Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

The influence of hospital volume and physician volume on early mortality in acute promyelocytic leukemia patients

Acute promyelocytic leukemia (APL) is a highly curable hematologic malignancy in the era of all-trans retinoic acid (ATRA) combination treatment. However, only a modest change in early mortality rate has been observed despite the wide availability of ATRA. In addition to the clinical characteristics of APL patients, studies on the hospital volume-outcome relationship and the physician volume-outcome relationship remained limited. We aim to evaluate the association between hospital and physician volume and the early mortality rate among APL patients. The patients were collected from Taiwan's National Health Insurance Research Database (NHIRD). Early mortality is defined as death within 30 days of diagnosis. Patients were categorized into four groups according to individual cumulative hospital and physician volume. The risk of all-cause mortality in APL patients with different cumulative volume groups was compared using a Cox proportional hazard model. The probability of overall survival was estimated using the Kaplan-Meier method. All 741 patients were divided into four quartile volume groups. In the multivariate analysis, only physician volume was significantly associated with early mortality rate. The physician volume of the highest quartile was a protective factor for early mortality compared with the physician volume of the lowest quartile (HR 0.10, 95% CI 0.02-0.65). Hospital characteristics were not associated with early mortality. In the sensitivity analyses, the results remained consistent using two other different definitions of early mortality. Higher physician volume was independently associated with lower early mortality, while hospital volume was not. Enhancing the clinical expertise of low-volume physicians may ensure better outcomes.

Free flap reconstruction at a rural-based tertiary medical college hospital: Barriers and outcomes

BACKGROUND AND OBJECTIVES

In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital.

METHODS

Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed.

RESULTS

A total of 56 patients were included. The most common free flap undertaken was free anterolateral thigh flap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods.

CONCLUSION

Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.

Cancer stages and mortality risk of breast cancer between women with and without disabilities: A national population-based cohort study in Taiwan

BACKGROUND

The second-most common cause of cancer-related death for women worldwide is breast cancer. However, there is little information about breast cancer among women with disabilities in Taiwan.

OBJECTIVES

This study investigated differences between women with and without disabilities regarding breast cancer stages and evaluated the probability of developing an advanced stage and the mortality risk of breast cancer.

METHODS

This study conducted a nationwide retrospective cohort study using the National Health Insurance Research Database and other nationwide databases. Our participants were newly diagnosed breast cancer patients, including women with and without disabilities, between 2004 and 2010. We matched both of them with propensity score matching methods (1:5), and all were followed up until the end of 2016.

RESULTS

This study included 50,683 participants with breast cancer. After matching, women with disabilities who did not receive breast cancer screening had a more significant proportion of advanced-stage breast cancer (19.95 %) than those without disabilities who did not receive breast cancer screening (16.87 %). After adjusting for related variables, women with disabilities were 1.27 times more likely to have advanced-stage breast cancer than those without disabilities. Additionally, after suffering from breast cancer, individuals with disabilities had a 1.23 times greater mortality risk compared to those without disabilities.

CONCLUSIONS

Although cancer stages were controlled, women with disabilities still had a higher mortality risk of breast cancer. Hence, policymakers should pay more attention to women with disabilities to treat them at an early stage, which can reduce the mortality risk attributable to advanced stages.

High-volume facilities are significantly more likely to use guideline-adherent systemic immunotherapy for metastatic Merkel cell carcinoma: implications for cancer care regionalization

Merkel cell carcinoma (MCC) is a neuroendocrine skin cancer with a high rate of mortality. While still relatively rare, the incidence of MCC has been rapidly rising in the US and around the world. Since 2017, two immunotherapeutic drugs, avelumab and pembrolizumab, have been FDA-approved for the treatment of metastatic MCC and have revolutionized outcomes for MCC. However, real-world outcomes can differ from clinical trial data, and the adoption of novel therapeutics can be gradual. We aimed to characterize the treatment practices and outcomes of patients with metastatic MCC across the US. A retrospective cohort study of adult cases of MCC in the National Cancer Database diagnosed from 2004 to 2019 was performed. Multivariable logistic regressions to determine the association of a variety of patient, tumor, and system factors with likelihood of receipt of systemic therapies were performed. Univariate Kaplan-Meier and multivariable Cox survival regressions were performed. We identified 1017 cases of metastatic MCC. From 2017 to 2019, 54.2% of patients received immunotherapy. This increased from 45.1% in 2017 to 63.0% in 2019. High-volume centers were significantly more likely to use immunotherapy (odds ratio 3.235, p = 0.002). On univariate analysis, patients receiving systemic immunotherapy had significantly improved overall survival (p < 0.001). One-, 3-, and 5-year survival was 47.2% (standard error [SE] 1.8%), 21.8% (SE 1.5%), and 16.5% (SE 1.4%), respectively, for patients who did not receive immunotherapy versus 62.7% (SE 3.5%), 34.4% (SE 3.9%), and 23.6% (SE 4.4%), respectively, for those who did (Fig. 1). In our multivariable survival regression, receipt of immunotherapy was associated with an approximately 35% reduction in hazard of death (hazard ratio 0.665, p < 0.001; 95% CI 0.548-0.808). Our results demonstrate that the real-world survival advantage of immunotherapy for metastatic MCC is similar to clinical trial data. However, many patients with metastatic disease did not receive this guideline-recommended therapy in our most recent study year, and use of immunotherapy is higher at high-volume centers. This suggests that regionalization of care to high-volume centers or dissemination of their practices, may ultimately improve patient survival.

Establishing a robust radioligand therapy program: A practical approach for North American centers

Radioligand therapy (RLT) is a targeted approach to treating cancer that has been shown to be safe and effective in a variety of disease states, including gastroenteropancreatic neuroendocrine tumors, lymphoma, and most recently, advanced prostate cancer. In the United States, patient access to this therapy is currently variable. Implementation of new RLT programs and expansion of existing programs are needed to broaden patient access to and standardize the delivery of RLT, especially as new therapies are introduced into clinical practice. Drawing from experience in establishing RLT programs in different settings, we have developed practical recommendations for building and implementing a robust RLT program. In this review, we present our recommendations for minimal requirements and optimal requirements, as well as system considerations, and special issues associated with implementing an RLT program in North American centers.

Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units?

Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical.

OBJECTIVE

To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals.

METHODS

In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital.

CONCLUSION

Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.

