We examined the impact of the COVID-19 consortium recommendations on the surgical management of breast cancer during the first year of the pandemic. Patients with newly diagnosed ER + DCIS, ER- DCIS, AJCC Stage cT1-2N0-1 ER + , HER2-, HER2 + , and triple negative breast cancer were identified from the National Cancer Database from 2018 to 2021. An interrupted time series design evaluated differences in surgical delay and use of neoadjuvant chemotherapy/immunotherapy (NAC) and endocrine therapy (NET) before and after the pandemic. A total of 895116 female patients were included in the study with a mean age of 61.7 years. Time to surgery decreased by an average 5.5 days from January 2020 to May 2020 for all breast cancer types, corresponding with a 62.2

BACKGROUND: Cancer outcome disparities have been reported in highly vulnerable communities. The objective of this study was to evaluate the association of social vulnerability with receipt of guideline-concordant care (GCC) and mortality risk for patients with colorectal cancer. STUDY DESIGN: This retrospective observational study identified patients with stage I to III colon or stage II to III rectal cancer between 2018 and 2020 from the National Program of Cancer Registries Database. Data were merged with the CDC Social Vulnerability Index (SVI) at the county level. GCC was defined as stage-appropriate lymphadenectomy, radiation therapy, or systemic therapy. Multivariable logistic regression and Cox proportional hazards regression investigated associations of SVI, as a continuous and categorical variable stratified into quartiles, with GCC and 3-year cancer-specific mortality risk, respectively. RESULTS: Among 124,950 patients (colon, 102,399; rectal, 22,551), median SVI was 60.9 (interquartile range 35.0 to 79.5). Patients in the highest SVI quartile had 21% decreased odds of receiving GCC (95% CI 0.76 to 0.83). Treatment at Commission on Cancer (CoC)-accredited hospitals was associated with increased GCC (odds ratio 1.79; 95% CI 1.72 to 1.85). Although there was an inverse, decreasing association between SVI and probability of GCC, probability at non-CoC-accredited hospitals declined faster than at CoC-accredited hospitals (p < 0.05). After adjusting for receipt of GCC, highly vulnerable patients treated at CoC-accredited hospitals had decreased mortality risk (hazard ratio 0.91; 95% CI 0.83 to 0.98). CONCLUSIONS: For highly vulnerable patients, treatment at CoC-accredited hospitals was associated with increased receipt of GCC and decreased mortality risk, which may reflect CoC accreditation requirements for treatment guideline adherence, community engagement, and addressing barriers to care.

256 Background: Current staging for colon cancer utilizing the American Joint Committee on Cancer TNM framework stratifies disease into groups according to how advanced the disease is and provides important standardized, individual prognostic information. Ideally, staging systems should exhibit hierarchical logic, with increasing stage reflecting worse prognosis. We sought to evaluate hierarchy within the 8th edition AJCC staging system for colon cancer. Methods: All patients with primary colon (including rectosigmoid) cancer diagnosed 2010-2017 were identified from the National Cancer Database (NCDB). Patients were only included if they carried a histologic diagnosis of invasive primary (non-recurrent) cancer, underwent radical surgery, and had complete pathologic staging data (T, N, M category data). Patients with missing follow-up data were excluded. Kaplan-Meier curves were used to assess overall survival by AJCC 8th edition pathologic summary stage group to determine whether staging was hierarchical for colon cancer. Multivariable modeling and log likelihood ratio test was then used to identify relative contributions of T and N variables to overall survival. Results: Among 270,584 colon cancer patients, pathologic staging was noted to be hierarchical by T category alone and by N category alone. However, summary staging was non-hierarchical in both instances. Multivariable modeling confirmed the AJCC non-hierarchy issue (colon HRs: 1, 1.54, 2.62, 2.60, 1.02, 2.15, and 4.38 for stage 1 as reference, 2a, 2b, 2c, 3a, 3b, 3c respectively). Multivariable modeling demonstrated that high T category (T4a, T4b) conferred the greatest risk of mortality based on hazard ratio (T4a HR 2.76, T4b HR 3.04), while high T category as well as high N category (N2a, N2b) contributed substantially to the survival model based on z-score. Further modeling assessing the predictive power of T and N category with respect to overall survival demonstrated that T category more strongly predicted overall survival than N category in colon cancer (likelihood chi-square test statistic pT:7009 vs pN:3586). Conclusions: Hierarchy in survival based on AJCC summary stage was not observed for patients with stage II-III colon cancer resulting in a paradoxical better observed survival with some stage III cancer subgroups compared to stage II cancer subgroups. High T category appears to more significantly impact survival than N category for patients with N0-N1 disease, while high N category appears more important for patients with T1-3 disease. Future revisions of the AJCC staging system should account for the differential impact of T and N category identified herein to more accurately confer prognostic information.

