75 Background: The assessment of comorbid cardiovascular disease can predict health outcomes and may risk-stratify patients for adverse events and death. Current methods used to estimate patient risk, such as the Charlson Comorbidity Index (CCI), are based on International Classification of Diseases (ICD) codes, which are a poor indicator of severity and complexity of comorbid disease. Alternatively, the number of cardiovascular drugs could be an efficient tool for estimating patient risk. In this study, we examined the relationship between cardiovascular medications and survival in patients being treated for metastatic hormone-sensitive prostate cancer (mHSPC). Methods: A nationwide retrospective observational study of US Veterans with de novo mHSPC in the Veterans Health Administration between 2011-2021 with at least 1 prescription medicine of any class. We determined the number of cardiovascular drugs from Anatomic Therapeutic Chemical (ATC) drug class C prescribed in the year prior up to 14 days before initiation of treatment. Multivariable logistic regression and Cox proportional hazard modeling was used to assess the association between number of drugs with overall survival (OS) while accounting for important covariates including age, body-mass index (BMI), prostate specific antigen (PSA), CCI, race, and weight change. Results: Among 7,875 veterans, a median (IQR) of 2 (1-4) unique cardiovascular medications were filled in the year prior to treatment. The mean age was 74.3 years (SD 10.0) with a median CCI of 3 (3-6). Age was associated with increased number of cardiac medicines with a mean of 1.6 drugs in <60 years, 2.2 drugs in 60-69, 2.5 drugs in 70-80, and 2.5 drugs in 80+ years (p<0.001). Increased number of medications was associated with decreased OS using the Kaplan-Meier method (p<0.001, see table). After adjusting for age, race, BMI, weight change, PSA, and CCI, the number of medications was independently associated with increased mortality with an adjusted hazard ratio (aHR) of 1.05 (1.03-1.06) for each additional cardiac drug. Increased mortality was observed in patients treated with 2 or more cardiac drugs (see table). Conclusions: The number of cardiovascular medications is associated with decreased survival in veterans undergoing treatment for mHSPC, even after accounting for important covariates including age, BMI, PSA, and CCI. The assessment of cardiovascular medications may provide a simple and reliable tool to estimate comorbid disease and survival in patients with cancer. [Table: see text]

74 Background: Diabetes is increasing in prevalence and management of comorbid disease in cancer is important for outcomes. Comorbid diabetes mellitus in patients with metastatic hormone sensitive prostate cancer (mHSPC) is important to consider as cancer treatments can adversely affect metabolic health and have added interactions with diabetes medicines. Little is known about the comparative effectiveness of diabetes management with insulin or oral medications. We aim to assess the survival of patients with comorbid diabetes based on insulin, oral, or no medication management. Methods: Patients diagnosed with mHSPC from 2000-2021 were identified within the Veterans Health Administration. Uncomplicated or complicated diabetes was determined using Charlson codes from the International Classification of Diseases. Treatment was determined by prescriptions of insulin, oral medication, or no use in VHA prescription records in the year prior, up to 14 days before diagnosis. Kaplan-Meier, ANOVA, and Cox proportional hazard models were used to analyze the data and covariates such as body-mass index, age, race, and baseline PSA. Results: Patients with mHSPC had significant differences in survival with diagnosis of diabetes, see table. Patients with complicated diabetes had a higher mean BMI than patients with uncomplicated diabetes (28.3 vs. 29.1, p <.001). In patients with diabetes (n = 4740), insulin was used in 1091, oral medication in 1833, or no medicines in 1816. Oral diabetes medication was associated with improved survival compared to insulin and no medication use had the lowest survival (26.6 months vs. 24.3 vs. 21.9, p <0.001). In an adjusted multivariable model, both insulin and oral medicine use were associated with increased risk of death with adjusted Hazard Ratio (aHR) for insulin 1.25 (95% CI 1.17-1.35), for oral medicine aHR 1.11 (95% CI 1.05-1.18). Conclusions: Among veterans with mHSPC, diabetes was associated with decreased survival. Within patients with a diagnosis of complicated or uncomplicated diabetes, the use of oral medication was associated with longer survival compared to insulin. Further assessment of the management of comorbid diabetes may help guide treatment and prevent adverse events. [Table: see text]