Systemic anticancer treatment in the Netherlands: Few hospitals treat many patients, many hospitals treat few patients

INTRODUCTION

The correlation between patient volume and clinical outcomes is well known for various oncological treatments, especially in the surgical field. The current level of centralisation of systemic treatment of (hemato-)oncology indications in Dutch hospitals is unknown.

OBJECTIVES

The aim of this study was to gain insight in patient volumes per hospital of patients treated with systemic anticancer treatment in the Netherlands.

METHODS

National claims data (Vektis) of all 73 Dutch hospitals that provide systemic anticancer medication in the Netherlands for the time period 2019 were used. The distribution of volumes of patients treated with anticancer medication for 38 different haematological or oncological indications was analysed. Hospitals were categorized into academic/specialised, general, and top clinical. Two volume cut off points (10 and 30 patients) were used to identify hospitals treating relatively few patients with anticancer medication. Four indications were investigated in more detail.

RESULTS

A wide distribution in patient volumes within hospitals was observed. Top clinical hospitals generally treated the most patients per hospital, followed by general and academic/specialised oncology hospitals. The volume cut off points showed that in 19 indications (50%) the majority (>50%) of all hospitals treated less than 10 patients and in 25 indications (66%) the majority of all hospitals treated less than 30 patients with anticancer medication. Four case studies demonstrated that relatively few hospitals treat many patients while many hospitals treat few patients with anticancer medication.

CONCLUSION

In the majority of oncology indications, a large proportion of Dutch hospitals treat small numbers of unique patients with anticancer medication. The high level of fragmentation gives ground for further exploration and discussion on how the organisation of care can support optimization of the efficiency and quality of care. Professional groups, policy makers, patients, and healthcare insurers should consider per indication whether centralisation is warranted.

Trend and characteristics of minimally invasive surgery for patients with endometrial cancer in Japan

OBJECTIVE

Owing to the potential benefits of minimally invasive hysterectomy for endometrial cancer, the practice pattern has recently shifted in Japan. This study examined the trends in minimally invasive surgery (MIS) in patients with endometrial cancer in Japan.

METHODS

This retrospective observational study examined the Japan Society of Obstetrics and Gynecology Tumor Registry database between 2015-2019. This study examined the time-specific proportion change and predictors of MIS use in initial endometrial cancer treatment in Japan, and compared it with the use of abdominal surgery. Additionally, the association between hospital surgical treatment volume and MIS use was examined.

RESULTS

A total of 14,059 patients (26.5%) underwent minimally invasive hysterectomy, and 39,070 patients (73.5%) underwent abdominal hysterectomy in the study period. Patients who underwent MIS were more likely to be treated at high-volume centers, younger, central, or western Japan residents, registered in recent years, and had a tumor with stage I disease, type 1 histology, and less myometrial invasion (all adjusted p<0.05). The proportion of MIS treatments increased from 19.1% in 2015 to 34.3% in 2019 (p<0.001). On multivariable analysis, treatment at high-volume centers was a contributing factor for MIS (adjusted odds ratio=3.85; 95% confidence interval=3.44-4.30). MIS at high-volume centers increased significantly from 24.8% to 41.0% (p<0.001) during the study period, whereas MIS at low-volume centers remained at median 8.8%.

CONCLUSION

MIS has increased significantly in recent years, accounting for nearly 34% of surgical management of endometrial cancer in Japan. High-volume treatment centers take the lead in performing MIS.

Patterns of better breast cancer care in countries with higher human development index and healthcare expenditure: Insights from GLOBOCAN 2020

Background

The huge burden of breast cancer (BC) necessitates the profound and accurate knowledge of the most recent cancer epidemiology and quality of care provided. We aimed to evaluate BC epidemiology and quality of care and examine the effects of socioeconomic development and healthcare expenditure on disparities in BC care.

Methods

The results from the GLOBOCAN 2020 study were utilized to extract data on female BC, including incidence and mortality numbers, crude rates, and age-standardized rates [age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs)]. The mortality-to-incidence ratio (MIR) was calculated for different locations and socioeconomic stratifications to examine disparities in BC care, with higher values reflecting poor quality of care and vice versa. In both descriptive and analytic approaches, the human development index (HDI) and the proportion of current healthcare expenditure (CHE) to gross domestic product (CHE/GDP%) were used to evaluate the values of MIR.

Results

Globally, 2,261,419 (95% uncertainty interval (UI): 2,244,260-2,278,710) new cases of female BC were diagnosed in 2020, with a crude rate of 58.5/100,000 population, and caused 684,996 (675,493-694,633) deaths, with a crude rate of 17.7. The WHO region with the highest BC ASIR (69.7) was Europe, and the WHO region with the highest ASMR (19.1) was Africa. The very high HDI category had the highest BC ASIR (75.6), and low HDI areas had the highest ASMR (20.1). The overall calculated value of female BC MIR in 2020 was 0.30, with Africa having the highest value (0.48) and the low HDI category (0.53). A strong statistically significant inverse correlation was observed between the MIR and HDI values for countries/territories (Pearson's coefficient = -0.850, p-value < 0.001). A significant moderate inverse correlation was observed between the MIR and CHE/GDP values (Pearson's coefficient = -0.431, p-value < 0.001).

Conclusions

This study highlighted that MIR of BC was higher in less developed areas and less wealthy countries. MIR as an indicator of the quality of care showed that locations with higher healthcare expenditure had better BC care. More focused interventions in developing regions and in those with limited resources are needed to alleviate the burden of BC and resolve disparities in BC care.

Association of Lymph Node Sampling and Clinical Volume in Lobectomy for Non-Small Cell Lung Cancer

BACKGROUND

Sampling of ≥10 lymph nodes during lobectomy for non-small cell lung cancer (NSCLC) was a previous surveillance metric and potential quality metric of the American College of Surgeons Commission on Cancer. We sought to determine guideline adherence and its relationship to hospital lobectomy volume within The Society of Thoracic Surgeons General Thoracic Surgery Database.

METHODS

Participant centers providing elective lobectomy for NSCLC within The Society of Thoracic Surgeons General Thoracic Surgery Database (2012-2019) were divided into tertiles according to annual volume. Average hospital nodal harvest of ≥10 nodes per lobectomy defined the primary outcome. Univariable analysis compared average patient and operative characteristics between the participant centers. Multivariable logistic regression was used to determine independent factors associated with average clinical center nodal harvest of ≥10 nodes.

