Objective:Timely care is a key quality indicator. Resection delayed beyond 8 weeks for early-stage non-small cell lung cancer (NSCLC) negatively impacts prognosis, yet diagnosis-to-treatment time has steadily increased. We sought to identify drivers of delayed surgical resection and generate evidence for timeliness metrics for optimal outcomes. Methods:We evaluated patient-level factors associated with delayed versus timely surgery (>8 vs ≤8 weeks after diagnosis) for clinical stage I-II NSCLC between 2009 and 2019. Factors were identified by estimating adjusted relative risks (aRRs) and 95% CIs using modified Poisson regression. Time to process-level steps from diagnosis, along with the number and combination of these steps, were examined by timeliness of surgery. Results:Among 2567 patients, 46.0% received timely surgery. Factors associated with delayed surgery included Black (aRR, 1.14; 95% CI, 1.02-1.27) and Asian (aRR, 1.14; 95% CI, 1.00-1.29) race, distance to surgical facility of >50 miles (aRR, 1.23; 95% CI, 1.08-1.40), and greater health care use (≥25 visits, aRR, 1.72; 95% CI, 1.53-1.93). More preoperative steps increased time to surgery, but no individual step drove delays. When performed, preoperative steps occurred within the following intervals in 75% of timely surgery recipients: positron emission tomography-computed tomography: 21 days, biopsy: 20 days, pulmonary function tests: 28 days, and thoracic surgery consult: 30 days. Conclusions:As health system and oncologic care processes grow in complexity, timely treatment warrants greater attention. Our results from an integrated health system indicate several patient- and process-level factors contribute to delays that can be mitigated and offer preliminary benchmarks to promote timely NSCLC management.

OBJECTIVES:Tobacco smoking and alcohol use may negatively influence HIV care, but associations have not been examined across cohorts. DESIGN:Multisite international collaboration of cohort studies. METHODS:People with HIV (PWH) were included from 11 cohorts; 5 North American and 6 Western European. Exposures were harmonized smoking and alcohol measures (2010-2018). Loss to care was defined as not having 2+ HIV care visits (HIV RNA and/or CD4 measurement dates) at least 60 days apart, within 12 months following alcohol measure date; HIV viral nonsuppression was defined as >200 copies/ml. Adjusted prevalence ratios (PRs) were estimated using modified Poisson regression; pooled effect estimates and the heterogeneity measure ( I2 ).were derived from a random-effect meta-analysis. RESULTS:Among 83 102 PWH (87.4% male, 46.1% white); 43.7% currently smoked, 44.5% reported low/moderate drinking, 6.9% heavy drinking, 48.6% did not drink. PWH who currently smoked had higher risk of loss to care than nonsmoking PWH (pooled PR [95% CI] = 1.12 [1.08-1.16], I2  = 18.1%); those with heavy drinking had higher risk than those with low/moderate drinking (1.13 [1.03-1.25], I2  = 57.8%). PWH who currently smoked had higher risk of viral nonsuppression than nonsmoking PWH (1.44 [1.25-1.67], I2  = 90.6%); those reporting heavy drinking had higher risk than those with low/moderate drinking (pooled PR [95% CI] = 1.18 [1.02-1.37], I2  = 68.9%). PWH who reported heavy drinking and current smoking, in comparison to low/moderate alcohol use but no current smoking, had highest risk of viral nonsuppression (pooled PR [95% CI] =1.74 [1.37-2.22]), I2  = 81.8%. CONCLUSIONS:Smoking and unhealthy alcohol use were associated with HIV loss to care and viral nonsuppression, with variability between cohorts.

Preoperative invasive nodal staging is standard of care for early-stage non-small cell lung cancer (NSCLC). Complications and delays in care are not negligible and diagnostic accuracy varies. In our system, invasive nodal staging is performed for clear radiographic indications (node > 1.0 cm short axis or standardized uptake value > 3.0, tumor > 4.0 cm). This study assessed whether unexpected mediastinal upstaging was less common in patients receiving preoperative invasive nodal staging. This retrospective study evaluated nodal upstaging, defined as pathological N2 or IIIA+ disease, based on receipt or non-receipt of invasive nodal staging. Clinical stage I–II NSCLC patients who underwent resection (2009–2019) were identified from our cancer registry. Stage and preoperative nodal staging information were confirmed through chart review. Associations between patient characteristics, invasive nodal staging receipt, and clinical to pathological stage changes were analyzed. Among 2576 patients, 18.7

