Publications by authors named "Miranda B Lam"

20 Publications

  • Page 1 of 1

Reforms to the Radiation Oncology Model: Prioritizing Health Equity.

Int J Radiat Oncol Biol Phys 2021 Jun;110(2):328-330

Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts. Electronic address:

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http://dx.doi.org/10.1016/j.ijrobp.2021.01.029DOI Listing
June 2021

Association of Medicaid expansion and insurance status, cancer stage, treatment and mortality among patients with cervical cancer.

Cancer Rep (Hoboken) 2021 May 2:e1407. Epub 2021 May 2.

Harvard Medical School, Boston, Massachusetts, USA.

Background: Currently, little is known about the effect of the Patient Protection and Affordable Care Act's Medicaid expansion on care delivery and outcomes in cervical cancer.

Aim: We evaluated whether Medicaid expansion was associated with changes in insurance status, stage at diagnosis, timely treatment, and survival outcomes in cervical cancer.

Methods And Results: Using the National Cancer Database, we performed a difference-in-differences (DID) cross-sectional analysis to compare insurance status, stage at diagnosis, timely treatment, and survival outcomes among cervical cancer patients residing in Medicaid expansion and nonexpansion states before (2011-2013) and after (2014-2015) Medicaid expansion. January 1, 2014 was used as the timepoint for Medicaid expansion. The primary outcomes of interest were insurance status, stage at diagnosis, treatment within 30 and 90 days of diagnosis, and overall survival. Fifteen thousand two hundred sixty-five patients (median age 50) were included: 42% from Medicaid expansion and 58% from nonexpansion states. Medicaid expansion was significantly associated with increased Medicaid coverage (adjusted DID = 11.0%, 95%CI = 8.2, 13.8, p < .01) and decreased rates of uninsured (adjusted DID = -3.0%, 95%CI = -5.2, -0.8, p < .01) among patients in expansion states compared with non-expansion states. However, Medicaid expansion was not associated with any significant changes in cancer stage at diagnosis or timely treatment. There was no significant change in survival from the pre- to post-expansion period in either expansion or nonexpansion states, and no significant differences between the two (DID-HR = 0.95, 95%CI = 0.83, 1.09, p = .48).

Conclusion: Although Medicaid expansion was associated with an increase in Medicaid coverage and decrease in uninsured among patients with cervical cancer, the effects of increased coverage on diagnosis and treatment outcomes may have yet to unfold. Future studies, including longer follow-up are necessary to understand the effects of Medicaid expansion.
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http://dx.doi.org/10.1002/cnr2.1407DOI Listing
May 2021

Clinical outcomes following high-dose-rate surface applicator brachytherapy for angiosarcoma of scalp and face.

J Contemp Brachytherapy 2021 Apr 14;13(2):172-178. Epub 2021 Apr 14.

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA.

Purpose: Angiosarcoma is a sub-type of soft tissue sarcoma, often presenting as a multifocal or diffuse disease process with poor prognosis. This study presents outcomes of a single institution cohort of patients with angiosarcoma of the scalp and face following treatment with multimodality therapy, including high-dose-rate surface applicator (HDR-SA) brachytherapy, and represents the largest cohort utilizing this therapeutic approach.

Material And Methods: Twenty patients with primary or recurrent angiosarcoma of the face or scalp were treated with HDR-SA brachytherapy between 2003-2018, with clinical characteristics and outcomes collected from medical records and used to identify prognostic features.

Results: Median follow-up was 45 months. Patients treated with HDR-SA brachytherapy had a 4-year local control rate of 63%, a 4-year progression-free survival (PFS) rate of 20%, and a 4-year overall survival rate of 54%. Disease features associated with worse loco-regional control (LRC) included location on the scalp (vs. face, = 0.04) and tumor size ≥ 5 cm ( = 0.0099). Outcomes after HDR-SA brachytherapy for salvage therapy vs. HDR-SA brachytherapy as a component of an initial treatment approach were also significantly different, with worse LRC ( = 0.0084) and worse overall survival (OS) ( = 0.0019) in a setting of salvage therapy.

Conclusions: Local control rates following HDR-SA brachytherapy for scalp or face angiosarcoma are moderate and similar to what is described in the literature using a variety of local control treatment modalities. Smaller tumors and those involving the face rather than scalp had better outcomes. PFS rates were poor and there is a pressing need for treatment intensification and novel therapeutic options.
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http://dx.doi.org/10.5114/jcb.2021.105285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060956PMC
April 2021

Changes in Racial Disparities in Mortality After Cancer Surgery in the US, 2007-2016.

