title: Variation in care in concurrent chemotherapy administration during radiation for locally advanced cervical cancer.
abstract: To evaluate the usage of concurrent chemo-radiotherapy (C-CRT) for the treatment of locally advanced cervical cancer.
  
  
  
  Patients with locally invasive cervical carcinoma diagnosed between January 1, 2004 and December 31, 2012 from the National Cancer Database (NCDB) were included. Outcomes for patients undergoing radiation therapy only, 'RT alone' group were compared to those receiving chemotherapy concurrent with radiation 'C-CRT group'. Trends in utilization of C-CRT and factors associated with the deviation from standard of care were explored. Lastly, the effect of hospital volume on utilization of C-CRT was investigated.
  
  
  
  A total of 18,164 patients undergoing definitive radiation therapy were available for analysis. Utilization of C-CRT increased from 72.4% in 2004 to 84.3% in 2012 (p-trend<0.001). After adjusting for patient, tumor, and treatment factors, a multivariable logistic regression model revealed increasing age, African-American race, Charlson-comorbidity index of ≥2, Medicaid insurance status, uninsured status, and Stage I disease were each independently associated with the lack of C-CRT. After adjusting for patient characteristics, low volume hospitals were noted to have overall significantly lower rates and greater variation in C-CRT administration. Patients in 'RT alone' group had an overall worse survival rate (adjusted-HR 1.47, 95%CI 1.4-1.56).
  
  
  
  Rates of C-CRT administration varied significantly across hospitals in the United States. Hospitals with a high case volume had higher rates and more consistent patterns of C-CRT administration. Furthermore, we identified independent factors, all of which represent noteworthy health disparities, associated with lower rates of C-CRT administration.
authors.affiliation: Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States. Electronic address: uppal@med.umich.edu.
authors.forename: Shitanshu
authors.initials: S
authors.lastname: Uppal
authors.affiliation: Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
authors.forename: Marcela G
authors.initials: MG
authors.lastname: Del Carmen
authors.affiliation: Division of Gynecologic Oncology, University of Wisconsin, Madison, WI, United States.
authors.forename: Laurel W
authors.initials: LW
authors.lastname: Rice
authors.affiliation: Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States.
authors.forename: R Kevin
authors.initials: RK
authors.lastname: Reynolds
authors.affiliation: Division of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States.
authors.forename: Shruti
authors.initials: S
authors.lastname: Jolly
authors.affiliation: Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
authors.forename: Amy
authors.initials: A
authors.lastname: Bregar
authors.affiliation: Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.
authors.forename: Zaid M
authors.initials: ZM
authors.lastname: Abdelsattar
authors.affiliation: Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
authors.forename: J Alejandro
authors.initials: JA
authors.lastname: Rauh-Hain
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D059248:Chemoradiotherapy / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000191:economics / Q000706:statistics & numerical data*; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D014481:United States / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology / Q000532:radiotherapy*
keywords: Cervix cancer; Concurrent chemo radiation; Health disparities; Variation in care