Importance:A unified salivary gland carcinoma (SGC)-specific tumor-node-metastasis (TNM) classification can enhance prognostic accuracy, support clinical decision-making, and improve the quality of patient care. Objective:To derive and validate an SGC-specific pTNM classification with improved prognostic accuracy and optimized stage distribution for version nine of the American Joint Committee on Cancer/Union for International Cancer Control staging protocol. Design, Setting, and Participants:This retrospective prognostic cohort study derived a novel pTNM classification using data from the National Cancer Database (NCDB) of patients with surgically treated major SGC (2012-2017) and validated it in an international major SGC cohort (2008-2021) and a single-institution minor SGC cohort (Memorial Sloan Kettering Cancer Center; 1985-2016). Data were analyzed from June to November 2024. Exposures:Surgery with or without postoperative radiotherapy or chemoradiotherapy. Main Outcomes and Measures:The primary end point was overall survival (OS). Cox proportional hazards multivariable analysis was used to confirm the prognostic importance of pathologically positive lymph node (LN) number and extranodal extension (pENE) and derive an optimal pTNM classification. Results:The NCDB dataset included 8409 patients with SGC: 7659 with M0 disease (5748 with pN0 disease and 1911 with pN+ disease) and 750 with M1 disease. Among the 7659 patients with M0 disease, the median (IQR) age was 60 (48-71) years, and 3861 (50.4%) were male. The median (IQR) follow-up was 88.4 (72.3-108.5) months. The 5-year OS was 87.2% (95% CI, 86.3-88.0) for N0 disease, 68.2% (95% CI, 63.9-72.8) for 1 positive LN without pENE, 60.2% (95% CI, 53.5-67.5) for 2 positive LNs without pENE, 68.4% (95% CI, 58.0-76.6) for 3 positive LNs without pENE, 47.5% (95% CI, 41.6-52.8) for more than 3 positive LNs without pENE, and 41.4% (38.1-44.8) for pENE-positive LNs. Multivariable analysis confirmed the independent prognostication of LN count compared with pN0 disease (1 positive LN: adjusted hazard ratio [aHR], 1.70; 95% CI, 1.44-2.01; 2 positive LNs: aHR, 1.61; 95% CI, 1.31-1.98; 3 positive LNs: aHR, 2.10; 95% CI, 1.65-2.68; 4 positive LNs : aHR, 2.46; 95% CI, 1.87-3.24; more than 4 positive LNs: aHR, 2.07; 95% CI, 2.08-2.91) and pENE-positive LNs compared with pENE-negative LNs (aHR, 1.27; 95% CI, 1.10-1.48). The proposed pN classification were pN1 for 1 to 3 positive LNs and pENE negativity and pN2 for more than 3 positive LNs or pENE positivity. Model fit improved with the proposed pN classification vs the current pN classification (Akaike Information Criterion, 26 442 vs 26 483). Based on the aHR model, the following stage groups were proposed: stage I: T1N0 (1 [reference]); stage II: T2N0 (aHR, 1.34; 95% CI, 1.11-1.61); stage IIIA: T1-2N1 or T3-4N0 (aHR, 2.36; 95% CI, 1.99-2.80); stage IIIB: T1-2N2 or T3-4N1-2 (aHR, 5.15; 95% CI, 4.38-6.06); and stage IV: M1 disease (aHR, 13.61; 95% CI, 11.37-16.29). The C index values were similar (proposed classification: 0.792; current classification: 0.790), while the AIC improved slightly (proposed classification: 26 441; current classification: 26 482). Stage-specific OS differences were evident in both the international major SGC cohort (n = 1015) and Memorial Sloan Kettering Cancer Center minor SGC cohort (n = 444). Conclusions and Relevance:This unified, SGC-specific staging system improved prognostic accuracy and sample size balance and was applicable to both major and minor SGCs.

