BACKGROUND:Hepatocellular carcinoma is the third-leading cause of cancer-related death worldwide. In the United States, California has the highest hepatocellular carcinoma incidence burden and a high level of racial/ethnic diversity. The impact of race/ethnicity on hepatocellular carcinoma treatment and survival in California has not been investigated. METHODS:We performed a retrospective analysis of patients diagnosed with hepatocellular carcinoma from 2000 to 2012 using the California Cancer Registry. Patients were categorized by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian). Overall five-year survival was calculated using the Kaplan-Meier method. Cox proportional hazards univariable and multivariable analyses were performed to identify factors that influenced survival. RESULTS:We analyzed data from 12,288 patients (4545 non-Hispanic White; 942 non-Hispanic Black; 3299 Hispanic; 3502 non-Hispanic Asian). Non-Hispanic Black patients were least likely to receive systemic treatment, chemoembolization, or surgery. Overall five-year survival was highest for non-Hispanic Asian patients (22.9 %), followed by Hispanics (16.8 %), non-Hispanic Whites (16.5 %), and non-Hispanic Blacks (11.9 %) (log-rank P < 0.001). Multivariable analyses identified factors that negatively influenced survival, including age (>70 years), race/ethnicity (non-Hispanic, non-Asian), low socioeconomic status, Deyo-Charlson comorbidity score ≥2, tumor size ≥5 cm, grade II/III/IV tumor differentiation, and AJCC stage of II, III, or IV at diagnosis. CONCLUSIONS:Multiple factors influence patients' hepatocellular carcinoma diagnosis, treatment, and survival. Future studies are needed to identify key factors that can impact treatment and survival among hepatocellular carcinoma patients of different racial/ethnic backgrounds. IMPACT:Despite California's diverse population, racial/ethnic backgrounds can still significantly impact treatment and survival among hepatocellular carcinoma patients.

Background There is a paucity of evidence supporting the use of adjuvant radiation therapy in resected biliary cancer. Supporting evidence for use comes mainly from the small SWOG S0809 trial, which demonstrated an overall median survival of 35 months. We aimed to use a large national database to evaluate the use of adjuvant chemoradiation in resected extrahepatic bile duct and gallbladder cancer. Methods Using the National Cancer Database, we selected patients from 2004 to 2017 with pT2-4, pN0-1, M0 extrahepatic bile duct or gallbladder adenocarcinoma with either R0 or R1 resection margins, and examined factors associated with overall survival (OS). We examined OS in a cohort of patients mimicking the SWOG S0809 protocol as a large validation cohort. Lastly, we compared patients who received chemotherapy only with patients who received adjuvant chemotherapy and radiation using entropy balancing propensity score matching. Results Overall, 4997 patients with gallbladder or extrahepatic bile duct adenocarcinoma with available survival information meeting the SWOG S0809 criteria were selected, 469 of whom received both adjuvant chemotherapy and radiotherapy. Median OS in patients undergoing chemoradiation was 36.9 months, and was not different between primary sites ( p = 0.841). In a propensity score matched cohort, receipt of adjuvant chemoradiation had a survival benefit compared with adjuvant chemotherapy only (hazard ratio 0.86, 95% confidence interval 0.77–0.95; p = 0.004). Conclusion Using a large national database, we support the findings of SWOG S0809 with a similar median OS in patients receiving chemoradiation. These data further support the consideration of adjuvant multimodal therapy in resected biliary cancers.

OBJECTIVE:Determine the effect of Medicare insurance status on quality of care and survival in cancer patients. BACKGROUND:Nearly half of current Medicare beneficiaries now enroll in Medicare Advantage (MA) plans and there is limited understanding of how overall cancer care and outcomes vary in MA compared to Traditional Medicare (TM). METHODS:Medicare beneficiaries undergoing treatment for stage 1-4 lung, esophageal, gastric, pancreatic, colon, and rectal cancer from 2000-2019 in California were identified. Access, timeliness, guideline concordance and overall survival were compared between MA and TM. RESULTS:170,537 Medicare beneficiaries were analyzed (cancer type: 62,161 lung, 5,518 esophageal, 6,856 gastric, 11,582 pancreatic, 66,742 colon, and 17,678 rectal). Compared to TM, patients in MA were equally likely, or for some cancers more likely, to receive guideline concordant care. But, enrollment in MA was associated with worse overall survival after adjusting for covariates (all cancer types, hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.02-1.04, P<0.001); most notable for lung (HR 1.04, 95% CI 1.02-1.06, P<0.001) and pancreatic (HR 1.10, 95% CI 1.05-1.15, P<0.001) cancer. Considering all cancer types together, the survival rates were particularly low for stage 4 cancer patients (HR 1.05, 95% CI 1.03-1.08, P<0.001). CONCLUSIONS:Compared to TM, MA enrollment was associated with limited access to accredited centers for cancer care but similar odds of guideline concordant care. Nonetheless, MA plan enrollment was independently associated with worse survival for lung, and pancreatic cancer; with greatest disparity for patients with stage 4 cancers.