Background: Assessment of comorbid diseases is essential to clinical research and may risk-stratify patients for mortality independent of established methods such as the Charlson Comorbidity Index (CCI). Methods: In a retrospective study of U.S. Veterans, we examined the association between the number of medications, 1-year mortality, and overall survival in Veterans being treated for metastatic castration-resistant prostate cancer (mCRPC) between 2011 and 2017. Results: Among 8855 Veterans, a median of 11 medications and 6 medication classes were filled in the year prior to initial treatment of mCRPC with abiraterone or enzalutamide. The median patient age was 74 years, 25.7% of patients were Black, and the median CCI was 3. Despite being associated with fewer medications, increasing age was associated with an increased CCI. After adjusting for patient, tumor, and treatment factors, both the number of medications and the number of medication classes were associated with increased 1-year mortality with adjusted OR (95% CI) of 1.03 (1.03, 1.04) and 1.08 (1.06, 1.11), respectively. Medications within Anatomic Therapeutic Class (ATC) N (nervous system) and ATC G (genitourinary and sex hormones) were associated with decreased OS, HR 1.18 (1.11, 1.25) and HR 1.15 (1.10, 1.20), respectively. Medications within ATC C (cardiovascular) were associated with increased OS, HR 0.91 (0.86, 0.97). Within a subgroup of patients with comparable age and CCI, the increased number of medications was associated with the increased risk of death. Conclusions: The number and type of medications were independently associated with survival in patients undergoing treatment for mCRPC. With new therapies for treatment of advanced prostate cancer, patients are living longer, which increases the need for better understanding of the impact of comorbid diseases. Simple methods to assess disease burden and prognosticate survival have the potential to guide treatment decisions and improve the quality of life in this patient population.

Objective: Approximately 3 million Americans served in the armed forces during the Vietnam War. Veterans have a higher incidence rate of lung cancer compared with the general population, which may be related to exposures sustained during service. Agent Orange, one of the tactical herbicides used by the armed forces as a means of destroying crops and clearing vegetation, has been linked to the development of several cancers including non - small cell lung cancer. However, traditional risk models of lung cancer survival and recurrence often do not include such exposures. We aimed to examine the relationship between Agent Orange exposure and overall survival and disease recurrence for surgically treated stage I non - small cell lung cancer. Methods: We performed a retrospective cohort study using a uniquely compiled dataset of US Veterans with pathologic I non - small cell lung cancer. We included adult patients who served in the Vietnam War and underwent surgical resection between 2010 and 2016. Our 2 comparison groups included those with identified Agent Orange exposure and those who were unexposed. We used multivariable Cox proportional hazards and Fine and Gray competing risk analyses to examine overall survival and disease recurrence for patients with pathologic stage I disease, respectively. Results: A total of 3958 Vietnam Veterans with pathologic stage I disease were identi fi ed (994 who had Agent Orange exposure and 2964 who were unexposed). Those who had Agent Orange exposure were more likely to be male, to be White, and to live a further distance from their treatment facility ( P < .05). Tumor size distribution, grade, and histology were similar between cohorts. Multivariable Cox proportional hazards modeling identi fi ed similar overall survival between cohorts (Agent Orange exposure hazard ratio, 0.97; 95 % CI, 0.86-1.09). Patients who had Agent Orange exposure had a 19 % increased risk of disease recurrence (hazard ratio, 1.19; 95 % CI, 1.02-1.40). Conclusions: Veterans with known Agent Orange exposure who undergo surgical treatment for stage I non - small cell lung cancer have an approximately 20 % increased risk of disease recurrence compared with their nonexposed counterparts. Agent Orange exposure should be taken into consideration when determining treatment and surveillance regimens for Veteran patients. (J Thorac Cardiovasc Surg 2024;167:1591-600)