RESULTS

Median annual lobectomy volume was 6.2, 19.9, and 42.7 for low-, medium-, and high-volume participant centers. Among 305 centers and 43 597 patients, 5.6% of lobectomies occurred in low-volume centers, 24.0% in medium-volume centers, and 70.4% in high-volume centers. Average rates of ≥10 nodes per lobectomy were excised in 44.0% of low-volume centers, 70.6% of medium-volume centers, and 75.2% of high-volume centers (P < .001). On multivariable analysis, average nodal excision of ≥10 nodes was strongly associated with medium-volume (odds ratio, 2.94; CI, 1.57-5.50, P < .01) and high-volume (odds ratio, 3.82; CI, 1.95-7.46; P < .001) participant centers.

CONCLUSIONS

Although higher center volume and increased nodal harvest are associated, 25% of high-volume centers average a rate of <10 lymph nodes per lobectomy for NSCLC. Low nodal yield may underestimate stage, with implications for adjuvant therapy and long-term survival.

Association of Hospital Surgical Volume With Survival in Early-Stage Cervical Cancer Treated With Radical Hysterectomy

OBJECTIVE

To evaluate the association of number of radical hysterectomies performed per year in each center with disease-free survival and overall survival.

METHODS

We conducted an international, multicenter, retrospective study of patients previously included in the Surveillance in Cervical Cancer collaborative studies. Individuals with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIA1 cervical cancer who underwent radical hysterectomy and had negative lymph nodes at final histology were included. Patients were treated at referral centers for gynecologic oncology according to updated national and international guidelines. Optimal cutoffs for surgical volume were identified using an unadjusted Cox proportional hazard model, with disease-free survival as the outcome and defined as the value that minimizes the P-value of the split in groups in terms of disease-free survival. Propensity score matching was used to create statistically similar cohorts at baseline.

RESULTS

A total of 2,157 patients were initially included. The two most significant cutoffs for surgical volume were identified at seven and 17 surgical procedures, dividing the entire cohort into low-volume, middle-volume, and high-volume centers. After propensity score matching, 1,238 patients were analyzed-619 (50.0%) in the high-volume group, 523 (42.2%) in the middle-volume group, and 96 (7.8%) in the low-volume group. Patients who underwent surgery in higher-volume institutions had progressively better 5-year disease-free survival than those who underwent surgery in lower-volume centers (92.3% vs 88.9% vs 83.8%, P=.029). No difference was noted in 5-year overall survival (95.9% vs 97.2% vs 95.2%, P=.70). Cox multivariable regression analysis showed that FIGO stage greater than IB1, presence of lymphovascular space invasion, grade greater than 1, tumor diameter greater than 20 mm, minimally invasive surgical approach, nonsquamous cell carcinoma histology, and lower-volume centers represented independent risk factors for recurrence.

CONCLUSION

Surgical volume of centers represented an independent prognostic factor affecting disease-free survival. Increasing number of radical hysterectomies performed in each center every year was associated with improved disease-free survival.

Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans

The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.

Patterns of First-Line Systemic Therapy Delivery and Outcomes in Advanced Epithelial Ovarian Cancer in Ontario

Background: First-line treatment of epithelial ovarian cancer (EOC) consists of a combination of cytoreductive surgery and platinum-based chemotherapy. Recently, targeted therapies such as bevacizumab have been shown to improve oncologic outcomes in a subset of a high-risk population. The objective of this study is to evaluate the patterns of practice and outcomes of first-line systemic treatment of advanced EOC, focusing on the adoption of bevacizumab. Methods: A population cohort study was conducted using administrative data in Ontario, Canada. Patients diagnosed with advanced stage non-mucinous EOC between 2014 and 2018 were identified. Datasets were linked to obtaining information on first-line treatment including surgery, systemic therapy, providers of care, systemic therapy facilities, and acute care utilization (emergency department (ED) visits and hospitalizations) during systemic treatment. Multivariate logistic regression was used to determine factors associated with systemic therapy utilization. Results: Among 3726 patients with advanced EOC, 2838 (76%) received chemotherapy: 1316 (47%) received neoadjuvant chemotherapy, 1060 (37%) underwent primary cytoreductive surgery followed by chemotherapy, and 462 (16%) received chemotherapy only. The median age was 67 (range: 20–100). Most chemotherapies were prescribed by gynecologic oncologists (60%) and in level 1 academic cancer centres (58%). Only 54 patients (3.1%) received bevacizumab in the first-line setting after its approval in Ontario in 2016. Bevacizumab was more likely to be administered by medical oncologists compared to gynecologic oncologists (OR 3.95, 95% CI 2.11–7.14). In total, 1561 (55%) and 1594 (56%) patients had at least one ED visit and/or hospitalization during systemic treatment, respectively. The most common reasons for ED visits were fever and bowel obstruction. Conclusion: Patterns of care for EOC in Ontario differed between care providers. The uptake of bevacizumab for first-line treatment of EOC was low. Acute care utilization related to EOC was high.

Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Improved survival in cervical cancer patients receiving care at National Cancer Institute-designated cancer centers

Background

Locally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.

Methods

Data for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.

Results

Median age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.

Conclusions

This study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

This study demonstrates survival benefit for patients receiving care for cervical cancer at National Cancer Institute–designated cancer centers that is not explained by receipt of guideline‐concordant treatment. Further understanding of these factors will promote equality across oncology care facilities resulting in survival equity for patients with cervical cancer.

High-Volume Hospitals’ Ovarian Cancer Care—Less Individual Approach or Better Treatment Results?

Ovarian cancer (OC) is the eighth most common cancer worldwide and is usually diagnosed in advanced stages. The relationship between treatment in high-volume hospitals (HVHs) and survival in OC has been documented by multiple studies, which showed that superior treatment and survival outcomes are associated with surgical expertise and multidisciplinary resources. To our study, 135 first-time patients treated in the years 2019–2020 in the Department of Oncology of Poznań University of Medical Sciences were enrolled. Th analysis showed a significant dependency between being treated in a HVH from the beginning of one’s diagnosis and the scope of the first intervention. Additionally, among patients treated in our centre, a significant portion of patients underwent laparoscopy, and from one year to another the number of laparoscopies performed increased. This may indicate that more patients began to qualify for neoadjuvant treatment. Patients benefit the most from surgery in a centre with more experience in treating ovarian cancer. In the future, we will be able to expand this study by using data from patients treated before 2019 and analysing larger cohorts of patients. This might enable us to update the rates of overall survival (OS), objective response rate (ORR) and progression-free survival (PFS).

Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care

BACKGROUND

This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010-2015).

METHODS

This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery.

RESULTS

6574 lung cancer patients and 5355 colorectal cancer patients were included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR] = 1.46; 95 % confidence interval [CI] = 1.22-1.76) and lower odds of receiving surgery (OR = 0.48; 95 % CI = 0.34-0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR = 1.53; 95 % CI = 1.17-2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR = 0.69; 95 % CI = 0.50-0.94 and OR = 0.68; 95 % CI = 0.52-0.89; respectively) than their non-Hispanic White and urban counterparts.

CONCLUSIONS

After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients' presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

Survival after minimally invasive vs. open radical nephrectomy for stage I and II renal cell carcinoma

BACKGROUND

A recently reported phase III randomized trial comparing open and minimally invasive hysterectomy showed significantly higher rates of local recurrence after minimally invasive surgery (MIS) for cervical cancer. This raised concerns regarding patterns of recurrences and survival after MIS in general. This study aims to determine the effect of MIS on all-cause mortality among patients undergoing radical nephrectomy for Stage I and II renal cell carcinoma (RCC).

METHODS

We utilized the National Cancer Database to identify patients diagnosed with clinical stage I-II RCCs between 2010 and 2013. Patients for whom a laparoscopic or robotic radical nephrectomy was attempted were compared to patients who underwent open radical nephrectomy (ORN). Adjusted regression models with inverse probability propensity score weighting (IPW) were utilized to identify independent predictors of receiving MIS. All-cause mortality rates were compared using IPW survival functions and log-rank tests. Adjusted Cox proportional hazard models were fitted to determine independent predictors of OS.

RESULTS

27,642 patients were identified; 11,524 (41.7%) had MIS, while 16,118 (58.3%) had ORN. Kaplan-Meier survival curves in the IPW cohort showed significant OS advantage for patients who underwent MIS (p < 0.001). Furthermore, length of hospital stays (3 vs. 4 days), 30 day readmission rates (2.4 vs. 2.87%), 30 day (0.53 vs. 0.96%) and 90 day mortality rates (1.04 vs. 1.77%) were significantly higher in the ORN group (p < 0.001).

CONCLUSIONS

MIS was associated with better OS outcomes compared to ORN for stage I and II RCC. In addition, MIS had lower post-operative readmission, 30- and 90 day mortality rates.

Surgical volume threshold to improve 3-year survival in designated cancer care hospitals in 2004-2012 in Japan

In Japan, cancer care hospitals designated by the national government have a surgical volume requirement of 400 annually, which is not necessarily defined based on patient outcomes. This study aimed to estimate surgical volume thresholds that ensure optimal 3‐year survival for three periods. In total, 186 965 patients who had undergone surgery for solid cancers in 66 designated cancer care hospitals in Osaka between 2004 and 2012 were examined using data from a population‐based cancer registry. These hospitals were categorized by the annual surgical volume of each 50 surgeries (eg, 0‐49, 50‐99, and so on). Using multivariable Cox proportional hazard regression, we estimated the adjusted 3‐year survival probability per surgical volume category for 2004‐2006, 2007‐2009, and 2010‐2012. Using the joinpoint regression model that computes inflection points in a linear relationship, we estimated the points at which the trend of the association between surgical volume and survival probability changes, defining them as surgical volume thresholds. The adjusted 3‐year survival ranges were 71.7%‐90.0%, 68.2%‐90.0%, and 79.2%‐90.3% in 2004‐2006, 2007‐2009, and 2010‐2012, respectively. The surgical volume thresholds were identified at 100‐149 in 2004‐2006 and 2007‐2009 and 200‐249 in 2010‐2012. The extents of change in the adjusted 3‐year survival probability per increase of 50 surgical volumes were +4.00%, +6.88%, and +1.79% points until the threshold and +0.41%, +0.30%, and +0.11% points after the threshold in 2004‐2006, 2007‐2009, and 2010‐2012, respectively. The existing surgical volume requirements met our estimated thresholds. Surgical volume thresholds based on the association with patient survival may be used as a reference to validate the surgical volume requirement.

Effect of Quality Control Program in Surgical Management of Early Cervical Cancer

BACKGROUND

Regular assessments of clinical performance in gynecologic cancer surgery is important for the safety of patients. We evaluated the effects of quality control (QC) program on the treatment pattern and clinical outcomes of early cervical cancer.

METHODS

Medical records of cervical cancer patients who received operation in our institution from January 2007 to December 2018 were retrospectively reviewed. Cases were divided into 2 groups, before and after the initiation of QC program, group 1 (2007-2013) and group 2 (2014-2018), based on the operation date. Two groups were compared in clinicopathologic variables, surgical methods, operative details, adjuvant treatments, recurrence and survival.

RESULTS

A total of 305 cervical cancer patients were included in the analysis, 210 in group 1 and 95 in group 2. In group 2, minimally invasive surgery (MIS) was more frequently performed (60.0% vs. 76.8%, P = 0.004), especially in earlier stages (stage IA, 72.6% vs. 100.0%; stage IB, 52.2% vs. 69.5%). However, the median tumor size treated by MIS was decreased in stage IB (20 mm vs. 17 mm, P = 0.015). Frequency of adjuvant treatment was also reduced in stage IB (56.5% vs. 37.3%, P = 0.016). Recurrence within 3 years, 3-year disease free survival and overall survival did not show significant difference; however, 3-year recurrence after MIS was significantly reduced in stage IB.

CONCLUSION

QC program enforced stricter patient selection criteria for MIS and positively affected clinical outcomes in cervical cancer patients who underwent surgery. Systemic monitoring should be considered for patient safety.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

Pulmonary Metastasectomy in Colorectal Cancer: A Population-Based Retrospective Cohort Study Using the Korean National Health Insurance Database

PURPOSE

The study aimed to investigate the current status and prognostic factors for overall survival in patients who had undergone pulmonary metastasectomy for colorectal cancer.

MATERIALS AND METHODS

The data of 2,573 patients who had undergone pulmonary metastasectomy after surgery for colorectal cancer between January 2009 and December 2014 were extracted from the Korean National Health Insurance Service claims database. Patient-, colorectal cancer-, pulmonary metastasis-, and hospital-related factors were analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis to identify prognostic factors for overall survival after pulmonary metastasectomy.