JAMA Netw Open 2020 12 1;3(12):e2027415. Epub 2020 Dec 1.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

Importance: Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time.

Objective: To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers.

Design, Setting, And Participants: In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer.

Exposures: Cancer surgery among Black and White patients.

Main Outcomes And Measures: Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery.

Results: A total of 870 929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103 446 patients had cancer operations (96 210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44).

Conclusions And Relevance: These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.27415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716190PMC
December 2020

Medicaid Expansion and Mortality Among Patients With Breast, Lung, and Colorectal Cancer.

JAMA Netw Open 2020 11 2;3(11):e2024366. Epub 2020 Nov 2.

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Medicaid expansion under the Patient Protection and Affordable Care Act may be associated with increased screening and may improve access to earlier treatment for cancer, but its association with mortality for patients with cancer is uncertain.

Objective: To determine whether Medicaid expansion is associated with improved mortality among patients with cancer.

Design, Setting, And Participants: This is a quasi-experimental, difference-in-difference (DID), cross-sectional, population-based study. Patients in the National Cancer Database with breast, lung, or colorectal cancer newly diagnosed from January 1, 2012, to December 31, 2015, were included. Data analysis was performed from January to May 2020.

Exposure: Living in a state where Medicaid was expanded vs a nonexpansion state.

Main Outcomes And Measures: The main outcome was mortality rate according to whether the patient lived in a state where Medicaid was expanded.

Results: A total of 523 802 patients (385 739 women [73.6%]; mean [SD] age, 54.8 [6.5] years) had a new diagnosis of invasive breast (273 272 patients [52.2%]), colorectal (111 720 patients [21.3%]), or lung (138 810 patients [26.5%]) cancer; 289 330 patients (55.2%) lived in Medicaid expansion states, and 234 472 patients (44.8%) lived in nonexpansion states. After Medicaid expansion, mortality significantly decreased in expansion states (hazard ratio [HR], 0.98; 95% CI, 0.97-0.99; P = .008) but not in nonexpansion states (HR, 1.01; 95% CI, 0.99-1.02; P = .43), resulting in a significant DID (HR, 1.03; 95% CI, 1.01-1.05; P = .01). This difference was seen primarily in patients with nonmetastatic cancer (stages I-III). After adjusting for cancer stage, the mortality improvement in expansion states from the periods before and after expansion was no longer evident (HR, 1.00; 95% CI, 0.98-1.02; P = .94), nor was the difference between expansion vs nonexpansion states (DID HR, 1.00; 95% CI, 0.98-1.02; P = .84).

Conclusions And Relevance: Among patients with newly diagnosed breast, colorectal, and lung cancer, Medicaid expansion was associated with a decreased hazard of mortality in the postexpansion period, which was mediated by earlier stage of diagnosis.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.24366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645694PMC
November 2020

Angiosarcoma of the Scalp and Face: A Dosimetric Comparison of HDR Surface Applicator Brachytherapy and VMAT.

Sarcoma 2020 25;2020:7615248. Epub 2020 Aug 25.

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA.

Purpose: Angiosarcoma of the face and scalp is a rare disease with high rates of recurrence. The optimal treatment approach is not well defined. This study presents a dosimetric comparison of high-dose-rate surface applicator (HDR-SA) brachytherapy to volumetric-modulated arc therapy (VMAT).

Methods: Between 2011 and 2018, 12 patients with primary or recurrent angiosarcoma of the face or scalp were treated with HDR-SA brachytherapy using CT-based planning at our institution. For comparison, deliverable VMAT plans for each patient were generated, and dose distribution was compared to the delivered HDR-SA brachytherapy plans.

Results: Both VMAT and HDR-SA brachytherapy plans delivered good coverage of the clinical target. However, the dose distribution of VMAT was significantly different from HDR-SA brachytherapy across a variety of parameters. Mean doses to the lacrimal gland, orbit, lens, and cochlea were significantly higher with HDR-SA brachytherapy vs. VMAT. Brain Dmax, V80%, and V50% were also significantly higher with HDR-SA brachytherapy.

Conclusions: There may be dosimetric advantages to VMAT over HDR-SA brachytherapy for many patients. However, individual tumor location, patient anatomy, and treatment reproducibility may result in HDR-SA brachytherapy being the preferred technique in a subset of patients. Ultimately, a personalized approach is likely to be the optimal treatment plan.
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http://dx.doi.org/10.1155/2020/7615248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468671PMC
August 2020

Accountable Care Organizations Are Associated with Savings Among Medicare Beneficiaries with Frailty.