Background/Aim: With new therapies for metastatic prostate cancer, patients are living longer, increasing the need for better understanding of the impact of comorbid disease. Prescription medications may risk-stratify patients independent of established methods, such as the Charlson Comorbidity Index (CCI) and guide treatment selection. Patients and Methods: In a nationwide retrospective study of US Veterans, we used multivariable logistic regression and Cox proportional hazard modeling to evaluate the association between number and class of prescription medications and overall survival (OS) with age, race, body-mass index, prostate specific antigen (PSA), and Charlson comorbidities as covariates in veterans treated for de novo metastatic hormone sensitive prostate cancer (mHSPC) between 2010-2021. Results: Among 8,434 Veterans, a median of nine medications and five medication classes were filled in the year prior to initial treatment with abiraterone or enzalutamide for mHSPC. Veterans on 1-4 medications had an average survival of 38 months compared to 5-9 medicines (33 months), 10-14 medicines (27 months), and 15+ medicines (22 months) (p<0.001). After adjusting for age, race, body mass index (BMI), PSA, CCI, and year of diagnosis, both the number of medications and medication classes were associated with increased mortality. The adjusted hazard ratio (aHR) [95% confidence interval (CI)] was 1.03 (1.02-1.03) for the number of medications and 1.05 (1.04-1.07) for medication classes. Medications within ATC B (blood/blood forming organs), ATC C (cardiovascular), and ATC N (nervous) were associated with worse OS, with aHRs of 1.14 (1.07, 1.21), 1.14 (1.06, 1.22), and 1.12 (1.06, 1.19), respectively. Conclusion: The number and class of medications were independently associated with overall survival in patients undergoing treatment for mHSPC. With new therapies for advanced prostate cancer, patients are living longer, highlighting the need for a better understanding of the impact of comorbid diseases. Simple methods to assess disease burden and prognosticate survival have the potential to guide treatment decisions.

Background: Socioeconomic deprivation has been associated with higher lung cancer risk and mortality in non-Veteran populations. However, the impact of socioeconomic deprivation on outcomes for non-small cell lung cancer (NSCLC) in an integrated and equal-access healthcare system, such as the Veterans Health Administration (VHA), remains unclear. Hence, we investigated the impact of area-level socioeconomic deprivation on access to care and postoperative outcomes for early-stage NSCLC in United States Veterans. Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving surgical treatment in the VHA between 1 October 2006 and 30 September 2016. A total of 9704 Veterans were included in the study and assigned an area deprivation index (ADI) score, a measure of socioeconomic deprivation incorporating multiple poverty, education, housing, and employment indicators. We used multivariable analyses to evaluate the relationship between ADI and postoperative outcomes as well as adherence to guideline-concordant care quality measures (QMs) for stage I NSCLC in the preoperative (positron emission tomography [PET] imaging, appropriate smoking management, pulmonary function testing [PFT], and timely surgery [≤12 weeks after diagnosis]) and postoperative periods (appropriate surveillance imaging, smoking management, and oncology referral). Results: Compared to Veterans with low socioeconomic deprivation (ADI ≤ 50), those residing in areas with high socioeconomic deprivation (ADI > 75) were less likely to have timely surgery (multivariable-adjusted odds ratio [aOR] 0.832, 95% confidence interval [CI] 0.732–0.945) and receive PET imaging (aOR 0.592, 95% CI 0.502–0.698) and PFT (aOR 0.816, 95% CI 0.694–0.959) prior to surgery. In the postoperative period, Veterans with high socioeconomic deprivation had an increased risk of 30-day readmission (aOR 1.380, 95% CI 1.103–1.726) and decreased odds of meeting all postoperative care QMs (aOR 0.856, 95% CI 0.750–0.978) compared to those with low socioeconomic deprivation. There was no association between ADI and overall survival (adjusted hazard ratio [aHR] 0.984, 95% CI 0.911–1.062) or cumulative incidence of cancer recurrence (aHR 1.047, 95% CI 0.930–1.179). Conclusions: Our results suggest that Veterans with high socioeconomic deprivation have suboptimal adherence to care QMs for stage I NSCLC yet do not have inferior long-term outcomes after curative-intent resection. Collectively, these findings demonstrate the efficacy of an integrated, equal-access healthcare system in mitigating disparities in lung cancer survival that are frequently present in other populations. Future VHA policies should continue to target increasing adherence to QMs and reducing postoperative readmission for socioeconomically disadvantaged Veterans with early-stage NSCLC.