RESULTS

The mean age of the patients was 60.9±10.5 years; 66.2% and 79.1% of the participants were male and had distally located colorectal cancer, respectively. Wedge resection (71.7%) was the most frequent extent of pulmonary resection; 21.8% of the patients underwent repeated pulmonary metastasectomies; 73% of pulmonary metastasectomy cases were performed in tertiary hospitals; 53.9% of patients were treated in Seoul area; 82% of patients received chemotherapy in conjunction with pulmonary metastasectomy. The median survival duration was 51.8 months. The 3- and 5-year overall survival rates were 67.7% and 39.4%, respectively. In multivariate analysis, female sex, distally located colorectal cancer, pulmonary metastasectomy-only treatment, and high hospital volume (> 10 pulmonary metastasectomy cases/yr) were positive prognostic factors for survival.

CONCLUSION

Pulmonary metastasectomy seemed to provide long-term survival of patients with colorectal cancer. The female sex, presence of distally located colorectal cancer, and performance of pulmonary metastasectomy in high-volume centers were positive prognostic factors for survival.

Thyrotropin Suppression for Papillary Thyroid Cancer: A Physician Survey Study

Background: Current guidelines recommend against thyrotropin (TSH) suppression in low-risk differentiated thyroid cancer patients; however, physician practices remain underexplored. Our objective was to understand treating physicians' approach to TSH suppression in patients with papillary thyroid cancer. Methods: Endocrinologists and surgeons identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles were surveyed in 2018-2019. Physicians were asked to report how likely they were to recommend TSH suppression (i.e., TSH <0.5 mIU/L) in three clinical scenarios: patients with intermediate-risk, low-risk, and very low-risk papillary thyroid cancer. Responses were measured on a 4-point Likert scale (extremely unlikely to extremely likely). Multivariable logistic regressions were performed to determine physician characteristics associated with recommending TSH suppression in each of the aforementioned scenarios. Results: Response rate was 69% (448/654). Overall, 80.4% of physicians were likely/extremely likely to recommend TSH suppression for a patient with an intermediate-risk papillary thyroid cancer, 48.8% for a patient with low-risk papillary thyroid cancer, and 29.7% for a patient with very low-risk papillary thyroid cancer. Surgeons were less likely to recommend TSH suppression for an intermediate-risk papillary thyroid cancer patient (odds ratio [OR] = 0.36 [95% confidence interval, CI, 0.19-0.69]) compared with endocrinologists. Physicians with higher thyroid cancer patient volume were less likely to suppress TSH in low-risk and very low-risk papillary thyroid cancer patients (i.e., >40 patients per year, OR = 0.53 [CI 0.30-0.96]; OR = 0.49 [CI 0.24-0.99], respectively, compared with 0-20 patients per year). Physicians who estimated higher likelihood of recurrence were more likely to suppress TSH in a patient with very low-risk papillary thyroid cancer (OR = 2.34 [CI 1.91-4.59]). Conclusions: Many patients with low-risk thyroid cancer continue to be treated with suppressive doses of thyroid hormone, emphasizing the need for more high-quality research to guide thyroid cancer management, as well as better understanding of barriers that hinder guideline adoption.

Implementation of a Multidisciplinary Expert Testicular Cancer Tumor Board Across a Large Integrated Healthcare Delivery System Via Early Case Ascertainment

PURPOSE

In 2016, Kaiser Permanente Northern California began regionalizing testicular cancer care using population-based tumor board review. This mixed methods evaluation describes implementation outcomes and learnings.

METHODS

We conducted in-depth interviews with key stakeholders, administered surveys to local oncologists and urologists, and used clinical data to evaluate changes in care delivery during 2015-2018.

RESULTS

An average of 135 patients with testicular cancer were diagnosed each year. Interviews with 16 key stakeholders provided several insights. Implementation resulted in high levels of satisfaction, was dependent on leadership and staff at various levels, and required technology and consulting solutions aligned to user agreements and clinical workflows. Of 123 local oncologists and urologists who completed surveys, 97% understood why care was regionalized and 89% agreed that tumor board review improved treatment decisions. Among 177 patients with stage I seminoma, the percentage appropriately observed rather than treated with adjuvant chemotherapy or radiation therapy increased from 48% (95% CI, 35 to 62) in 2015 to 87% (75 to 99) in 2018. Review altered care based on pathology and radiology re-review in 14.5 % of cases.

CONCLUSION

Regionalization was feasible and effective.

Informed consent and a risk-based approach to oncologic surgery in a cancer center during the COVID-19 pandemic

BACKGROUND

Cancer patients configure a risk group for complications or death by COVID-19. For many of them, postponing or replacing their surgical treatments is not recommended. During this pandemic, surgeons must discuss the risks and benefits of treatment, and patients should sign a specific comprehensive Informed consent (IC).

OBJECTIVES

To report an IC and an algorithm developed for oncologic surgery during the COVID-19 outbreak.

METHODS

We developed an IC and a process flowchart containing a preoperative symptoms questionnaire and a PCR SARS-CoV-2 test and described all perioperative steps of this program.

RESULTS

Patients with negative questionnaires and tests go to surgery, those with positive ones must wait 21 days and undergo a second test before surgery is scheduled. The IC focused both on risks and benefits inherent each surgery and on the risks of perioperative SARS-CoV-2 infections or related complications. Also, the IC discusses the possibility of sudden replacement of medical staff member(s) due to the pandemic; the possibility of unexpected complications demanding emergency procedures that cannot be specifically discussed in advance is addressed.

CONCLUSIONS

During the pandemic, specific tools must be developed to ensure safe experiences for surgical patients and prevent them from having misunderstandings concerning their care.

Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer

CONTEXT

The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs.

OBJECTIVE

To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer.

METHODS

This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer.

RESULTS

Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67).

CONCLUSIONS

Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.

Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

BACKGROUND

In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea.

METHODS

We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future.

RESULTS

The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future.