J Gen Intern Med 2020 Aug 31. Epub 2020 Aug 31.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-020-06166-6DOI Listing
August 2020

Consolidation Among Cardiologists Across U.S. Practices Over Time.

J Am Coll Cardiol 2020 08;76(5):590-593

Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri; Washington University Institute for Public Health, Center for Health Economics and Policy, St. Louis, Missouri. Electronic address: https://twitter.com/kejoynt.

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http://dx.doi.org/10.1016/j.jacc.2020.04.081DOI Listing
August 2020

Stereotactic Body Radiation Therapy to a Splenic Metastasis in Oligoprogressive Non-small Cell Lung Cancer.

Adv Radiat Oncol 2020 May-Jun;5(3):516-521. Epub 2019 Dec 31.

Departments of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.adro.2019.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276683PMC
December 2019

Definitive re-irradiation of locally recurrent esophageal cancer after trimodality therapy in patients with a poor performance status.

Mol Clin Oncol 2020 Jul 11;13(1):27-32. Epub 2020 May 11.

Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA 02115, USA.

There are few treatment guidelines for locally recurrent esophageal cancer after trimodality treatment (pre-operative chemoradiation followed by surgery) in patients with a poor performance status. The purpose of this single institutional, retrospective study was to evaluate the clinical outcomes and toxicities of definitive-intent re-irradiation for patients with recurrent esophageal cancer with a poor performance status [ECOG (Eastern Cooperative Oncology Group) ≥2]. Seven patients were identified with a median age of 74 years (range, 61-81 years). Four patients were ECOG 2 and three patients were ECOG 3. The median follow-up time after re-irradiation was 49 months. The median interval between initial radiotherapy and re-treatment was 32 months. Six patients received concurrent chemotherapy [carboplatin + paclitaxel in three patients; folinic acid, fluorouracil, oxaliplatin (FOLFOX) + 5-fluorouracil in one patient; FOLFOX in one patient, and capecitabine in one patient]. At the last follow-up, the six patients who underwent concurrent chemotherapy had stable disease (86%), while the one who did not receive chemotherapy progressed (14%). Two patients developed metastases. Three patients developed acute (<6 months) grade 4 toxicities (dysphagia, anemia, esophagitis). There were no early deaths attributable to treatment. Late toxicities (>6 months) were limited to grades 1 and 2 dysphagia and pneumonitis in four patients. In conclusion, definitive re-irradiation of recurrent esophageal cancer in patients with a poor performance status appears to be safe with acceptable acute toxicity and late complications. It also appears to result in durable local control when combined with chemotherapy, albeit with a small number of patients and limited follow-up.
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http://dx.doi.org/10.3892/mco.2020.2044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241232PMC
July 2020

Microcystic Adnexal Carcinoma of the Face Treated With Definitive Chemoradiation: A Case Report and Review of the Literature.

Adv Radiat Oncol 2020 Mar-Apr;5(2):301-310. Epub 2019 Dec 13.

Department of Radiation Oncology Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.adro.2019.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136639PMC
December 2019

Regional Lymph Nodes in Scalp Angiosarcomas: The Hidden Harbinger of Doom?

Ann Surg Oncol 2020 Aug 6;27(8):2589-2590. Epub 2020 Apr 6.

Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.

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http://dx.doi.org/10.1245/s10434-020-08412-xDOI Listing
August 2020

Response to hyperfractionated accelerated radiotherapy in chemotherapy-refractory non-Hodgkin lymphoma.

Leuk Lymphoma 2020 06 26;61(6):1428-1434. Epub 2020 Feb 26.

Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA.

Patients with chemotherapy-refractory non-Hodgkin lymphoma (NHL) have a poor prognosis with a median overall survival (OS) of only 10 months. To investigate the role of radiotherapy (RT) in such patients, we conducted a retrospective review of 17 patients with biopsy-proven refractory NHL who received hyperfractionated accelerated RT between 2000 and 2017. Forty-seven percent had stages I and II and 53% had stages III and IV disease. Majority (59%) had diffuse large B-cell lymphoma. One-year local control rate was 82%. Fifty-nine percent proceeded to hematopoietic stem cell transplantation (HSCT). At a median follow-up time of 8.8 months (range: 13 days to 17.4 years), 10 were alive with five in remission. Six patients were long-term survivors with a median OS of 8.1 years. Hyperfractionated accelerated RT in chemotherapy-refractory NHL provides durable local disease control in the majority of cases. Combined with HSCT, the RT regimen may also provide long-term disease remission in a subset of patients.
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http://dx.doi.org/10.1080/10428194.2020.1719096DOI Listing
June 2020

Self-reported Reasons and Patterns of Noninsurance Among Cancer Survivors Before and After Implementation of the Affordable Care Act, 2000-2017.

