title: Impact of care at comprehensive cancer centers on outcome: Results from a population-based study.
abstract: BACKGROUND
  Rigorous processes ensure quality of research and clinical care at National Cancer Institute-designated comprehensive cancer centers (NCICCCs). Unmeasurable elements of structure and process of cancer care delivery warrant evaluation. To the authors' knowledge, the impact of NCICCC care on survival and access to NCICCCs for vulnerable subpopulations remain unstudied.
  
  
  METHODS
  The current study's population-based cohort of 69,579 patients had newly diagnosed adult-onset (aged 22-65 years) cancers reported to the Los Angeles County cancer registry between 1998 and 2008. Geographic information systems were used for geospatial analysis.
  
  
  RESULTS
  With regard to overall survival across multiple diagnoses, patients not receiving their first planned treatment at NCICCCs experienced poorer outcomes compared with those treated at NCICCCs; differences persisted on multivariable analyses after adjusting for clinical and sociodemographic factors (hepatobiliary: hazard ratio [HR], 1.5; 95% confidence interval [95% CI], 1.4-1.7 [P<.001]; lung: HR, 1.4; 95% CI, 1.3-1.6 [P<.001]; pancreatic: HR, 1.5; 95% CI, 1.3-1.7 [P<.001]; gastric: HR, 1.3; 95% CI, 1.1-1.7 [P = .01]; breast: HR, 1.3; 95% CI, 1.1-1.5 [P<.001]; and colorectal: HR, 1.2; 95% CI, 1.0-1.4 [P = .05]). With regard to barriers to care, multivariable analyses revealed that a lower likelihood of treatment at NCICCCs was associated with race/ethnicity (African-American: OR range across diagnoses: 0.4-0.7 [P<.03]; Hispanic: OR range, 0.5-0.7 [P<.04]); lack of private insurance (public: OR range, 0.6-0.8 [P<.004]; uninsured: OR range, 0.1-0.5 [P<.04]); less than high socioeconomic status (high-middle: OR range, 0.4-0.7 [P<.02]; middle: OR range, 0.3-0.5 [P<.001]; and low: OR range, 0.2-0.6 [P<.01]), and residing >9 miles from the nearest NCICCC (OR range, 0.5-0.7 [P<.02]).
  
  
  CONCLUSIONS
  Among individuals aged 22 to 65 years residing in Los Angeles County with newly diagnosed adult-onset cancer, those who were treated at NCICCCs experienced superior survival compared with those treated at non-NCICCC facilities. Barriers to care at NCICCCs included race/ethnicity, insurance, socioeconomic status, and distance to an NCICCC.
authors.affiliation: Department of Population Sciences, City of Hope, Duarte, California.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Wolfson
authors.affiliation: Department of Population Sciences, City of Hope, Duarte, California.
authors.forename: Can-Lan
authors.initials: CL
authors.lastname: Sun
authors.affiliation: Department of Population Sciences, City of Hope, Duarte, California.
authors.forename: Laura P
authors.initials: LP
authors.lastname: Wyatt
authors.affiliation: Department of Population Sciences, City of Hope, Duarte, California.|Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California.
authors.forename: Arti
authors.initials: A
authors.lastname: Hurria
authors.affiliation: Department of Population Sciences, City of Hope, Duarte, California.|Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama.
authors.forename: Smita
authors.initials: S
authors.lastname: Bhatia
mesh_terms: D000328:Adult; D000368:Aged; D002173:Cancer Care Facilities / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000592:standards; D005260:Female; D062489:Health Impact Assessment / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D054547:National Cancer Institute (U.S.); D009369:Neoplasms / Q000401:mortality* / Q000628:therapy*; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000592:standards; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States
keywords: National Cancer Institute; cancer; cancer centers; outcomes