CONCLUSION

The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

Benefits of Local Treatment Including External Radiotherapy for Hepatocellular Carcinoma with Portal Invasion

We aimed to identify the oncologic benefits of local treatment including radiotherapy (LRT) in hepatocellular carcinoma (HCC) invading the portal vein. We used clinical data of patients with HCC invading the portal vein from 2008 to 2014 provided by 50 hospitals nationwide. A total of 1163 patients were included in the analysis. The LRT group was younger than the best supportive care (BSC) group (p < 0.001). The mean Child-Pugh score of the LRT group (6.1) was significantly lower than that of the BSC group (7.7) (p < 0.001). Propensity score-matched analysis generated 222 pairs. The median survival of all patients, LRT, and BSC groups were 5.0, 8.0, and 2.0 months, respectively. The overall survival (OS) rates in the LRT and BSC groups were 34.2% and 16.2% at one year, and 12.6% and 6.8% at two years, respectively (p < 0.001). Multivariate analysis showed that LRT (HR 0.41, 95% CI 0.32-0.52), age >60 years, extrahepatic metastases, tumor size ≥10 cm, and Child-Pugh class (CPC) B or C were independent predictors of higher mortality (all p < 0.05). Statistical differences in survival were maintained in all CPC-albumin-bilirubin classes (all p < 0.05). LRT was significant in patients with HCC with portal invasion, valid for patients with CPC A and B.

Managing axial bone sarcomas in childhood

Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.

Effect of treatment center volume on outcomes in gastroenteropancreatic neuroendocrine tumor patients

Background

Medical centers with varying levels of expertise treat gastroenteropancreatic neuroendocrine tumors (GEP-NETs), which are relatively rare tumors. This study assesses the impact of center volume on GEP-NET treatment outcomes.

Methods

We used the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims data. The data includes patients diagnosed between 1995 and 2010 who had no health maintenance organization (HMO) coverage, participated in Medicare parts A and B, were older than 65 at diagnosis, had tumor differentiation information, and had no secondary cancer. We identified medical centers at which patients received GEP-NET treatment (surgery, chemotherapy, somatostatin analogues, or radiation therapy) using Medicare claims data. Center volume was divided into 3 tiers – low, medium, and high – based on the number of unique GEP-NET patients treated by a medical center over 2 years. We used Kaplan-Meier curves and Cox regression to assess the association between volume and disease-specific survival.

Results

We identified 899 GEP-NET patients, of whom 37, 45, and 18% received treatment at low, medium volume, and high-volume centers, respectively. Median disease-specific survival for patients at low and medium tiers were 1.4 years and 5.3 years, respectively, but was not reached for patients at high volume centers. Results showed that patients treated at high volume centers had better survival than those treated in low volume centers (HR: 0.63, 95% CI: 0.4–0.9), but showed no difference in outcomes between medium and high-volume centers.

Conclusions

Our results suggest that for these increasingly common tumors, referral to a tertiary care center may be indicated. Physicians caring for GEP-NET patients should consider early referral to high volume centers.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Complicaciones de la linfadenectomía retroperitoneal postquimioterapia en pacientes con tumor germinal de origen testicular: Experiencia de 12 años en un centro de referencia en Colombia

Objetivo El objetivo de este estudio, fue describir las complicaciones intraoperatorias y postoperatorias, así como la necesidad de cirugías concomitantes en la linfadenectomía retroperitoneal postquimioterapia en un centro de referencia de manejo de cáncer.

Métodos Se recolectaron datos de una cohorte retrospectiva de pacientes con diagnóstico de tumor germinal de origen testicular que hubiesen recibido quimioterapia y en quienes se documentó tumor residual retroperitoneal y fueron sometidos a LRP-PC durante 12 años en un centro de referencia de manejo de cáncer.

Resultados Se practicó LRP-PC a 64 pacientes. La edad promedio al momento de la cirugía fue 28,1 años (18-47 años). El tamaño promedio de la masa retroperitoneal post quimioterapia fue 6,7 (1–28 cm). La estancia hospitalaria promedio fue 7,9 días (rango 1-99 días), la tasa de cirugías adicionales fue del 20%. La tasa de complicaciones mayores fue de 7,8%. Tener seminoma en la histología testicular inicial se asoció con un mayor sangrado y el tamaño de la masa retroperitoneal residual se asoció con la necesidad de cirugías concomitantes.

Conclusiones La LRP-PC es una cirugía de alto nivel de complejidad que se asocia a complicaciones mayores y a la necesidad de cirugías concomitantes. Esta cohorte de pacientes muestra desenlaces similares a los descritos en la literatura, recalcando el hecho de que esta cirugía, debería ser realizada en centros de referencia de manejo del cáncer.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Patient and Caregiver Considerations and Priorities When Selecting Hospitals for Complex Cancer Care

BACKGROUND

Healthcare policies have focused on centralizing care to high-volume centers in an effort to optimize patient outcomes; however, little is known about patients' and caregivers' considerations and selection process when selecting hospitals for care. We aim to explore how patients and caregivers select hospitals for complex cancer care and to develop a taxonomy for their selection considerations.

METHODS

This was a qualitative study in which data were gathered from in-depth interviews conducted from March to November 2019 among patients with hepatopancreatobiliary cancers who were scheduled to undergo a pancreatectomy (n = 20) at a metropolitan, urban regional, or suburban medical center and their caregivers (n = 10).

RESULTS

The interviews revealed six broad domains that characterized hospital selection considerations: hospital factors, team characteristics, travel distance to hospital, referral or recommendation, continuity of care, and insurance considerations. The identified domains were similar between participants seen at the metropolitan center and urban/suburban medical centers, with the following exceptions: participants receiving care specifically at the metropolitan center noted operative volume and access to specific services such as clinical trials in their hospital selection; participants receiving care at urban/suburban centers noted health insurance considerations and having access to existing medical records in their hospital selection.

CONCLUSIONS

This study delineates the many considerations of patients and caregivers when selecting hospitals for complex cancer care. These identified domains should be incorporated into the development and implementation of centralization policies to help increase patient access to high-quality cancer care that is consistent with their priorities and needs.

Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience

As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope’s (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.

Practice patterns and outcomes for adults with acute myeloid leukemia receiving care in community vs academic settings

Consistent with observations in other disease settings, retrospective studies have indicated that treatment outcomes for adults with acute myeloid leukemia (AML) are better in higher- vs lower-volume hospitals and academic vs nonacademic centers, with greatest benefits noted in acute promyelocytic leukemia. Younger age, more frequent receipt of chemotherapy and hematopoietic cell transplantation, and differences in comorbidities and socioeconomic factors may partially account for these differences. With new therapeutic options including oral small molecule inhibitors and parenteral drugs suitable for outpatient administration, there is increasing interest from patients and physicians in treating AML in the community setting and avoiding referral to academic centers. This may be particularly true for older adults, for whom treatment rates in the community have historically been low, and for those with comorbidities, because treatment benefits are estimated to be low, and thus travel to academic centers is perceived as especially burdensome. How the volume-outcome relationship is affected by the shift of the treatment landscape in AML over the last few years is unknown. Additionally, improvements in supportive care (transfusion support, broad-spectrum oral antimicrobials), resulting in gradually decreasing early death rates over time, and the growing focus on the impact of AML therapy on quality of life and treatment cost concerns further fuel the larger trend toward an increasing proportion of care delivered in the outpatient setting. Here, we examine whether the current shift of administering chemotherapy and supportive care to the outpatient setting can be translated to the community setting without compromising patient outcomes.