JAMA Oncol 2019 Oct 10;5(10):e191973. Epub 2019 Oct 10.

Dana-Farber Cancer Institute McGraw/Patterson Center for Population Sciences, Boston, Massachusetts.

Importance: Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined.

Objective: To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014.

Design, Setting, And Participants: This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded.

Exposures: Insurance status.

Main Outcomes And Measures: Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression.

Results: Among 17 806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4%) were men. A total of 1842 participants (10.3%) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6% vs 6.2%; aOR 1.75; 95% CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2% for age younger than mean vs 6.5% for age older than mean; aOR, 1.84; 95%, CI, 1.62-2.10), annual family income below the poverty threshold (21.4% vs 8.0%; aOR, 1.97; 95%, CI, 1.69-2.30), Hispanic ethnicity (18.8% vs 9.0%; aOR, 1.87; 95% CI, 1.51-2.33), noncitizen status (24.3% vs 9.2%; aOR, 2.38; 95% CI, 1.69-3.34), and current smoking (18.6% vs. 6.7%; aOR, 2.65; 95% CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3% for ≥6 years vs 8.9% for 0-5 years; aOR, 1.47; 95% CI 1.26-1.70) as was black race (13.9% for black patients vs 10.4% for nonblack patients; AOR, 1.29; 95% CI, 1.04-1.61), but after the ACA, they no longer were (6.8% for ≥6 years vs 5.6% for 0-5 years; aOR, 1.12; 95% CI, 0.82-1.54; and 6.9% for black patients vs 6.2% for nonblack patients; aOR, 0.81; 95% CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6% vs 37.6%, aOR [pre-ACA vs post-ACA], 0.62; 95% CI, 0.46-0.85; unemployment, 37.1% vs 28.5%; aOR 0.62; 95% CI, 0.45-0.87).

Conclusions And Relevance: The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage.
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http://dx.doi.org/10.1001/jamaoncol.2019.1973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537771PMC
October 2019

Early Accountable Care Organization Results in End-of-Life Spending Among Cancer Patients.

J Natl Cancer Inst 2019 12;111(12):1307-1313

Background: Spending on cancer patients is substantial and has increased in recent years. Accountable care organizations (ACOs) are arguably the most important national experiment to control health-care spending. How ACOs are managing patients with cancer at the end of life (EOL) is largely unknown. We conducted this study with the objective of determining whether becoming an ACO is associated with subsequent changes in EOL spending or utilization among patients with cancer.

Methods: Using national Medicare claims from 2011 to 2015, we identified patients who died in 2012 (pre-ACO, n = 12 248) and 2015 (post-ACO, n = 12 248), assigning each decedent to a practice. ACOs were matched to non-ACOs within the same geographic region. We used a difference-in-difference model to examine changes in EOL spending and utilization associated with becoming an ACO in the Medicare Shared Savings Program for beneficiaries with cancer.

Results: We found that the introduction of ACOs had no meaningful impact on overall EOL spending in cancer patients (change in overall spending in ACOs = -$1687 vs -$1434 in non-ACOs, difference = $253, 95% confidence interval = -$1809 to $1304, P= .75). We found no changes in total patient spending by cancer type examined or by spending categories, including cancer-specific categories of radiation, therapy, and hospice services. Finally, emergency department visits, inpatient hospitalization, intensive care unit admissions, radiation therapy, chemotherapy, and hospice use did not meaningfully differ between ACO and non-ACO patients.

Conclusions: The introduction of ACOs does not appear to have had any meaningful effect on EOL spending or utilization for patients with a cancer diagnosis.
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http://dx.doi.org/10.1093/jnci/djz033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910163PMC
December 2019

Individualization of Clinical Target Volume Delineation Based on Stepwise Spread of Nasopharyngeal Carcinoma: Outcome of More Than a Decade of Clinical Experience.