Background and ObjectivesTotal mesorectal excision (TME) remains the standard of care for patients with rectal cancer who have an incomplete response to total neoadjuvant therapy (TNT). A minority of patients will refuse curative intent resection. The aim of this study is to examine the outcomes for these patients.MethodsA retrospective cohort study of stage 1-3 rectal adenocarcinoma patients who underwent neoadjuvant chemoradiation therapy or TNT at a single institution. Patients either underwent TME, watch-and-wait protocol, or if they refused TME, were counseled and watched (RCW). Clinical outcomes and resource utilization were examined in each group.ResultsOne hundred seventy-one patients (Male 59%) were included with a median surveillance of 43 months. Twenty-nine patients (17%) refused TME and had shortened overall survival (OS). Twelve patients who refused TME converted to a complete clinical response (cCR) on subsequent staging with a prolonged OS. 92% of these patients had a near cCR at initial staging endoscopy. Increased physician visits and testing was utilized in RCW and WW groups.ConclusionA significant portion of patients convert to cCR and have prolonged OS. Lengthening the time to declare cCR may be considered in select patients, such as those with a near cCR at initial endoscopic staging.

Background: Although survival outcomes for neuroendocrine liver metastases (NETLM) are improved with liver-direct therapies (LDT), including hepatic debulking and nonsurgical trans-arterial embolization, the benefit is less established in the setting of concurrent extrahepatic disease (EHD). We performed a population-based study to characterize the rates of LDT being performed for NETLM with EHD patients and whether LDT is associated with survival outcomes. Methods: Patients with NETLM and EHD were identified using the California Cancer Registry database merged with data from the California Office of Statewide Health Planning and Development between 2000 and 2012. Demographics, clinical characteristics, and survival outcomes were analyzed for these patients with and without LDT. Results: 327 NETLM patients with EHD were identified. EHD sites included lung, peritoneum, bone, and brain. A total of 71 (22%) of these patients underwent LDT. Compared to NETLM with EHD patients who did not undergo LDT, patients who received LDT had longer median overall survival (27 vs. 16 months, p = 0.006). Within the LDT group, 23 patients underwent liver resection. Liver resection was associated with longer median overall survival compared to nonsurgical LDT (138 vs. 13 months, p < 0.001). Conclusions: LDT candidacy should be determined for patients on a case-by-case basis, but the presence of EHD should not preclude LDT with appropriate patient selection.

Background and Objectives: Surgical site infections (SSIs) after cytoreductive surgery (CRS) +/- hyperthermic intraperitoneal chemotherapy (HIPEC) are a major cause of potentially avoidable morbidity. We explored the association of negative pressure wound therapy (NPWT) with SSI in patients undergoing CRS/HIPEC. Methods: Retrospective analysis of consecutive patients undergoing CRS/HIPEC for non-gynecologic cancers. Exposure was the receipt of NPWT versus traditional skin closure. Primary outcome was SSI within 90 days of surgery. We performed multivariable logistic regression (before and after entropy balancing) to evaluate the association of exposure with outcomes. Results: A total of 251 patients were included, of which 43 (17%) received NPWT and 26 (10.4%) developed SSIs. Baseline demographics and clinicopathologic characteristics were similar between the two groups with some exceptions: Patients who received NPWT had a higher Peritoneal Carcinomatosis Index (median 19 vs. 11, p = 0.002) and operative time (10 vs. 8.2 h, p = 0.003) but were less likely to undergo HIPEC (84% vs. 95%, p < 0.05). After entropy balancing, on multivariable logistic regression, NPWT was not associated with 90-day SSI (odds ratio = 0.90; 95% confidence interval = 0.21-3.80; p = 0.89). Conclusion: NPWT was not associated with a reduction in SSIs. These findings prompt a reevaluation of the routine use of NPWT in CRS/HIPEC.