The optimal numerosity of the referral population of pituitary tumors centers of excellence (PTCOE): A surgical perspective

Surgical experience is of paramount importance to reach therapeutic success and minimize operative complications. In the field of pituitary surgery, this led to the concept of Pituitary Center of Excellence (PTCOE) defined as a center where an interdisciplinary team works in collaboration and where surgeons can be trained appropriately to reach and keep excellence in daily practice. To review the literature to define the optimal referral population size to establish a PTCOE to optimize both training and specific field research. A review of the literature was performed about epidemiology. The time needed to observe 200 cases of PAs in a single PTCOE and to reach the minimal surgical experience threshold (MSET) was calculated for different referral population groups. The time needed to reach MSET decreased as population size increased. We defined a population as the optimal one to be served by a single PTCOE with a single dedicated neurosurgeon. PTCOEs should be established after an analysis of the referral population, number of cases suitable for surgical treatment and number of dedicated neurosurgeons.

Optimal staffing in community health centers to improve quality of care

OBJECTIVE

To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services.

DATA SOURCES

We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs.

STUDY DESIGN

We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function.

FINDINGS

Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ.

CONCLUSION

As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs.

Characterizing Physician Practice in Nursing Homes Using Claims-Based Measures: Correlation With Nursing Home Administrators' Perceptions

Heterogeneity in physician practice within nursing homes (NHs) may explain variations in quality. However, data on physician practice organization in NHs are hard to obtain. We characterized NH physician practice using two claims-based measures: (a) concentration of NH care among physicians (measured by Herfindahl-Hirschman index of visits); and (b) physician NH practice specialization (measured by the proportion of a physician's visits to NHs). We examined the relationship between the measures and NH administrator perceptions of physician practice reported in the Shaping Long-Term Care in America (SLTCA) Survey. All 2011 Part B claims from 13,718 physicians who treated Medicare fee-for-service patients in 2,095 NHs in the SLTCA survey were analyzed. The median Herfindahl-Hirschman index was 0.44 (interquartile range [IQR] 0.28-0.70), and the median specialization was 38.1% (IQR 19.9% to 60.9%). NHs with higher physician specialization reported more frequent physician participation in care coordination activities. Claims-based measures could inform the study of NH physician practice.

The impact of craniotomy for brain tumor case volume on patient safety indicators and in-hospital mortality

OBJECTIVES

The relationship between outcomes, patient safety indicators and volume has been well established in patient's undergoing craniotomy for brain tumor. However, the determination of "high" and "low" volume centers have been subjectively derived. We present a paper with a novel method of objectively determining "high" volume centers for craniotomy for brain tumor.

METHODS

Patients from 2002 to 2011 were identified in the Nationwide Inpatient Sample database using ICD-9 codes related to craniotomy for brain tumor. Primary endpoints of interest were hospital PSI event rate, in-hospital mortality rate, observed-to-expected PSI event ratio, and O/E in-hospital mortality ratio. Using a zero-inflated gamma model analysis and a cutpoint analysis we determined the volume threshold between and "high" and "low" volume hospitals. We then completed an analysis using this determined threshold to look at PSI events and mortality as they relate to "high" volume and "low" volume hospitals.

RESULTS

12.4 % of hospitals were categorized as good performers using O/E ratios. Regarding in-hospital mortality, 16.8 % were good performers. Using the above statistical analysis the threshold to define high vs. low volume centers was determined to be 27 craniotomies. High volume centers had significantly lower O/E ratios for both PSI and mortality events. The PSI O/E ratio was reduced 55 % and mortality O/E ratio reduced 73 % at high volume centers as defined by our analysis.

CONCLUSIONS

Patients treated at institutions performing >27 craniotomies per year for brain tumors have a lower likelihood of PSI events and decreased in-hospital morbidity and mortality.

Antifungal prophylaxis during 7 + 3 induction chemotherapy for acute myeloid leukemia is associated with improved survival, in a setting with low incidence of invasive mold infections

Invasive fungal infections (IFIs) are a major cause of morbidity and mortality in patients undergoing induction chemotherapy for acute myeloid leukemia (AML). In this patient population, antifungal prophylaxis (AP) has been associated with decreased incidence of IFIs and better survival. However, some centers have not adopted AP during induction chemotherapy for AML, as it is unclear whether AP improves outcomes in settings where the incidence of invasive mold infections is low. We retrospectively assessed the differences in clinical outcomes and resource utilization in patients undergoing 7 + 3 induction chemotherapy for AML, after implementing a policy of AP as part of a dedicated inpatient malignant hematology service (HS) at Rhode Island Hospital. Between January 1, 2007 and April 1, 2019, 56 patients with AML received AP during 7 + 3 induction chemotherapy and 52 patients did not, without significant differences in their baseline characteristics. Use of AP was associated with less proven or probable IFI (0% vs. 6%, P = 0.1) and lower all-cause in-hospital mortality (7% vs. 21%, P < 0.05), without significant increases in resource utilization or toxicities. Empiric and targeted antifungal therapies were more frequently started in the non-AP group (69%) than changed in the AP group (41%, P < 0.005). Having a dedicated inpatient malignant hematology service was also associated with improved outcomes. However, use of AP was associated with better survival (30-day post-induction survival log-rank P < 0.05), prior to the implementation of this clinical service as well, which is suggestive of an independent benefit from AP.

Does institutional patient accrual volume impact overall survival in patients with inoperable non-small-cell lung cancer receiving radical (chemo)radiation? A secondary analysis of TROG 99.05

INTRODUCTION

Increased hospital patient volume, reflecting greater experience, has been shown to be associated with improved survival for some cancers. However, there is no evidence to support the volume-outcome hypothesis for inoperable non-small-cell lung cancer (NSCLC) patients within the Australasian setting. We examined the relationship between overall survival (OS) and institutional patient accrual volume (IPAV) in a large prospective Australasian NSCLC database (TROG 99.05).