BACKGROUND:Depression is highly prevalent among people with HIV (PWH), and treatment is critical. We examined associations between sociodemographic and clinical characteristics, focusing on alcohol use and smoking, with use of depression treatment. METHODS:Electronic health record data from an integrated healthcare system in Northern California were used to identify PWH who had a primary care visit (index) between 1/1/2014-12/31/2020 and a depression diagnosis within 6 months of the index date. Outcomes included separate indicators for outpatient mental health (MH) encounters and antidepressant prescription fills in the year post index. RESULTS:Among 3078 PWH, 24.7 % (761) had a depression diagnosis; of those, 52.6 % were aged 50+, 10.5 % female, 56.1 % White, 36.4 % reported alcohol use in the past 3 months and 18.7 % reported current smoking. Seventy-six percent used depression treatment services (antidepressants [68 %] and outpatient MH [35 %]). Patients aged 50-59 years (OR = 0.52, CI = 0.34, 0.80) and 60+ years (OR = 0.27, CI = 0.14, 0.50) were less likely to have outpatient MH encounters compared to patients ≤40 years. Compared to White patients, Black (OR = 0.37, CI = 0.23, 0.59) and Hispanic (OR = 0.48, CI = 0.31, 0.75) patients were less likely to have antidepressant prescription fills, and Black (OR = 0.47, CI = 0.28, 0.77), Hispanic (OR = 0.58, CI = 0.35, 0.94) and Asian (OR = 0.48, CI = 0.25, 0.93) patients were less likely to use any depression treatment. Neither alcohol use nor smoking were associated with depression treatment. CONCLUSIONS:We found substantial demographic disparities in use of depression treatment services among PWH and depression. Facilitating access to mental health care for older and racial and ethnic minority patients should be prioritized.

Background In 2021, the Commission on Cancer implemented Standard 5.8 requiring lymph node sampling from ≥3 mediastinal and ≥1 hilar stations (3N2+1N1) during curative-intent lung cancer resections. Before Standard 5.8, sampling ≥10 lymph nodes was recommended. To date, the optimal nodal sampling strategy is still unknown, particularly for sublobar resections. We assessed 3N2+1N1 sampling patterns and potential associations with recurrence and mortality by resection type. Methods In this multicenter retrospective study, we evaluated early-stage non-small cell lung cancer (NSCLC) patients who underwent lobectomy or sublobar resection (2009-2019). We calculated the proportion with 3N2+1N1 sampled. Using multivariable Cox regression, we assessed associations of 3N2+1N1 sampling with 1-year recurrence and 5-year overall mortality, stratified by lobectomy vs sublobar resection. Results Among 2096 lobectomy patients, 43% had 3N2+1N1 sampling. In contrast, among 386 sublobar resection patients, 23% had 3N2+1N1. We found 3N2+1N1 sampling was not significantly associated with 1-year recurrence or 5-year mortality after lobectomy, but was associated with reduced 1-year recurrence (adjusted hazard ratio, 0.62; 95% CI, 0.39-0.98) after sublobar resection. Conclusions A minority of lobectomy and sublobar resection patients had 3N2+1N1 sampling. Although 3N2+1N1 sampling was not associated with improvements across all outcomes, our findings suggest that Standard 5.8 may be a meaningful step toward improved quality of lymph node evaluations in some patients.

IntroductionWhile biomarker testing can guide lung cancer treatment, its real-world application in community practice remains underexplored. This study examines the prevalence, predictors, and outcomes of biomarker testing in non-small cell lung cancer (NSCLC).MethodsThis retrospective cohort study included adults diagnosed with primary NSCLC from 2013 to 2020 within a large integrated healthcare system. We linked cancer registry and electronic health records to determine the prevalence of biomarker testing, including single-gene, multi-gene, and next-generation sequencing (NGS), overall and stratified by patient characteristics including age, gender, race/ethnicity, smoking status, and stage. Multivariable regression analyses were conducted to identify independent predictors of biomarker testing and evaluate associations between type of biomarker testing and 3-year all-cause mortality, overall and stratified by stage.ResultsAmong 8,267 NSCLC patients, 38.9% received biomarker testing. Testing prevalence increased with disease stage: I (6.9%), II (18.0%), III (34.8%), IV (71.1%). Testing was more prevalent in patients aged <65 years, of Asian race, and who never smoked, lived in less deprived neighborhoods, and had non-squamous tumors. Younger age, never smoking, Asian race, and stage IV disease were independent predictors of biomarker testing. NGS vs. no testing was associated with 13% decreases in 3-year all-cause mortality.ConclusionsBiomarker testing prevalence was higher in advanced stage NSCLC as expected, with decreased 3-year mortality in patients who received NGS testing. Our findings in a large real-world diverse population suggest that broader uptake of comprehensive biomarker testing across all stages of NSCLC is warranted for improved outcomes.