Background: The oncologic benefit of liver resection for colorectal liver metastases (CRLM) in the setting of concurrent extrahepatic disease (EHD) is controversial. We performed a population-based, cross-sectional study to determine the practice patterns and overall survival (OS) of patients with CRLM + EHD who underwent liver resection. Methods: Patients with CRLM + EHD were identified using the California Cancer Registry from 2000 to 2019. Records were linked to the Office of Statewide Health Planning Inpatient Database. Patient demographics, clinical characteristics, and survival were compared between CRLM + EHD patients with and without liver resection. Results: Of 170 978 patients with CRLM, 62 003 (36%) had concurrent EHD (CRLM + EHD). In all, 3736 (6%) of CRLM + EHD underwent liver resection compared to 22% of patients with liver limited CRLM. Compared to CRLM + EHD without liver resection, CRLM + EHD with resection were younger, had fewer comorbidities, received higher frequencies of perioperative chemotherapy, and were more likely to have only a single site of EHD rather than multiple sites. Median OS was significantly higher for CRLM + EHD with resection compared to without (52 vs. 27 months, HR 0.46 [95% CI 0.44-0.47], p < 0.001). Regarding the location of EHD, this survival benefit was observed with liver resection for lung, peritoneal, intraabdominal lymph nodes, ovarian, and bone metastases. Conclusions: In a large population-based setting, subsets of CRLM + EHD patients that undergo liver resection are associated with prolonged survival. These results support surgery with thoughtful patient selection to optimize survival outcomes in this population.

Objective: Living in a food desert is a known negative health risk, with recent literature finding an associated higher mortality in patients with cancers. Gynecologic cancers have not specifically been studied. We aimed to describe patients with gynecologic cancers who live in a food desert and determine if there is an association between living in a food desert and gynecologic cancer mortality. Methods: The 2013 -2019 California Cancer Registry (CCR) was used to identify patients with endometrial, ovarian, or cervical cancers. Patient residential census tract was linked to food desert census tracts identified by the 2015 United States Department of Agriculture Food Access Research Atlas. Comorbidity data were obtained from the California Office of Statewide Health Planning and Development database (OSHPD). Treatment, diagnosis, and survival outcomes were obtained from the CCR 's variables and compared by food desert status. Five-year disease -specific survival was analyzed by applying Cox proportional hazards analysis. Results: 40,340 gynecologic cancer cases were identified. 60.1 % had endometrial cancer, 23.2 % had ovarian cancer, and 15.9 % had cervical cancer. The average age of the cohort was 59.4 years, 48.0 % was non -Hispanic White, 50.3 % was privately insured, and 6.8 % of lived in a food desert. Living in a food desert was associated with higher disease -specific mortality for patients with gynecologic cancers (endometrial cancer HR 1.43p < 0.001 95 % CI 1.22 -1.68; ovarian cancer HR 1.47p < 0.001 95 % CI 1.27 -1.69; cervical cancer HR 1.24p = 0.045 95 % CI 1.01 -1.54). Conclusion: Patients living in food deserts had worse disease -specific survival, making access to food a modifiable risk factor that may result in mitigating gynecologic cancer disparities.

AbstractObjectivesPapillary thyroid cancer (PTC) is the most frequent subtype of thyroid cancer with overall favorable survival. Currently, little is known about the PTC experience within the United States (U.S.) Armenians. We performed the first study comparing clinicopathologic variables and clinical outcomes of U.S. Armenian PTC patients to a matched control group of non‐Armenians.MethodsWe performed a single‐center, retrospective, case–control study of adult Armenian PTC patients who received care at COH from 2005 to 2022. Armenian ethnicity was determined by surnames ending in “‐ian” and “‐yan”. We report and compare clinicopathologic presentation and disease outcomes with a gender‐ and age‐matched control non‐Armenian population.ResultsFifty‐eight Armenian patients comprised our study cohort. Positive margin status (p = .038), angioinvasion (p = .006), and extrathyroidal extension (p = .014) were more prevalent in the Armenian population. Higher rates of both persistent disease and death due to disease were seen in the Armenians regardless of age groupings. Multivariable analysis revealed significant impact of Armenian status on outcomes. Calculated 5‐ and 10‐ year disease‐specific survival rates in the Armenian cohort were 88% and 73.2%, respectively, compared with 100% and 94.6% in the non‐Armenian group (p < .002). The 5‐ and 10‐ year progression‐free survival was worse in the Armenian group at 61.8% and 50.1%, respectively, compared with 87.5% and 87.5% in the non‐Armenian group (p < .001).ConclusionArmenian PTC patients displayed more aggressive disease than non‐Armenians. In addition, Armenian PTC patients had higher incidence of disease relapse and worse clinical outcomes.Level of Evidence5