Abstract Objective: Socioeconomic deprivation (SED) has been associated with higher lung cancer risk and mortality. However, the effects of SED on lung cancer outcomes in an integrated, single-payer healthcare system, such as the Veterans Health Administration (VHA), remains unknown. We sought to examine the impact of area-level SED on access to care and outcomes in veterans with early-stage non-small cell lung cancer (NSCLC). Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving definitive surgical treatment in the VHA from 2006-2016. Patients were assigned an area deprivation index (ADI) score, a ZIP code-level measure of SED incorporating multiple poverty, education, housing, and employment indicators from the United States Census. Using multivariable analysis, we evaluated the relationship between ADI and guideline-concordant quality metrics (QMs) that stage I NSCLC patients should routinely meet in the preoperative (positron emission tomography [PET] imaging, smoking cessation support [SCS], pulmonary function testing [PFT], and timely surgery) and postoperative (cancer surveillance imaging, SCS, and appropriate oncology referral) periods. We also assessed the association between ADI and various cancer-specific outcomes including overall survival (OS). Results: The study included 9,704 patients. High ADI was associated with lower likelihood of receiving PET imaging (ADI ≥76 vs. ≤50: adjusted odds ratio [aOR] 0.592, 95% CI 0.502-0.698) and PFT (ADI ≥76 vs. ≤50: aOR 0.816, 95% CI 0.694-0.959) before surgery. High ADI was also associated with delayed surgery (>12 weeks after diagnosis; ADI ≥76 vs. ≤50: aOR 1.202, 95% CI 1.058-1.366). ADI was associated with 30-day readmission after surgery (ADI ≥76 vs. ≤50: aOR 1.380, 95% CI 1.103-1.726) but not with 30-day mortality (ADI ≥76 vs. ≤50: aOR 1.221, 95% CI 0.816-1.826), major complications (ADI ≥76 vs. ≤50: aOR 0.927, 95% CI 0.780-1.101), prolonged hospital length of stay (≥14 days; ADI ≥76 vs. ≤50: aOR 0.893, 95% CI 0.755-1.056), or 90-day mortality (ADI ≥76 vs. ≤50: aOR 0.876, 95% CI 0.645-1.190). ADI was not associated with adherence to postoperative QMs (ADI ≥76 vs. ≤50: aOR 0.888, 95% CI 0.764-1.032), OS (ADI ≥76 vs. ≤50: aOR 0.984, 95% CI 0.911-1.062), or cumulative incidence of cancer recurrence (ADI ≥76 vs. ≤50: aOR 1.047, 95% CI 0.930-1.179). Conclusions: Area-level SED is associated with inadequate adherence to preoperative QMs and increased readmission after surgery for stage I NSCLC. Our data suggests that veterans with high SED experience inadequate access to quality preoperative care for early-stage NSCLC but do not have inferior long-term outcomes after resection. Future VHA policies should focus on providing more equitable guideline-concordant preoperative care and preventing postoperative readmission for stage I NSCLC. Citation Format: Steven Tohmasi, Daniel B. Eaton, Brendan T. Heiden, Nikki E. Rossetti, Martin W. Schoen, Su-Hsin Chang, Yan Yan, Mayank R. Patel, Bryan F. Meyers, Benjamin D. Kozower, Varun Puri. Area-level socioeconomic deprivation is associated with inadequate access to quality preoperative care and increased readmission after surgery for early-stage lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 799.

Background:Currently, there is no consensus on how to comprehensively assess comorbidities in lung cancer patients in the clinical setting. Prescription medications may be a preferred comorbidity assessment tool and provide a simple mechanism for predicting postoperative outcomes for lung cancer. We examined the relationship between prescription medications and postoperative outcomes for early-stage non-small cell lung cancer (NSCLC). Methods:We conducted a retrospective cohort study of patients with clinical stage I NSCLC who underwent surgical resection in the Veterans Health Administration (VHA) between 10/01/2006 and 09/30/2016. Details of all outpatient prescriptions filled by patients within the VHA system from 1-year up to 14 days before surgery were collected. Medications were categorized using the Anatomical Therapeutic Chemical (ATC) Level One classification system. We assessed the association of medications prescribed in the year prior to surgery with postoperative adverse events (composite of death or major complication) at 30 and 90 days following surgery and overall survival (OS). Results:We included 9,741 veterans in the analysis. The median number of prescription medications filled in the year preceding surgery was 11 (interquartile range: 7-16). In multivariable-adjusted analyses, a higher number of prescription medications was associated with increased risk of 30-day [multivariable-adjusted odds ratio (aOR): 1.016; 95% confidence interval (CI): 1.007-1.026] and 90-day postoperative adverse events (aOR: 1.015; 95% CI: 1.006-1.024) and decreased OS (adjusted hazard ratio: 1.019; 95% CI: 1.014-1.023). Within a subgroup of patients with a high comorbidity burden (Charlson-Deyo Comorbidity Index score of 6-8), a higher number of prescription medications was also associated with reduced OS (P<0.001). Patients prescribed medications from the ATC respiratory system class had elevated risk of postoperative adverse events at 30 days (aOR: 1.255; 95% CI: 1.095-1.439) and 90 days (aOR: 1.254; 95% CI: 1.097-1.434) compared to patients without these prescription medications. Significantly increased odds for 90-day postoperative adverse events were observed with each additional prescription medication from the ATC respiratory (aOR: 1.057; 95% CI: 1.027-1.088) and nervous system (aOR: 1.035; 95% CI: 1.005-1.066) classes. Conclusions:The number of medications prescribed preoperatively is associated with short- and long-term postoperative outcomes for early-stage NSCLC, even when adjusting for several covariates including age and comorbidity burden. Patients prescribed a higher number of medications acting primarily on the respiratory and nervous systems are at elevated risk for postoperative adverse events after curative-intent resection. Prescription medications may be a reliable tool to assess comorbidities and perioperative risk for patients with NSCLC.