Rationale. Following initial detection of a potentially malignant pulmonary lesion by imaging, preoperative evaluation may involve a biopsy to confirm malignancy. Data are limited on the frequency and timing of preoperative biopsy and the extent to which patient characteristics are associated with preoperative biopsy for lung cancer. Methods. Using linked cancer registry and electronic health record data, we identified a retrospective cohort of all patients diagnosed with stage I or II non-small cell lung cancer (NSCLC) from 2014 to 2020 who underwent surgical resection in a large integrated healthcare system in California. Patient data on sociodemographic and clinical factors, including age, sex, race and ethnicity, smoking status, neighborhood deprivation index, Elixhauser comorbidity index, NSCLC stage, and method of detection (screening vs. non-screening), were ascertained relative to diagnosis. The frequency and timing of preoperative biopsy were examined in patients who underwent biopsy within six months before surgery. Unadjusted and adjusted relative risks (RR) and 95% confidence intervals (CI) were calculated using Poisson regression with robust standard errors to determine the association between sociodemographic and clinical factors and receipt of preoperative biopsy. Results. Of the 2,204 patients identified with surgically resected early-stage NSCLC (mean age 69.6 ± 8.9 years), the majority were female (61%) and of non-Hispanic White (63%), followed by Asian or Pacific Islander (18%), Hispanic (8%), and non-Hispanic Black (7%) race/ethnicity; 28% had never smoked; and 3% were detected via lung cancer screening. Approximately 67% received a preoperative biopsy, with a median of 41 (interquartile range (IQR): 28-58) days from biopsy to surgery. The largest variation in the median duration from biopsy to surgery was observed for smoking status, being 39 (IQR: 28-55), 40 (IQR: 28-57), and 48 (IQR: 32-68) days for never, former, and current smoking, respectively. In the model adjusted for all sociodemographic and clinical factors examined, the likelihood of preoperative biopsy was higher for Asian or Pacific Islander (vs. non-Hispanic White) race (RR: 1.1; 95% CI: 1.0-1.2), for residing in the most (vs. least) deprived neighborhoods (RR: 1.2; 95% CI: 1.1-1.3), and for clinical stage II (vs. I) disease (RR: 1.2; 95% CI: 1.1-1.3). Conclusions. Our data indicate that about two-thirds of surgically resected early-stage NSCLC patients undergo biopsy, within a median of 6 weeks before surgery, and revealed no major disparities in preoperative biopsy across sociodemographically disadvantaged groups. Further investigation is needed to determine if any pulmonary lesion characteristics influence biopsy receipt.

Unadjusted and adjusted mortality rate differences and excess mortality rate for cancer groups and common individual cancers, stratified by calendar era

Unadjusted mortality rate differences and excess mortality rate for common individual cancers, stratified by time from cancer diagnosis

BACKGROUND:With extended lifespans for people with human immunodeficiency virus (PWH), there is a corresponding increased burden of chronic illnesses, including cancer. Our objective was to estimate the excess mortality among PWH with cancer compared with people without HIV (PWoH), accounting for the higher background mortality in the general PWH population. METHODS:We identified 39,000 PWH and 387,767 demographically matched PWoH in three integrated healthcare systems from 2000 to 2016. We estimated excess mortality among PWH with cancer, computed as the cancer mortality rate difference-in-difference comparing PWH and PWoH. We evaluated five cancer groups: any cancer; virus-, human papillomavirus-, and Epstein-Barr virus -related cancers; virus-unrelated cancers, and common individual cancers. We fitted a multivariable additive Poisson model to estimate excess mortality among PWH with cancer. RESULTS:PWH with any cancer had excess mortality compared with PWoH [41.3/1,000 person-years (py), 95% confidence interval (CI), 34.0-48.7]. The highest excess mortality was observed for Epstein-Barr virus-related cancers (63.2/1,000 py, 95% CI, 47.8-78.7), lung cancer (147.7/1,000 py, 95% CI, 41.1-254.3), and non-Hodgkin lymphoma (70.5/1,000 py, 95% CI, 51.4-89.6). Excess mortality among PWH was attenuated from 2009 to 2016, and PWH with cancer had no excess mortality 5 years after diagnosis. CONCLUSION:PWH in care may have excess mortality from certain cancer types, although disparities may have attenuated over time and do not persist beyond 5 years after diagnosis. IMPACT:Findings may guide improved clinical practice and suggest further research is needed to investigate whether cancer treatment or other factors contribute to mortality disparities for PWH with cancer.

