in the US A Patterns of Care Analysis Xiang Gao 1 Amanda Kahl 2 Paolo Goffredo 1 Imran Hassan 1 Mary Charlton 2 1 University of Iowa Department of Surgery 2 University of Iowa College of Public Health ID: 1041099
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1. Treatment of Stage IV Colon Cancer in the US: A Patterns of Care AnalysisXiang Gao1, Amanda Kahl2 , Paolo Goffredo1, Imran Hassan1, Mary Charlton21University of Iowa, Department of Surgery; 2University of Iowa, College of Public HealthNAACCR/IACR Combined Annual Conference 2019
2. DisclosuresThe authors have nothing to disclose
3. Background - Colon Cancer3rd most common cancer diagnosis3rd leading cause of cancer-related deathsLifetime riskMen: 1 in 22Women: 1 in 24Stage IV 5-year survival: 14%77-90% present with unresectable diseaseSource: American Cancer Society. https://www.cancer.org/cancer/colon-rectal-cancer.html
4. 4Background - SEER POC 2014
5. 5Background - Stage IV TreatmentTumor resection, metastasectomy, neo/adjuvant chemotherapyChemotherapy + biologics, then re-evaluate Chemotherapy + biologicsChemotherapy + biologicsColon resection if: imminent risk of obstruction, significant bleeding, perforation, or other significant tumor symptoms
6. Objective6Examine the patient, tumor, and hospital factors associated with treatment regimens in stage IV colon cancer.
7. Patients aged >20 yearsDiagnosed in 2014Stage IV colon- first and only cancerSampling proportionate to registry sizeConnecticut, New Jersey, Iowa, Detroit, Kentucky, Louisiana, Atlanta, California, Hawaii, New Mexico, Seattle, UtahOversampling of racial minorities7Methods - Study Population
8. Methods - Treatment VariablesTreatment variables:Primary tumor resection (PTR, yes/no)Radiation (yes/no)ChemotherapyTargeted biologic agentsTreatment groups:Resection plus chemotherapyChemotherapy onlyGiven within 7 weeks of diagnosisResection onlyNo treatment
9. Methods - Additional VariablesCharlson IndexSEER Registry region: Northeast: Connecticut, New JerseyNorth Central: Iowa, DetroitSouth: Kentucky, Louisiana, AtlantaWest: California, Hawaii, New Mexico, Seattle, Utah9
10. Treatment patterns by SEER regionChi-square testsPatient, tumor, hospital/region characteristics by treatmentMultinomial logistic regression Patient, tumor, hospital/region characteristics by treatment with chemotherapy only as reference groupOverall survivalKaplan-MeierCox proportional hazards10Methods - Statistical Analysis
11. Results11SEER 18 Registry POC patients diagnosed with stage IV colon cancer in 2014 (N=1445)Stage IV adenocarcinoma of colon(N=1407)Exclude histologies that are notmalignant neoplasm, carcinoma, adenocarcinona, mucinous adenocarcinoma, or signet ring cell carcinomaN=38
12. Results - Overall PopulationSurgery to metastasis28%
13. 13Results - Patterns of Treatment by Region
14. 14Results - Univariable Analysis by Treatment GroupPatient DemographicsAge at diagnosisSexRaceInsurance statusMarital statusClinical characteristicsCharlson IndexPerforationObstructionHospital/registry characteristicsRegistry RegionHospital bed sizeResidency program statusTumor characteristicsHistologyGradeT, N, M stagesKRAS, BRAF statusMSITreatment variablesPTR and chemotherapy sequenceSurgery to metastasisRadiationChemotherapyVEGF inhibitorEGFR inhibitor
15. 15Results - Multinomial RegressionFactors associated with PTR + Chemotherapy (vs chemotherapy only)
16. 16Results-Results - Multinomial RegressionFactors associated with PTR only (vs chemotherapy only)
17. 17Results - Multinomial RegressionFactors associated with no treatment (vs chemotherapy only)
18. 18Results - Kaplan Meier Overall SurvivalMedian survivalPTR + Chemotherapy: >24 monthsChemotherapy Only: 14 monthsPTR only: 5 monthsNo treatment: 2 months
19. 19Results - Cox Proportional HazardsAdjusted for: Age, sex, race, insurance status, marital status, Charlson Index, SEER region, hospital bed size, hospital residency status, tumor histology, grade, T, N, and M stages, KRAS, BRAF, MSI, perforation, obstruction, surgery to metastasis
20. SummaryPTR + ChemoNode positiveLower metastatic burden+ perforation+ obstructionMarriedSmall, non-academic hospitals57% of patients received PTR (+/- chemotherapy)PTR onlyAdvanced T, N Lower metastatic burden+ perforation+ obstructionOlderMedicaidSmall hospitalsNo treatmentUnknown genetic markersOlderAfrican American
21. ConclusionsResection is frequently used in treatment of stage IV colon cancerResection should be reserved to severe symptoms or curative intentVariation in treatment patterns by hospital factorsSupport for guideline implementation may be particularly beneficial in small, non-academic hospitalsVariation in treatment patterns by race, insurance status, ageEfforts that identify/address barriers to care, patient education21
22. Thank you22