 1 (least access) through quintile 5 (greatest access).

Main Outcomes and Measures

Multilevel logistic regression was performed to estimate odds ratios (ORs) of receipt of surgery and radiotherapy. Hazard ratios (HRs) of lung cancer-specific mortality were estimated using Fine and Gray subdistribution hazard regression.

Results

Among 65 259 patients, the mean (SD) age was 69.4 (10.1) years; 33 114 patients (50.7%) were female, 1071 (1.6%) were uninsured, and 7541 (11.6%) were enrolled in Medicaid. The least (vs greatest) geographic access to thoracic surgeons (HR, 1.10; 95% CI, 1.03-1.18; P < .001 for trend) and radiation oncologists (HR, 1.11; 95% CI, 1.04-1.18; P < .001 for trend) was associated with higher lung cancer mortality. Patients in counties with the least (vs greatest) access to thoracic surgeons were less likely to undergo surgery (OR, 0.80; 95% CI, 0.69-0.93; P < .001 for trend); this association was much stronger in Asian than non-Hispanic White patients and in Medicaid-insured than non-Medicaid-insured patients. Although there was no significant association overall, geographic access to radiation oncologists was significantly associated with radiotherapy use in older (OR, 0.85; 95% CI, 0.76-0.95), Hispanic (OR, 0.65; 95% CI, 0.49-0.86), and uninsured (OR, 0.63; 95% CI, 0.43-0.94) patients.

Conclusions and Relevance

In this cohort study, geographic access to cancer care was associated with guideline-recommended treatment for early-stage NSCLC and outcomes, particularly in socially marginalized patients, underscoring the importance of ensuring appropriate geographic allocations of cancer care resources and addressing travel barriers to health care to improve NSCLC treatment, prognosis, and equity.

Long-Term Impact of Regionalization of Thoracic Oncology Surgery

BACKGROUND

In 2007, Cancer Care Ontario created Thoracic Surgical Oncology Standards for the delivery of surgery, including lobectomy, esophagectomy, and pneumonectomy. These standards regionalized thoracic surgery into designated centers and mandated physical and human resources. This analysis sought to identify the impact of these standards, hereafter referred to as "regionalization," on outcomes after thoracic oncology surgery in Ontario, Canada.

METHODS

This study was a population-level analysis of patients undergoing lobectomy, esophagectomy, or pneumonectomy, and it used multilevel regression models to compare 30- and 90-day mortality and length of stay before, during, and after regionalization. Interrupted time series models were used to assess for an impact of regionalization while controlling for ongoing trends.

RESULTS

A total of 22,195 surgical procedures (14,902 lobectomies, 4958 esophagectomies, and 2408 pneumonectomies) were performed within the study period. A total of >99% of cases were performed at a designated center after regionalization. Mean annual volumes per designated center increased after regionalization for lobectomy and esophagectomy and decreased for pneumonectomy. The 30- and 90-day mortality and length of stay improved for lobectomy and esophagectomy over the study period, as did 90-day mortality for pneumonectomy. However, the interrupted time series analysis did not demonstrate any statistically significant effect of regionalization on these outcomes, separate from preexisting trends.

CONCLUSIONS

Consistent improvements in mortality and length of stay in thoracic surgical oncology occurred on a provincial level between 2003 and 2020, although this analysis does not attribute these improvements to implementation of Thoracic Surgical Oncology Standards including regionalization.

Improving care in lung cancer surgery: a review of quality measures and evolving standards

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines.

RECENT FINDINGS

Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection.

SUMMARY

Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.