Int J Radiat Oncol Biol Phys 2019 03 15;103(3):654-668. Epub 2018 Oct 15.

Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: Radiation-related toxicity in nasopharyngeal carcinoma (NPC) is common. There are no well-established guidelines for clinical target volume (CTV) delineation with long-term follow-up. Current consensus continues to rely heavily on bony landmarks and fixed margins around the gross tumor volume (GTV), an approach used to define fields in the conventional 2- and 3-dimensional radiation therapy era.

Methods And Materials: We retrospectively evaluated patients with newly diagnosed nonmetastatic NPC treated with definitive radiation therapy using a technique of CTV delineation based on individual tumor extent and the orderly stepwise pattern of tumor spread. Dosimetric comparisons were made between national protocol HN001 and our contouring strategies on a representative early- and advanced-stage NPC. The primary endpoints were patterns of failure and local control; secondary endpoints included regional control and survival, estimated using the Kaplan-Meier method.

Results: Between 1999 and 2013, 73 patients (88% with stage 3-4 disease) were treated with median follow-up of 90 months for surviving patients. Median dose to GTV was 70 Gy. Four patients developed local recurrence and 1 patient developed regional recurrence. All locoregional recurrences occurred within the high-dose GTV. The 5-year local control, regional control, and overall survival was 94% (95% confidence interval [CI], 85%-98%), 99% (95% CI, 90%-100%), and 84% (95% CI, 73%-91%), respectively. Compared with HN001, our contouring strategy resulted in 62% and 36% reduction in CTV for T1 and T4 disease, respectively. In the T1 tumor, the reduction of doses to the contralateral parotid, optic nerve, and cochlea were 54%, 50%, 34% respectively. In the T4 case, there was a decrease of optic chiasm dose of 46% and contralateral optic nerve of 37%. There were 10 grade 3 toxicities. There was no grade 2 or higher xerostomia and no grade 4/5 toxicity.

Conclusions: Our long-term experience with individualized CTV delineation based on stepwise patterns of spread results in excellent local control, with no recurrence outside the GTV.
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http://dx.doi.org/10.1016/j.ijrobp.2018.10.006DOI Listing
March 2019

Association between patient outcomes and accreditation in US hospitals: observational study.

BMJ 2018 Oct 18;363:k4011. Epub 2018 Oct 18.

Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA 02115, USA

Objectives: To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations.

Design: Observational study.

Setting: 4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017.

Participants: 4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).

Main Outcome Measures: Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission.

Results: Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 3.2, 0.1 (-0.003 to 0.2), P=0.06).

Conclusions: US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193202PMC
http://dx.doi.org/10.1136/bmj.k4011DOI Listing
October 2018

Palliative radiation and fractionation in medicare patients with incurable non-small cell lung cancer.

Adv Radiat Oncol 2018 Jul-Sep;3(3):382-390. Epub 2018 Apr 23.

Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: Palliative radiation therapy (RT) can improve quality of life but also incurs time and financial costs. The aim of this study was to evaluate factors associated with use and intensity of palliative RT for incurable non-small cell lung cancer (NSCLC).

Methods And Materials: This was a retrospective analysis of Medicare's Surveillance, Epidemiology and End Results data. We identified patients who were diagnosed with incurable (American Joint Committee on Cancer 6 edition stage IIIB with malignant effusion or stage IV) NSCLC between 2004 and 2011. Univariable and multivariable logistic regressions were used to identify factors associated with the receipt of palliative RT and the use of >10 fractions during the first course of radiation. Among patients who were treated with radiation, freestanding versus hospital-based center information was collected on the basis of the location of the RT delivery claim.

Results: Among 55,258 patients with incurable NSCLC, 38% (21,053 patients) received palliative RT during the first year after diagnosis. Among patients who received RT, 56% (11,717 patients) received >10 fractions. On multivariable analysis, factors associated with greater RT use included younger age group (overall  < .01), lower modified Charlson comorbidity score (overall  < .01), female sex (odds ratio [OR]: 1.1;  < .01), marital status (OR: 1.1;  < .01), and chemotherapy use (OR: 3.6;  < .01). Predictors for >10 fractions were chemotherapy use (OR: 1.7;  < .01) and treatment at a freestanding versus hospital-based facility (58% vs 43%; OR: 1.7;  < .01).