BackgroundGuideline-concordant care (GCC) is associated with improved survival for patients with cancer; however, variations in receipt of GCC remain a concern. The objective of this study was to evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of GCC and survival among patients with colon cancer.MethodsThis retrospective observational study identified patients diagnosed with stage I-IV colon cancer from 2018 to 2020 from the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results Program Database. Guideline concordance was defined as receipt of stage-appropriate lymphadenectomy or chemotherapy. Multivariable logistic regression models investigated associations with receipt of GCC. Cox proportional hazards regression models assessed 3-year cancer-specific mortality risk.ResultsOf 222,583 patients with colon cancer, 146,629 (91.2%) of eligible patients received guideline-concordant lymphadenectomy and 70,586 (81.9%) of the eligible patients received guideline-concordant chemotherapy. Treatment at CoC-accredited hospitals was the strongest modifiable predictor for receipt of guideline-concordant lymphadenectomy (odds ratio [OR] 1.82; 95% confidence interval [CI] 1.75-1.88) and chemotherapy (OR 2.14; 95% CI 2.06-2.23). Among patients treated at CoC-accredited hospitals, risk adjusted mortality was decreased for patients with stage I-II disease (hazard ratio [HR] 0.94; 95% CI 0.80-0.99), stage III disease (HR 0.93; 95% CI 0.88-0.98), and stage IV disease (HR 0.88; 95% CI 0.84-0.92).ConclusionsFor patients with colon cancer, treatment at CoC-accredited hospitals was associated with increased receipt of GCC and decreased mortality risk. Benchmarking data may serve as a valuable accountability tool for quality assessment to improve cancer treatment and outcomes.

Background Although cancer prognosis is most commonly estimated by tumor stage, survival is multifactorial. Our objective was to develop an American College of Surgeons “Biliary Tract Cancer Survival Calculator” prototype using machine learning to generate personalized survival estimates based on patient, tumor, and treatment factors. Methods The National Cancer Database was used to identify all patients with biliary tract malignancies between 2010 and 2017 including intrahepatic bile duct, extrahepatic bile duct, and gallbladder cancers. Included variables were determined based on random forest algorithms and review by subject matter experts. Data were split into 80% training and 20% test data sets. Extreme gradient boosting with survival embeddings, a machine learning class, generated 3-year survival curves. Internal 5-fold cross validation was evaluated through concordance statistics (c-index), Brier scores, distant calibration, and time-dependent area under the curve. Results Overall, 62,877 patients were included. Metastatic disease, age at diagnosis, and lack of surgical treatment were identified as most influential on worse survival outcomes via random forest. The final model included patient (age, sex, race and ethnicity, comorbidities), tumor (clinical TNM stage, disease site, grade), and treatment (surgery, chemotherapy, radiation) factors. Accurate model discrimination, calibration, and performance was demonstrated on internal validation (c-index: 0.74, Brier score: 0.14, distant calibration: P < .001, area under the curve: 0.83). These metrics were notably improved compared to a model based solely on stage (c-index: 0.64, Brier score: 0.18, distant calibration: P < .001, time-dependent area under the curve: 0.68). Conclusion This “Biliary Tract Cancer Survival Calculator” represents a highly accurate and comprehensive prognostic tool to estimate individualized survival estimates in real time.

