CANCER CENTER AFFILIATION ASSOCIATED WITH IMPROVED SURVIVAL FOR GENITOURINARY CANCERS AT SAFETY NET HSOPITALS

Abstract

Introduction

Safety net hospitals (SNH) care for a substantial proportion of vulnerable populations. Addressing health disparities at a hospital level through strategic partnerships with cancer centers is a potential strategy to improve outcomes of vulnerable populations. We thus compared outcomes for metastatic prostate (mPCa), kidney (mKCa), and urothelial cancer (mUC) among national cancer institute (NCI) centers, NCI affiliated SNHs (NCI-SNH), and non-affiliated SNHs using the Texas Cancer Registry (TCR).

Methods

The TCR has 98% case ascertainment of all cancers diagnosed in Texas. The TCR can identify each facility a patient was diagnosed and treated, allowing detailed hospital level comparisons of outcomes. The TCR was queried from 2004-2017 for mPCa, mKCa, and mUC. Publicly available data identified Texas NCI cancer centers. The top quartile of Disproportionate Share Hospital Index values identified SNHs. Safety net hospitals with established relationships with NCI centers were designated as NCI-SNH's while the remainder were SNHs. Hospitals not affiliated with NCI centers or defined as SNH's were non-SNHs. Vulnerable populations were defined as age > 75, non-US natives, non-whites, and uninsured or Medicaid patients. Cox multivariable regression was used to assess survival by cancer type and hospital designation.

Results

The TCR identified 20,503 metastatic genitourinary (GU) cancers. MPCa comprised 47.7% of cases, followed by mKCa (41.2%), and mUC (11.1%). NCI centers accounted for 18.6% of cases, and NCI-SNH accounted for 5.3% of cases. Most patients seen at NCI-SNH's were identified as medically vulnerable (84.6%, p<0.01) compared to NCI (41.2%), other SNH (58.6%) or non-SNH (58.6%). For mPCa, rates of systemic hormone therapy were similar between NCI-SNH (76.7%) and NCI (76.2%), but significantly greater than SNH (51.5%) or non-SNH (49.7%). Receipt of chemotherapy or immunotherapy was greater at NCI-SNHs compared to other SNHs or non-SNH's for both mKCa (36.1% vs 31.1% vs 27.1%, p<0.01) and mUC (44.0% vs 36.7% vs 33.2%, p<0.01). On multivariable cox analysis, overall mortality was significantly lower at NCI-SNHs for mPCa, mKCa, and mUC compared to Non-SNHs and equivalent to NCI centers (Table 1).

Conclusions

NCI affiliated SNHs accounted for a large proportion of vulnerable patient cancer care within their systems. NCI-SNHs had a greater proportion of patients receive systemic therapies for metastatic GU cancers than other SNH's. Further, NCI-SNHs had superior survival compared to other SNHs and equivalent survival to NCI centers. Future initiatives to improve cancer care should focus on strengthening existing relationships between NCI centers and SNHs, and mechanisms to improve centralization of care of vulnerable populations to these facilities.