68 Background: Robustassessment of comorbid conditions is essential to clinical care and the risk-stratification of patients for adverse events and death. Prescription medications may be a simple and readily available tool to estimate patient risk independent of established comorbidity indices, such as the Charlson Comorbidity Index (CCI). Clinicians have access to medication lists, facilitating assessment of comorbidities. We sought to examine the relationship between prescription medications and long-term outcomes in veterans treated for metastatic hormone-sensitive prostate cancer (mHSPC). Methods: We conducted a nationwide retrospective observational study of United States Veterans diagnosed with mHSPC in the Veterans Health Administration from 2010-2021. We determined the number of unique drugs and their respective Anatomic Therapeutic Chemical (ATC) Level One classes prescribed in the year prior to the initiation of treatment. Multivariable logistic regression and Cox proportional hazard modeling was used to assess the association between number of drugs with all-cause 90-day mortality and overall survival (OS) while accounting for covariates including age, CCI, body mass index, prostate specific antigen, and race. Results: Among 8,434 Veterans, a median (IQR) of 9 (5-14) unique medications and 5 (3-7) unique ATC medication classes were filled in the year prior to treatment. The mean age was 74.2 (SD 10.1) years, and 2,126 Veterans were black (25.2%). The median CCI was 3 (2.75-6). Increasing age was associated with increased CCI across age strata with mean CCI of 3.16 in age <60, 3.76 in 60-70, 4.43 in 70-80, and 5.25 in 80+ (p<0.001). Increasing age was associated with an increased number of unique medicines with mean 8.59 in age <60, 9.53 in 60-70, 10.1 in 70-80, and 10.4 in 80+ (p<0.001). There was no significant difference in the number of medications prescribed based on race. Veterans with 1-4 medicines had the longest average survival at 38.2 months compared to 5-9 medicines (33.1 months), 10-14 medicines (27.1 months), and 15+ medicines (22.0 months) (p<0.001). After adjusting for relevant patient, tumor, and treatment factors, the number of medications and drug classes were each independently associated with increased mortality with adjusted HR (95% CI) of 1.03 (1.02-1.03) and 1.05 (1.04-1.07), respectively. Veterans treated with 5-9, 10-14, and 15+ medicines had an increased risk of death compared to Veterans on 1-4 medicines [aHR 1.11 (1.03-1.19); 1.29 (1.19-1.39); and 1.51 (1.39-1.65) respectively]. Conclusions: The number of prescription medications and drug classes are independently associated with OS in patients diagnosed with mHSPC, even after accounting for important covariates including age and CCI. Assessment of patient medications may provide a simple, yet reliable tool to assess comorbidities, risk of adverse events, and death.