Conclusions: More than a third of patients diagnosed with incurable lung cancer receive palliative RT and 56% received >10 fractions. The use of RT varied by region and patient characteristics, and patients treated at freestanding RT centers were more likely to receive >10 fractions. Further research into factors that influence treatment decisions including potential financial incentives may contribute to the high value and strategic utilization of palliative RT.
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http://dx.doi.org/10.1016/j.adro.2018.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128034PMC
April 2018

Spending Among Patients With Cancer in the First 2 Years of Accountable Care Organization Participation.

J Clin Oncol 2018 10 29;36(29):2955-2960. Epub 2018 Aug 29.

Miranda B. Lam, Jose F. Figueroa, Jie Zheng, E. John Orav, and Ashish K. Jha, Harvard T.H. Chan School of Public Health; Miranda B. Lam, Brigham and Women's Hospital/Dana-Farber Cancer Institute; Jose F. Figueroa and Ashish K. Jha, Brigham and Women's Hospital; and Miranda B. Lam, Jose F. Figueroa, E. John Orav, and Ashish K. Jha, Harvard Medical School, Boston, MA.

Purpose: Spending on patients with cancer can be substantial and has continued to increase in recent years. Accountable Care Organizations (ACOs) are arguably the most important national experiment to control health care spending, yet how ACOs are managing patients with cancer diagnoses is largely unknown. We aimed to determine whether practices that became ACOs had changes in overall or cancer-specific spending among patients with cancer.

Methods: Using 2011 to 2015 national Medicare claims, practices that became part of ACOs were identified and matched to non-ACO practices within the same geographic region. We calculated total and category-specific annual spending per beneficiary as well as spending for and utilization of emergency departments, inpatient admissions, hospice, chemotherapy, and radiation therapy. A difference-in-differences model was used to examine changes in spending and utilization associated with ACO contracts in the Medicare Shared Savings Program for beneficiaries with cancer.

Results: We found that the introduction of ACOs had no meaningful impact on overall spending in patients with cancer (-$308 per beneficiary in ACOs v -$319 in non-ACOs; difference, $11; 95% CI, -$275 to $297; P = .94). We found no changes in total spending in patients within any of the 11 different cancer types examined. Finally, changes in spending and utilization did not meaningfully differ between ACO and non-ACO patients within various categories, including cancer-specific categories.

Conclusion: Compared with patients with cancer treated at non-ACO practices, being a patient with a cancer diagnosis in a Medicare ACO is not associated with significantly reduced spending or heath care utilization. The introduction of ACOs does not seem to have had any meaningful effect on spending or utilization for patients with a cancer diagnosis.
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http://dx.doi.org/10.1200/JCO.18.00270DOI Listing
October 2018

Proportion of patients with cancer among high-cost Medicare beneficiaries: Who they are and what drives their spending.

Healthc (Amst) 2018 Mar 3;6(1):46-51. Epub 2018 Feb 3.

Department of General Internal Medicine (AKJ), VA Boston Healthscare System; the Harvard Global Health Institute (AKJ), 42 Church St., Cambridge, MA 02138, United States. Electronic address:

Background: A small proportion of patients account for the majority of health care spending. Of this group, little is known about what proportion have a cancer diagnosis and how their spending pattern compares to those without cancer.

Methods: Using national Medicare data of enrollees 65 or older, we identified patients in the top decile of spending in 2014 and designated them as high-cost. We used ICD-9 codes to identify patients with a cancer diagnosis and examined cancer prevalence among both high-cost and non-high-cost patients. We examined patterns of spending for high-cost patients with and without cancer.

Results: While 14.8% of all Medicare beneficiaries have a cancer diagnosis, we found that the prevalence of a cancer diagnosis was much higher among high-cost patients (32.5% versus 12.9% of non-high-cost patients). Thus, having a cancer diagnosis was associated with a 3.1 times greater odds of being high-cost, even after accounting for age (odds ratio 3.09, 95% CI 3.07-3.11; P < 0.001). High-cost patients with cancer had higher total annual spending than high-cost patients without cancer ($66,685 vs. $59,427; p < 0.0001); costs among high-cost cancer patients were driven by greater use of outpatient treatments (19.2% of total spending vs. 13.6% among non-cancer high-cost patients, p < 0.0001) and more prescription drugs (11.9% vs. 9.9%; p < 0.0001).

Conclusions: There is a high prevalence of cancer diagnoses among high-cost Medicare patients.

Implications: Programs that target high-cost patients may need to customize interventions based on whether the patient has a cancer diagnosis.
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http://dx.doi.org/10.1016/j.hjdsi.2018.01.001DOI Listing
March 2018