METHODS

TROG 99.05 was an observational study which accrued patients from 1999 to 2007 to examine the relationship between primary lung cancer volume and survival. To be eligible for inclusion, patients had to have inoperable, biopsy-proven NSCLC planned for radiotherapy to a minimum dose of 50Gy in 20 fractions, with or without chemotherapy. Participating institutions were de-identified and grouped according to whether accrual was low, medium or high. OS was compared between groups and adjusted for prognostic factors using Cox regression.

RESULTS

About 509 patients were accrued from 16 centres. Median potential follow-up time was 60 months. Median survival for all groups was 20 months (95% CI 18.3-21.8 months). There were no statistically significant differences in OS with increasing patient accrual across the three groups after adjustment for prognostic factors (P = 0.84, 2 df). The hazard ratios (HR) for group accrual volumes, relative to that for high-accrual volume, were as follows: low, 1.18; medium, 1.14. Test for trend: HR = 0.91 per group (95% CI 0.76-1.09, P = 0.31).

CONCLUSION

In the setting of a clinical trial with rigorous quality assurance, we found no evidence for an association between institutional accrual and survival.

Association Between Facility Volume and Overall Survival for Patients with Grade II Meningioma after Gross Total Resection

BACKGROUND

The role of adjuvant radiation after gross total resection (GTR) for grade II meningioma is evolving, prompting further evaluation in NRG-BN003, a phase 3 national trial. Furthermore, the relationship between facility volume and outcomes in patients with grade II meningioma after GTR has not been examined at a national level. We aim to assess overall survival (OS) of patients with grade II meningioma after GTR by surgical case volume and OS by receipt of adjuvant radiation.

METHODS

We used the National Cancer Database to identity 2823 patients diagnosed with grade II meningioma who underwent GTR. Propensity score matching was applied to balance covariates in patients with grade II meningioma after GTR stratified by adjuvant radiation status. Multivariable logistic regression was used to assess factors associated with radiation receipt. Kaplan-Meier and log-rank tests were used to assess OS by facility volume.

RESULTS

As facility volume increased, OS increased, with a 5-year OS of 72.8% for facilities with GTR grade II meningioma volumes of ≤8 cases per decade and 87.5% for >8 cases per decade (P < 0.0001). There was no difference in 5-year OS between GTR alone and GTR with adjuvant radiation (84.8% vs. 86.4%; P = 0.151). Covariates significantly associated with radiation receipt included facility location, facility volume, distance, and tumor size.

CONCLUSIONS

Treatment at higher surgical case volume facilities is associated with improved OS for GTR grade II meningioma. These facilities also have more patients receiving adjuvant radiation. However, we observed no difference in OS between adjuvant radiation and surgery alone.

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

BACKGROUND

Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.

METHODS

Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.

RESULTS

Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.

DISCUSSION

Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Improved survival of glioblastoma patients treated at academic and high-volume facilities: a hospital-based study from the National Cancer Database

OBJECTIVE

The present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment.

METHODS

Based on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1-G4): < 5.0, 5.0-14.9, 15.0-24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15.0 cases/year). Outcomes include overall survival (OS), the receipt of surgery and adjuvant therapies, 30-day readmission/mortality, 90-day mortality, and prolonged length of inpatient hospital stay (LOS). Kaplan-Meier methods and accelerated failure time (AFT) models were applied for survival analysis, and multivariable logistic regression models were performed to compare differences in the receipt of treatment and related short-term outcomes by facility type and volume.

RESULTS

A total of 40,256 GBM patients diagnosed between 2004 and 2014 were included. Patients treated at an AC & HVF experienced the longest survival (median OS: 13.3, 11.8, 11.1, and 10.3 months; time ratio [TR]: 1.00 [Ref.], 0.96, 0.92, and 0.89; for AC & HVF, AC & LVF, non-AC & HVF, and non-AC & LVF, respectively), regardless of care transition/treatment referral. Tumor resection, radiotherapy, and chemotherapy were most frequently utilized in AC & HVF. Prolonged LOS, 30-day readmission, and 90-day mortality were decreased by 20%, 22%, and 16% (p ≤ 0.001), respectively, at AC & HVF.

CONCLUSIONS

This study provides evidence of superior outcomes when GBM patients are treated at AC and HVF. Standardization of health care across facility type and/or volume and comprehensive neuro-oncological care should be a potential goal in the management of GBM patients.

The association between facility volume and overall survival in patients with Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma is an uncommon malignancy often requiring multidisciplinary management. The purpose of this study was to determine whether high-volume facilities have improved outcomes in patients with Merkel cell carcinoma relative to lower-volume facilities.

METHODS

A total of 5304 patients from the National Cancer Database with stage I-III Merkel cell carcinoma undergoing surgery were analyzed. High-volume facilities were the top 1% by case volume. Multivariable Cox regression and propensity score-matching were performed to account for imbalances between groups.

RESULTS

Treatment at high-volume facilities (hazard ratio: 0.74; 95% confidence interval: 0.65-0.84, P < .001) was independently associated with improved overall survival (OS) in multivariable analyses. In propensity score-matched cohorts, 5-year OS was 62.3% at high-volume facilities vs 56.8% at lower-volume facilities (P < .001). Median OS was 111 months at high-volume facilities vs 79 months at lower-volume facilities.

CONCLUSION

Treatment at high-volume facilities is associated with improved OS in Merkel cell carcinoma. Given the impracticality of referring all elderly patients with Merkel cell carcinoma to a small number of facilities, methods to mitigate this disparity should be explored.

Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel

BACKGROUND

Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.

OBJECTIVE

To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.

STUDY DESIGN

We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.

RESULTS

We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both).

CONCLUSION

The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

Models of care for adolescent and young adult cancer programs

This review draws on the experience of adolescent and young adult (AYA) cancer clinicians from Australia, the United States, and the United Kingdom to summarize common aspects of models of care implemented in their countries. The principles underpinning these models include patient- and family-focused care informed by an understanding of normal AYA development, enhancing existing adult or pediatric cancer services to meet the needs of AYA, and promoting collaboration between pediatric and adult oncologists. Common elements of AYA cancer care include establishing an AYA multidisciplinary team that integrates medical and psychosocial care, efforts to centralize complex care, providing access and equity for all AYA, promoting clinical trials, and helping facilitate transition to healthy survivorship. Several organizational approaches are described, noting that local program development depends on resources, infrastructure, and assessment of unmet needs within the region. The development of national networks provides opportunities for shared learning and approaches to evaluation.