This study evaluated the quality of cancer recurrence data in the National Cancer Database (NCDB) to determine if missingness and reporting consistency have improved enough to support national research. This multi-methods study included NCDB analyses and a cancer registry staff survey. Trends in recurrence data missingness from 2004 to 2021 and multivariable analyses of factors associated with missingness from 2017 to 2021 were evaluated for 4,568,927 patients with non-metastatic cancer. A survey of cancer registry staff at Commission on Cancer-accredited hospitals investigated challenges with recurrence data abstraction. From 2004 to 2021, recurrence data missingness decreased from 15.7 to 8.4

Importance Prior reports demonstrated that patients with cancer experienced worse outcomes from pandemic-related stressors and COVID-19 infection. Patients with certain malignant neoplasms, such as high-risk gastrointestinal (HRGI) cancers, may have been particularly affected. Objective To evaluate disruptions in care and outcomes among patients with HRGI cancers during the COVID-19 pandemic, assessing for signs of long-term changes in populations and survival. Design, Setting, and Participants This retrospective cohort study used data from the National Cancer Database to identify patients with HRGI cancer (esophageal, gastric, primary liver, or pancreatic) diagnosed between January 1, 2018, and December 31, 2020. Data were analyzed between August 23 and September 4, 2023. Main Outcome and Measures Trends in monthly new cases and proportions by stage in 2020 were compared with the prior 2 years. Kaplan-Meier curves and Cox regression were used to assess 1-year mortality in 2020 compared with 2018 to 2019. Proportional monthly trends and multivariable logistic regression were used to evaluate 30-day and 90-day mortality in 2020 compared with prior years. Results Of the 156 937 patients included in this study, 54 994 (35.0%) were aged 60 to 69 years and 100 050 (63.8%) were men. There was a substantial decrease in newly diagnosed HRGI cancers in March to May 2020, which returned to prepandemic levels by July 2020. For stage, there was a proportional decrease in the diagnosis of stage I (-3.9%) and stage II (-2.3%) disease, with an increase in stage IV disease (7.1%) during the early months of the pandemic. Despite a slight decrease in 1-year survival rates in 2020 (50.7% in 2018 and 2019 vs 47.4% in 2020), survival curves remained unchanged between years (all P > .05). After adjusting for confounders, diagnosis in 2020 was not associated with increased 1-year mortality compared with 2018 to 2019 (hazard ratio, 0.99; 95% CI, 0.97-1.01). The rates of 30-day (2.1% in 2018, 2.0% in 2019, and 2.1% in 2020) and 90-day (4.3% in 2018, 4.4% in 2019, and 4.6% in 2020) operative mortality also remained similar. Conclusions and Relevance In this retrospective cohort study, a period of under diagnosis and increase in stage IV disease was observed for HRGI cancers during the pandemic; however, there was no change in 1-year survival or operative mortality. These results demonstrate the risks associated with gaps in care and the tremendous efforts of the cancer community to ensure quality care delivery during the pandemic. Future research should investigate long-term survival changes among all cancer types as additional follow-up data are accrued.