BACKGROUND:The survival impact of American College of Surgeons Commission on Cancer (CoC) accreditation on colorectal cancer care remains uncertain, particularly when assessed using both outcome-based and process-based quality frameworks. STUDY DESIGN:Hospitals were evaluated using two approaches: an Outcome Method based on 5-year mortality hazard and a Criteria Method based on adherence to evidence-based quality metrics. Data were derived from the National Cancer Database and Centers for Medicare & Medicaid Services. Hospitals were compared by performance tier and CoC accreditation status. RESULTS:Among 1,227 CoC-accredited hospitals, the Outcome Method classified 168 (14%) high-, 861 (70%) medium-, and 198 (16%) low-tier hospitals. Compared with medium-tier hospitals, high-tier hospitals demonstrated lower 5-year mortality hazard (HR 0.63, 95%CI 0.6-0.66), whereas low-tier hospitals had higher hazard (HR 1.51, 95%CI 1.44-1.58). The Criteria Method identified 194 (16%) high-performing and 1,033 (84%) average-performing hospitals; high-performing hospitals had reduced 5-year mortality (HR 0.86, 95%CI 0.81-0.90). Compared with 2,107 non-CoC hospitals, treatment at CoC-accredited hospitals was associated with reduced 1-year mortality using both methods: Outcome Method-high-tier HR 0.81 (95%CI 0.76-0.87), medium-tier HR 0.91 (95%CI 0.87-0.95); Criteria Method-high-performing HR 0.83 (95%CI 0.77-0.88), average-performing HR 0.92 (95%CI 0.88-0.96). CONCLUSIONS:Higher-quality colorectal cancer care, defined by either mortality-based or criteria-based methodologies, is associated with improved survival. CoC accreditation is consistently associated with reduced short-term mortality, supporting its role as a systems-level marker of quality.

BACKGROUND:The National Cancer Database (NCDB) captures 73.7% of newly diagnosed cancers in the USs and underpins thousands of outcomes studies informing oncologic practice. To remain relevant amid rapid therapeutic and policy changes, the NCDB has undergone substantial structural and variable-level revisions. We characterized major updates during the past decade and their implications for research. STUDY DESIGN:We performed a narrative review of annual NCDB data dictionary revisions, American College of Surgeons bulletins, and internal program updates in collaboration with NCDB leadership. Structural modifications, variable additions, and policy changes affecting data capture, follow-up, staging, and accessibility were systematically summarized. RESULTS:The NCDB now includes data from 1,413 Commission on Cancer-accredited hospitals and more than 55 million records. Since 2020, the Rapid Cancer Reporting System enables near-real-time monthly submissions. Embargo periods were reduced from 5 to 3 years for survival data and 2 years for other variables, increasing analytic timeliness. Follow-up was limited to 15 years beginning January 1, 2022. Variable refinements include continuous tumor size in millimeters (since 2016), separation of tumor grade into clinical, pathologic, and posttherapy fields (since 2018), phased radiation treatment reporting (since 2018), and American Joint Committee on Cancer eighth edition staging implementation in January 2018 with nineth edition rollout ongoing. New data elements include Medicaid expansion status (2020), COVID-19 variables (2020 to 2021; 12.4% reduction in cases in 2020), smoking status (2023), and planned programmed death-ligand 1 reporting for non-small cell lung cancer beginning in 2025. CONCLUSIONS:The NCDB has evolved toward more granular, contemporary, and policy-relevant data capture while maintaining broad national coverage. Investigators must account for staging transitions, variable maturation, follow-up limits, and registry-specific biases to ensure valid interpretation of NCDB-based research.

Background Anatomic TNM staging lacks patient information that can influence cancer survival. Using machine learning, specifically extreme gradient boosting with survival embeddings, a model can be developed to improve predictive accuracy of patient survival by including additional clinical information. Methods A retrospective study of 382,531 colon cancer cases diagnosed between 2018 and 2021 using the National Cancer Database. A random forest analysis was performed followed by training a machine learning model to develop survival predictions. Model 1 used only TNM staging to predict survival, whereas model 2 used TNM and the additional variables to predict survival. Predictive efficacy was compared using integrated Brier scores (a measure that predicts error rates), Harrell concordant indices (a measure that evaluates the discriminative ability of survival models), and time-dependent areas under the curve (a measure that assesses the performance of survival models). Results Predictive accuracy metrics demonstrated improvements in all areas including a 4-year Brier score of 0.19 for the TNM-only model, and 0.14 for the TNM with predictors model; a Harell concordance index for TNM-only of 0.73 and 0.83 for TNM with predictors. Finally, the average time-dependent area under the curve for TNM only was 0.75, and the average time-dependent area under the curve for TNM with predictors was 0.87. Conclusion Machine learning can be used to develop models of cancer survival that include clinical parameters resulting in more accurate predictions of patient outcomes compared with traditional TNM anatomic staging.