OBJECTIVE:Despite recognition that people with HIV (PWH) are more vulnerable to sleep issues, there is limited understanding of clinically recognized sleep disorders in this population. Our objective was to evaluate the full spectrum of sleep disorder types diagnosed among PWH in care. METHODS:We conducted a retrospective cohort study of PWH, and a comparator group of people without HIV (PWoH), in a large healthcare system. The incidence of clinically diagnosed sleep disorders was calculated using Poisson regression for three outcomes: any type of sleep disorder, insomnia, and sleep apnea. Incidence was compared between PWH and PWoH by computing the adjusted incidence rate ratio (aIRR), accounting for sleep disorder risk factors. Comparisons to PWoH were made for all PWH combined, then with PWH stratified by HIV management status (well-managed HIV defined as being on antiretroviral therapy, HIV RNA <200 copies/mL, and CD4 count ≥500 cells/μL). RESULTS:The study included 9076 PWH and 205 178 PWoH (mean age 46 years, 90% men). Compared with PWoH, sleep disorder incidence was greater among PWH overall [aIRR = 1.19, 95% confidence interval (CI): 1.12-1.26], particularly for insomnia (aIRR = 1.56, 95% CI: 1.45-1.67). Sleep apnea incidence was lower among PWH (aIRR = 0.90, 95% CI: 0.84-0.97). In HIV management subgroups, PWH without well-managed HIV had lower sleep apnea incidence (vs. PWoH: aIRR = 0.79, 95% CI: 0.70-0.89) but PWH with well-managed HIV did not (vs. PWoH: aIRR = 0.97, 95% CI: 0.89-1.06). CONCLUSIONS:PWH have high sleep disorder incidence, and insomnia is the most common clinical diagnosis. Lower sleep apnea incidence among PWH may reflect underdiagnosis in those with sub-optimally treated HIV and will be important to investigate further.

BACKGROUND:Most patient variables that impact cancer case complexity and outcomes are not modifiable preoperatively; however, the time from diagnosis to surgical resection is fluid. This retrospective study sought to identify the optimal interval from diagnosis of non-small cell lung cancer (NSCLC) to surgery to reduce mortality. METHODS:We evaluated adult patients with early-stage NSCLC who underwent upfront surgical resection between 2009 and 2019 using institutional data. The date of NSCLC diagnosis was defined uniformly as the date of a computed tomography (CT) scan that prompted a diagnostic workup. We evaluated the time to surgery in 2-week intervals. Using Cox regression analysis with adjustment for key patient sociodemographic, clinical, and cancer characteristics, we examined time to surgery associations with recurrent/new lung cancer and overall mortality at 1 and 5 years after surgery. RESULTS:Among 2567 early-stage NSCLC patients, the median time to surgery was 57.0 days (interquartile range, 41.0-79.0 days). Five-year mortality was elevated for surgeries performed at >8 weeks versus those performed at ≤8 weeks (adjusted hazard ratio [aHR], 1.19; 95% confidence interval [CI], 1.06-1.33) and at >12 weeks versus ≤12 weeks (aHR, 1.31; 95% CI, 1.10-1.55) after diagnosis. The rate of 1-year recurrence was also elevated for surgeries delayed for >8 weeks versus ≤8 weeks (aHR, 1.25; 95% CI, 0.98-1.60) and for >12 weeks versus ≤12 weeks (aHR, 1.62; 95% CI, 1.12-2.36). CONCLUSIONS:Although NSCLC aggressiveness varies, quality metrics for time to surgery are needed to optimize outcomes. This will be increasingly important as more early-stage, resectable NSCLC cases are identified. Our results suggest that performing surgery within 8 weeks of CT-based clinical diagnosis may be an important health system target for early-stage NSCLC patients.

Background:While cannabis use is prevalent among people with HIV (PWH), factors associated with higher-risk use require further study. We examined factors associated with indicators risk for cannabis use disorder (CUD) among PWH who used cannabis. Methods:Participants included adult (≥18 years old) PWH from 3 HIV primary care clinics in Kaiser Permanente Northern California who reported past three-month cannabis use through the computerized Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) screening. Primary outcome was TAPS cannabis score (range 1-3), categorized as any use (1) and higher risk for CUD (≥2). Measures included sociodemographics (age, sex, race, neighborhood deprivation index [NDI]), Charlson Comorbidity Index (CCI), HIV RNA, CD4 cell counts, higher risk tobacco use (TAPS tobacco score≥2), depression, and anxiety symptoms. Unadjusted and multivariable logistic regression examined factors associated with higher risk for CUD. Results:Of the complete sample (N=978; 94.1% Male; 58.3% White; Age Mode=51-60), 35.8% reported higher risk for CUD. Unadjusted models indicated younger age, Black race, higher CCI, depression, anxiety, and higher risk tobacco use were associated with higher risk, while only Black race (OR=1.84, 95% CI[1.29, 2.63]), anxiety (OR=1.91, 95% CI[1.22, 2.98]), and higher risk tobacco use (OR=2.27, 95% CI[1.47, 3.51]) remained significant in the multivariable model. Conclusions:Black race, anxiety and tobacco use, but not HIV clinical markers, were associated with higher risk for CUD among PWH. Clinical efforts to screen and provide interventions for preventing CUD alongside anxiety and tobacco use among PWH should be evaluated.

Number of prevalent and incident cancers by HIV status

BACKGROUND:People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH. METHOD:We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models. RESULTS:Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI. LIMITATIONS:SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor. CONCLUSIONS:HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.