BACKGROUND:Lung cancer screening guidelines were introduced in the United States in 2013, with variable implementation. This study evaluated temporal diagnostic trends in non-small cell lung cancer (NSCLC) diagnosis since the introduction of these guidelines. METHODS:This retrospective cohort analysis used data from the Veterans Administration Corporate Data Warehouse and the National Cancer Database. We evaluated temporal trends in the distribution of NSCLC stage at the time of diagnosis along with differences based on insurance coverage type, including uninsured, privately insured, Medicare, Medicaid, and Veterans Affairs (VA) coverage, with adjustment for clinically relevant variables. RESULTS:Among 1,450,965 patients diagnosed from 2006 to 2020, the proportion of NSCLC cases diagnosed at stage I increased in all insurance groups by 12.74%, 2%, 0.25%, and 2.57% for the VA, Medicare, private insurance, and Medicaid, respectively. If all insurance systems achieved the unadjusted stage distribution seen in the Veterans Health Administration, an additional 45,684 patients would be diagnosed with stage I NSCLC and 65,933 fewer patients would be diagnosed with stage IV disease. CONCLUSIONS:For patients with any form of insurance, there has been an increase in the proportion of early-stage NSCLC (stage I and II) and a corresponding decrease in the proportion of stage III and IV since the introduction of national lung cancer screening guidelines. As the largest integrated single-payer health care system in the United States, the VA dramatically outperforms other insurance types, perhaps attributable to universal coverage and robust lung cancer screening programs.

96 Background: Increased body-mass index (BMI) is associated with increased prostate cancer incidence and death. However, an ‘obesity paradox’ exists where patients with BMI have longer survival once diagnosed with cancer. We investigated the influence of BMI on overall survival of veterans with metastatic hormone-sensitive prostate cancer (mHSPC) and metastatic castration-resistant prostate cancer (mCRPC). Methods: Two cohorts were identified in the US Veterans Health Affairs. The mHSPC cohort included patients diagnosed with de-novo mHSPC from 2011-2021. The mCRPC cohort was treated with abiraterone or enzalutamide from May 2011 to June 2017. We determined BMI at time of treatment and weight loss during the one year prior. BMI was categorized as ≤20, >20-25, >25-30 or >30 kg/m2. We used Kruskal-Wallis testing for ordinal variables and Cox hazard models to assess the association between BMI, age, Charlson comorbidity index, PSA level at diagnosis, Black race, weight loss, and survival. Results: We identified 5019 veterans with mHSPC and 8159 with mCRPC. Mean BMI was 27.2 (SD 5.9) in mHSPC and 28.2 (SD 5.8) in mCRPC. Mean age was 75.7 years (SD 9.8) in mHSPC and mean age of 74.6 (SD 9.3) in mCRPC. Median overall survival was 25.6 months (95% CI 24.6-26.6) in mHSPC and 20.5 months (95% CI 19.9-21.1) in mCRPC. There were significant differences in age, Black race, and PSA at diagnosis across BMI strata with BMI>30 having the youngest age, lowest percentage of Black race, lowest PSA, and longest survival in mHSPC and mCRPC (see Table). In unadjusted analyses, veterans with BMI>30 had lowest risk of death with Hazard Ratio (HR) 0.66 (95% CI 0.60-0.71) in mHSPC and 0.60 (95% CI 0.56-0.64) in mCRPC compared to BMI>20-25. In adjusted analyses, veterans with BMI>30 had lowest risk of death with adjusted hazard ratio (HR) 0.89 (95% CI 0.81-0.97) in mHSPC and HR 0.77 (95% CI 0.72-0.83) in mCRPC compared to BMI>20-25. Conclusions: Increased BMI is associated with younger age at diagnosis, lower PSA, and longer survival in both mHSPC and mCRPC. Further studies between BMI and prostate cancer are warranted to understand these complex interactions. [Table: see text]