Importance Hospital-level factors, such as hospital type or volume, have been demonstrated to play a role in treatment disparities for Black patients with cancer. However, data evaluating the association of hospital accreditation status with differences in treatment among Black patients with cancer are lacking. Objective To evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of guideline-concordant care and mortality among non-Hispanic Black patients with colon cancer. Design, Setting, and Participants This population-based cohort study used the National Program of Cancer Registries, which is a multicenter database with data from all 50 states and the District of Columbia, and covers 97% of the cancer population in the US. The participants included non-Hispanic Black patients aged 18 years or older diagnosed with colon cancer between January 1, 2018, and December 31, 2020. Race and ethnicity were abstracted from medical records as recorded by health care facilities and practitioners. The data were analyzed from December 7, 2023, to January 17, 2024. Exposure CoC hospital accreditation. Main Outcome and Measures Guideline-concordant care was defined as adequate lymphadenectomy during surgery for patients with stages I to III disease or chemotherapy administration for patients with stage III disease. Multivariable logistic regression models investigated associations with receipt of guideline-concordant care and Cox proportional hazards regression models assessed associations with 3-year cancer-specific mortality. Results Of 17 249 non-Hispanic Black patients with colon cancer (mean [SD] age, 64.8 [12.8] years; 8724 females [50.6%]), 12 756 (74.0%; mean [SD] age, 64.7 [12.8] years) were treated at a CoC-accredited hospital and 4493 (26.0%; mean [SD] age, 65.1 [12.5] years) at a non–CoC-accredited hospital. Patients treated at CoC-accredited hospitals compared with those treated at non–CoC-accredited hospitals had higher odds of receiving guideline-concordant lymphadenectomy (adjusted odds ratio [AOR], 1.89; 95% CI, 1.69-2.11) and chemotherapy (AOR, 2.31; 95% CI, 1.97-2.72). Treatment at CoC-accredited hospitals was associated with lower cancer-specific mortality for patients with stages I to III disease who received surgery (adjusted hazard ratio [AHR], 0.87; 95% CI, 0.76-0.98) and for patients with stage III disease eligible for chemotherapy (AHR, 0.75; 95% CI, 0.59-0.96). Conclusions and Relevance In this cohort study of non-Hispanic Black patients with colon cancer, patients treated at CoC-accredited hospitals compared with those treated at non–CoC-accredited hospitals were more likely to receive guideline-concordant care and have lower mortality risk. These findings suggest that increasing access to high-quality guideline-concordant care at CoC-accredited hospitals may reduce variations in cancer treatment and outcomes for underserved populations.

BACKGROUND:Standardization of procedures for data abstraction by cancer registries is fundamental for cancer surveillance, clinical and policy decision-making, hospital benchmarking, and research efforts. The objective of the current study was to evaluate adherence to the four components (completeness, comparability, timeliness, and validity) defined by Bray and Parkin that determine registries' ability to carry out these activities to the hospital-based National Cancer Database (NCDB). METHODS:Tbis study used data from U.S. Cancer Statistics, the official federal cancer statistics and joint effort between the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI), which includes data from National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) to evaluate NCDB completeness between 2016 and 2020. The study evaluated comparability of case identification and coding procedures. It used Commission on Cancer (CoC) standards from 2022 to assess timeliness and validity. RESULTS:Completeness was demonstrated with a total of 6,828,507 cases identified within the NCDB, representing 73.7% of all cancer cases nationwide. Comparability was followed using standardized and international guidelines on coding and classification procedures. For timeliness, hospital compliance with timely data submission was 92.7%. Validity criteria for re-abstracting, recording, and reliability procedures across hospitals demonstrated 94.2% compliance. Additionally, data validity was shown by a 99.1% compliance with histologic verification standards, a 93.6% assessment of pathologic synoptic reporting, and a 99.1% internal consistency of staff credentials. CONCLUSION:The NCDB is characterized by a high level of case completeness and comparability with uniform standards for data collection, and by hospitals with high compliance, timely data submission, and high rates of compliance with validity standards for registry and data quality evaluation.