Bone metastases from gastroenteropancreatic neuroendocrine neoplasms (GEPNENs) have been associated with poor prognosis, but it is unclear whether patients with concurrent bone metastases who receive liver-directed therapy (LDT) would derive survival benefit. The California Cancer Registry dataset, merged with data from the California Office of Statewide Health Planning and Development, was used to perform a retrospective study of GEPNENs metastatic to both liver and bone between 2000 and 2012. A total of 203 patients were identified. Of these, 14.8% underwent LDT after bone metastasis diagnosis, 22.1% received LDT prior to that diagnosis, and 63.1% never received LDT. The median overall survival from the time of bone metastasis diagnosis was significantly longer in those that received LDT after diagnosis when compared with those that never received LDT (p = 0.005) and was not significantly different from the median overall survival of those that had received LDT prior to diagnosis (p = 0.256). LDT may still be associated with improved survival even after a diagnosis of bone metastasis.

PURPOSENearly half of all Medicare beneficiaries are enrolled in privatized Medicare insurance plans (Medicare Advantage [MA]). Little comparative information is available about access, outcomes, and cost of inpatient cancer surgery between MA and Traditional Medicare (TM) beneficiaries. We set out to assess and compare access, postoperative outcomes, and estimated cost of inpatient cancer surgery among MA and TM beneficiaries.METHODSRetrospective cohort analysis of MA or TM beneficiaries undergoing elective inpatient cancer surgery (for cancers located in lung, esophagus, stomach, pancreas, liver, colon, or rectum) was performed using the Office of Statewide Health Planning Inpatient Database linked to California Cancer Registry from 2000 to 2020. For each cancer site, risk-standardized access to high-volume hospitals, postoperative 30-day mortality, complications, failure to rescue, and surgery-specific estimated costs were compared between MA and TM beneficiaries.RESULTSThis analysis of 76,655 Medicare beneficiaries (median age 74 years, 51% female, 39% MA) included 31,913 colectomies, 10,358 proctectomies, 4,604 hepatectomies, 2,895 pancreatectomies, 3,639 gastrectomies, 1,555 esophagectomies, and 21,691 lung resections. Except for colon surgery, MA beneficiaries were less likely to receive care at a high-volume hospital. Mortality was significantly higher among MA beneficiaries ( v TM) for gastrectomy (adjusted risk difference [ARD], 1.5%; 95% CI, 0.01 to 2.9; P = .036), pancreatectomy (ARD, 2.0%; CI, 0.80 to 3.3; P = .002), and hepatectomy (ARD, 1.4%; 95% CI, 0.1 to 2.9; P = .04). By contrast, compared with TM, MA beneficiaries incurred lower estimated hospital costs.CONCLUSIONEnrollment in MA plan is associated with lower estimated hospital costs. However, compared with TM, MA beneficiaries had lower access to high-volume hospitals and increased 30-day mortality for stomach, pancreas, or liver surgery.

BACKGROUND:Reports on age-adjusted incidence rates of synchronous colorectal liver metastases (CRLM) among patients with stage IV colorectal cancer (CRC) are uncommon. This study presents in detail differences in CRLM incidence rates by sex, race, and age group.METHODS:Incidence rates were obtained for adults diagnosed with Stage IV CRC in the years 2010-2015 using SEER. The ratio of CRLM incidence to stage IV CRC incidence was used to calculate the rate ratio.RESULTS:Average age-adjusted CRLM incidence rate was 7.09 per 100,000 (95% CI, 6.93-7.26). CRLM incidence was higher at 8.68 (95% CI, 8.35-9.03) for males compared with 5.77 (95% CI, 5.64-5.90) for females. Highest incidence rate of 11.50 (95% CI, 10.43-11.76) was observed among Blacks. By age group the highest CRLM incidence was 24.42 (95% CI, 23.13-25.71) among adults age >75. The average rate ratio of CRLM to CRC incidence rate was 0.72 (95% CI, 0.71-0.73).CONCLUSION:Age-adjusted incidence rates of synchronous CRLM are higher for men, Blacks, and older patients. The risk ratio indicates that 72% of stage IV CRC cases are at risk of synchronous CRLM, although CRLM risk appears to decline with age.