Objective: Current guidelines recommend adjuvant therapy for patients with completely resected non-small cell lung cancer (NSCLC) with high-risk clinical or pathologic features. Despite this, the relationship between these features and cancer recurrence is poorly elucidated. Methods: We conducted a retrospective cohort study using a uniquely compiled dataset from the US Veterans Health Administration (VHA) including all Veterans with pathologic early-stage (≤5cm, N0) NSCLC receiving definitive surgical treatment (2010-2016). Based on National Comprehensive Cancer Network guidelines, we evaluated 6 high-risk features: tumor size, tumor grade, visceral-pleural invasion, lymphovascular invasion, non-anatomic wedge resection, and adequacy of nodal sampling. We developed a score reflecting the relationship between these high-risk features and recurrence, using a multivariable competing risk model (death as competing event). The score performance was then tested in an external cohort from the National Cancer Database (NCDB). Results: The study included 3,799 Veterans. The median follow-up was 7.1 years. Recurrence was detected in 800 (21.1%) patients. The association between high-risk features and cancer recurrence were as follows: tumor size (e.g., 31-40mm vs. 0-10mm, multivariable-adjusted hazard ratio, aHR 1.676, 95% CI 1.229-2.285, p=0.001), tumor grade (e.g., III vs. I, aHR 1.884, 95% CI 1.448-2.449, p<0.001), visceral-pleural invasion (aHR 1.096, 95% CI 0.905-1.329, p=0.35), lymphovascular invasion (aHR 1.747, 95% CI 1.441-2.117, p<0.001), non-anatomic wedge resection (aHR 1.335, 95% CI 1.101-1.619, p=0.003), and adequacy of nodal sampling (e.g., 1-4 lymph nodes vs. ≥10 lymph nodes, aHR 1.392, 95% CI 1.149-1.687, p<0.001). Using these parameters, a score was created reflecting the association between high-risk features and recurrence. The score ranged from 0-36, with higher scores reflecting higher cumulative incidence of recurrence. The score was further divided into low- (0-11, n=1,263, 33.3%; 5-yr recurrence risk 13.0%), moderate- (12-15, n=1,134, 29.9%; 5-yr recurrence risk 19.0%), and high-risk (16-36, n=1,402, 36.9%; 5-yr recurrence risk 27.1%) categories. Higher scores were also associated with diminished overall survival (median OS, low-risk: 9.0 yrs; moderate-risk: 7.3 yrs; high-risk: 5.4 yrs). The score was further tested in a cohort of 63,232 patients from the NCDB and higher scores remained associated with worse overall survival (median OS, low-risk: 9.4 yrs; moderate-risk: 8.0 yrs; high-risk: 6.3 yrs). Conclusions: High-risk clinicopathologic features are associated with dramatically higher risk of recurrence and worse overall survival. Multivariable assessment of these features using a comprehensive yet pragmatic score may help to standardize adjuvant treatment eligibility following curative intent resection. Citation Format: Brendan T. Heiden, Daniel B. Eaton, Su-Hsin Chang, Yan Yan, Martin W. Schoen, Bindiya G. Patel, Theodore S. Thomas, Bryan F. Meyers, Benjamin D. Kozower, Varun Puri. Comprehensive validation of high-risk clinicopathologic features in early-stage, node-negative non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 734.

Objective: To define the relationship between the duration of smoking cessation and postoperative complications for patients with lung cancer undergoing surgical treatment. Background: Smoking increases the risk of postoperative morbidity and mortality in patients with lung cancer undergoing surgical treatment. Although smoking cessation before surgery can mitigate these risks, the ideal duration of preoperative smoking cessation remains unclear. Methods: Using a uniquely compiled Veterans Health Administration dataset, we performed a retrospective cohort study of patients with clinical stage I non-small cell lung cancer undergoing surgical treatment between 2006 and 2016. We characterized the relationship between duration of preoperative smoking cessation and risk of postoperative complications or mortality within 30-days using multivariable restricted cubic spline functions. Results: The study included a total of 9509 patients, of whom 6168 (64.9%) were smoking at the time of lung cancer diagnosis. Among them, only 662 (10.7%) patients stopped smoking prior to surgery. Longer duration between smoking cessation and surgery was associated with lower odds of major complication or mortality (adjusted odds ratio [aOR] for every additional week, 0.919; 95% confidence interval [CI], 0.850-0.993; P = 0.03). Compared to nonsmokers, patients who quit at least 3 weeks before surgery had similar odds of death or major complication (aOR, 1.005; 95% CI, 0.702–1.437; P = 0.98) whereas those who quit within 3 weeks of surgery had significantly higher odds of death or major complication (aOR, 1.698; 95% CI, 1.203–2.396; P = 0.003). Conclusion: Smoking cessation at least 3 weeks prior to the surgical treatment of lung cancer is associated with reduced morbidity and mortality. Providers should aggressively encourage smoking cessation in the preoperative period, since it can disproportionately impact outcomes in early-stage lung cancer.

Objective:Adequate intraoperative lymph node (LN) assessment is a critical component of early-stage non-small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients. Methods:We performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables. Results:Our study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS. Conclusions:Adherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.

OBJECTIVE:The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC).BACKGROUND:Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population.METHODS:We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB).RESULTS:The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001).CONCLUSIONS:Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.