11064 Background: Widespread health system integration of hospitals continues to reshape the landscape of U.S. healthcare delivery. While complex cancer care has become centralized to high-volume centers, care for common cancers happens across the spectrum of hospital sizes, with known variation in receipt of evidence-based practice (EBP) based on system affiliation. Strategies are needed to evaluate system performance in order to identify system characteristics and processes that contribute to high-quality cancer care. Methods: Using a novel data linkage between the National Cancer Database and AHRQ Compendium of U.S. Health Systems, adult patients treated for breast, colon, melanoma, and thyroid cancers between 2010 and 2020 at Commission on Cancer (CoC) hospitals were identified. Systems were categorized based on number of CoC hospitals (small, 2-3; medium, 4-9; large, 10+). Eight EBP measures were developed using national multidisciplinary guidelines, and measure-specific cohorts were extracted to calculate system-level EBP performance and within-system variation using mixed effects multivariable logistic regression models. Systems were then ranked across all measures for performance and variation, and average rankings were compared by system size. Results: 3,052,453 patients with breast (60.0%), colon (17.0%), melanoma (14.0%), and thyroid (9.0%) cancers were treated at 866 CoC hospitals in 368 health systems. The 8-measure analytic cohort had 104 systems, most of which were small systems (n=74, 71.2%). Large systems (n=9, 8.7%) had worse average performance rankings compared to medium or small systems, though this was not statistically significant (p=0.1) (Table). A significant increase in within-system variation (as measured by average ranking of variability across EBP measures) was seen with increasing system size (p<0.001). Conclusions: Significant variation in EBP performance for common cancers was noted based on health system size in this large, contemporary cohort, with greater within-system variation as system size increased. Future work will identify modifiable system characteristics associated with performance that could aid system leaders and policy makers to design, measure, and incentivize systems that employ effective cancer care delivery strategies. System rankings from 1 to 104 (best to worst), averaged over all measures; data presented as median (IQR). [Table: see text]

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.

This cohort study assesses alterations in cancer treatment during the first year of the COVID-19 pandemic among adults in the US.

e18811 Background: The Covid-19 pandemic caused unprecedented challenges in the diagnosis and evaluation of cancer. At the same time, cancer treatment was potentially impacted by significant constraints on patients and hospitals; however, the extent and differential influence on different hospital types is unknown. Our objective was to assess the patterns of treatment utilization to better characterize the impact of the first year of the Covid-19 pandemic on the US healthcare system. Methods: The National Cancer Database (NCDB) was queried for patients treated for any type of malignancy diagnosed from 2018-2020. Autoregressive models were used to forecast expected findings for 2020 based on observations from the prior two years. Descriptive univariate statistics using chi-squared tests were performed to compare observed-to-expected findings for treatment utilization and losses in provided care in 2020. Results: Overall, 1,229,654 patients underwent treatment for any newly diagnosed cancer in the NCDB in 2020, representing a 16.8% reduction compared to what was expected. Stratified by treatment modality, 146,805 fewer patients than expected underwent surgery, 80,480 fewer received radiation and 68,014 fewer received chemotherapy. Reductions in treatment were examined by hospital type. Academic hospitals experienced the greatest reduction in provided care (-105,093 patients, -19%) compared to community programs (-72,432 patients, -14%) and integrated networks (-40,827 patients, -13%). However, there were fewer hospitals in the academic cohort which exaggerated the impact on each hospital. Thus, academic hospitals lost approximately 484 patients per hospital while community hospitals lost 99 patients and integrated networks lost 110 patients per hospital. The losses in provided care were most dramatic in terms of surgical care, as academic hospitals operated on 314 fewer patients per hospital (-20%) than expected while community hospitals on average operated on 69 fewer patients (-16%) and integrated networks 71 fewer patients (-14%). Conclusions: The impact of the first year of the Covid-19 pandemic on cancer treatment was heterogenous, resulting in nearly twice the number of missed surgical patients, compared to other treatment modalities. While all hospital types were affected by the pandemic, cancer care at academic hospitals experienced disproportionate reductions, with each hospital losing more than 4 times the number of treated patients than other hospital types. Continued efforts to recover from the strain of the pandemic on the US healthcare system will need to consider the complex influence of treatment declines across hospital types and different cancer service lines.