INTRODUCTION: The American Joint Committee on Cancer (AJCC) staging system undergoes periodic revisions to maintain contemporary survival outcomes related to stage. Recently, the AJCC has developed a novel, systematic approach incorporating survival data to refine stage groupings. The objective of this study was to demonstrate data-driven optimization of the version 9 AJCC staging system for anal cancer assessed through a defined validation approach.METHODS: The National Cancer Database was queried for patients diagnosed with anal cancer in 2012 through 2017. Kaplan-Meier methods analyzed 5-year survival by individual clinical T category, N category, M category, and overall stage. Cox proportional hazards models validated overall survival of the revised TNM stage groupings.RESULTS: Overall, 24,328 cases of anal cancer were included. Evaluation of the 8th edition AJCC stage groups demonstrated a lack of hierarchical prognostic order. Survival at 5 years for stage I was 84.4%, 77.4% for stage IIA, and 63.7% for stage IIB; however, stage IIIA disease demonstrated a 73.0% survival, followed by 58.4% for stage IIIB, 59.9% for stage IIIC, and 22.5% for stage IV (p <.001). Thus, stage IIB was redefined as T1-2N1M0, whereas Stage IIIA was redefined as T3N0-1M0. Reevaluation of 5-year survival based on data-informed stage groupings now demonstrates hierarchical prognostic order and validated via Cox proportional hazards models.CONCLUSION: The 8th edition AJCC survival data demonstrated a lack of hierarchical prognostic order and informed revised stage groupings in the version 9 AJCC staging system for anal cancer. Thus, a validated data-driven optimization approach can be implemented for staging revisions across all disease sites moving forward.

The 8th edition AJCC gastric cancer staging manual was refined using Japanese and Korean data from the International Gastric Cancer Association (IGCA). This study evaluated the eighth edition’s validity for U.S. populations.

6004 Background: The National Quality Forum (NQF) endorsed QMs for breast and colorectal (CR) cancer in 2007. Application by cancer registries may yield inaccurately low measures of QM concordance because of incomplete data on systemic therapy and radiation. Linkage of registry data to insurance claims may provide a more robust measure of quality at the community level. This study examined concordance with NQF QMs using payer claims linked to the National Cancer Data Base and the Ohio Cancer Incidence Surveillance System (combined data = REG). Methods: Claims from United Healthcare and Anthem Blue Cross Blue Shield of Ohio were linked to REG for patients treated in Ohio during 2004-06 for breast and CR cancer. Cases with fewer than 270 days of claims were excluded. Concordance with NQF QM's was assessed by examining radiation, chemotherapy, and endocrine therapy defined from REG and claims as treatment actually administered. Results: The claims-registry linkage identified 2,447 women with stage 0–III breast cancer and 668 patients with stage 0–III CR cancer. The Table shows concordance with NQF QMs. Conclusions: Linkage of claims to registries allows more accurate community-wide assessment of quality of cancer care. Concordance with NQF QMs among insured patients in Ohio was very high. Efforts to expand claims-registry linkages are warranted for quality assessment. NQF measure N cases Concordance with NQF QMs by data source Registry only Claims only Claims + registry Stage I-III breast cancer; breast-conserving surgery; age < 70; radiation < 365 days of diagnosis (Dx) 932 84% 95% 96% T1cN0M0 and stage II-III breast cancer; hormone receptor negative; age < 70; chemotherapy < 120 days of Dx 267 77% 92% 94% T1cN0M0 and stage II-III breast cancer; hormone receptor positive; endocrine therapy < 365 days of Dx 613 61% 84% 92% Stage III colon cancer; age < 80 chemotherapy < 120 days of Dx 161 82% 91% 96% Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration UnitedHealthCare

599 The National Quality Forum (NQF) recently adopted accountability cancer quality measures. Careful specification of target populations makes it so that omission of recommended therapy should be uncommon. One measure is use of radiation (RT) with breast conserving therapy (BCT) for women under age 70. This study examines nationwide use of RT in 2003–04 to determine the extent of variation and the need for improvement within these tight specifications. Methods: Data from 1,303 hospitals reporting to the National Cancer Data Base (NCDB) on women under age 70 treated with BCT in 2003–04 for invasive breast cancer were examined for factors associated with the use of RT in a multivariate model. The attributable provider unit was the reporting hospital. Results: Overall among 90,611 women under age 70, RT was reported with BCT in 74.5%. RT began within 6 months diagnosis in 54% and 1 yr in 74.2%. On multivariable analysis ( Table 1 ), RT was significantly less likely among African American and Hispanic vs. Caucasian women, those with less vs. more education, with no insurance or Medicaid vs. managed care, those with Charlson comorbidity > 0, women treated outside the Great Lakes/Midwest census regions, and treated at hospitals in the lower vs. higher quartiles of case volume. RT was administered to 73% of women in non-urban hospitals, and to 82% of women in urban hospitals. RT was administered to 75% and 77% of women age 50 - 59 and 60 - 69, respectively, compared to 68% and 72% of women age < 40 and 40 - 49. Conclusions: Despite limiting measurement to populations that should clearly receive RT with BCT, there are significant variations associated with patient and institutional characteristics. Reporting cancer care quality data is important, and the use of RT with BCT is a key quality measure for improvement and provider accountability. [Table: see text] No significant financial relationships to disclose.