Using NCDB to Improve Cancer Care in the VA

Our encounter with the National Cancer Database (NCDB) started about 10 years ago when the Louis Stokes Cleveland VA Medical Center became an accredited ACS Commission on Cancer (CoC) Cancer Center. Since then it has become an important tool for us to scrutinize the cancer care in the VA by comparing the management patterns with other medical facilities in the nation. Our comparison was focused on genitourinary cancers, which account for more than one-third of all cancer cases (incidence and prevalence) in our VA system.

One important issue we have examined is the utilization pattern of expectant management, such as active surveillance, for low-risk prostate cancer. Prostate cancer is the most common cancer in men, and low-risk prostate cancer accounts for more than one-third of all prostate cancer in the VA. It is known for the indolent nature, and aggressive treatment is considered as overtreatment, particularly in elderly patients. It results in significant treatment-related morbidities, such as urinary incontinence and erectile dysfunction, without overall survival benefit to the patients. Using NCDB, we were able to examine the utilization pattern of expectant management in patients with low risk prostate cancer in the VA and other medical facilities in the nation over the years. To our surprise, expectant management was significantly underutilized for low risk prostate cancer patients in all other medical facilities except the VA. Interestingly, this trend of overtreatment did not significantly change over the years. This finding was selected for press release by the American Urological Association Annual Meeting in 2014 and was published on JAMA Internal Medicine.

Similarly, we have also examined the utilization of various treatment options for essentially all the genitourinary cancers (penile, testicular, bladder, kidney, and prostate cancer). The findings have helped us to identify the various shortfalls when compared with NCCN guidelines and allocate resources to better serve the veterans. This is exemplified by providing gas vouchers and LYFT service to the needed VA cancer patients as we identified that VA patients must travel significantly longer distance to receive their cancer care.

NCDB not only has helped us to make contributions to the cancer literature, but also enable us to scrutinize our treatment pattern to better care the patients in an evidence-based approach. The impact it has on the care of the VA patients makes it a great tool in our fight against cancer.

  1. Maurice MJ, Abouassaly R, Zhu H. American trends in expectant management utilization for prostate cancer from 2000 to 2009. Can Urol Assoc J. 2014 Nov;8(11-12):E775-82. doi: 10.5489/cuaj.2073. PMID: 25485003
  2. Kohut R, Minnillo BJ, Zhu, H. Changes in Adjuvant Therapy Utilization in Stage I Seminoma: Are They Enough to Prevent Overtreatment? Urology. 84(6):1319-24, 2014 Dec.
  3. Maurice MJ, Zhu H, Abouassaly R. Low Use of Immediate and Delayed Postoperative Radiation for Prostate Cancer with Adverse Pathological Features. J Urol. 2015 Oct;194(4):972-6. doi: 10.1016/j.juro.2015.03.122. Epub 2015 Apr 6. PMID: 25858420
  4. Tabayoyong W, Abouassaly R, Kiechle JE, Cherullo EE, Meropol NJ, Shah ND, Dong S, Thompson RH, Smaldone MC, Zhu H, Ialacci S, Kim SP. Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses. J Urol. 2015 Jun 19. pii: S0022-5347(15)04211-1. doi: 10.1016/j.juro.2015.06.076. PMID: 26094808
  5. Ferry EK, Minnillo BJ, Maurice MJ, Abouassaly R, Zhu H. Trends of Systemic Therapy Use for Renal Cell Carcinoma in the United States. Urology. 2015 Jun;85(6):1399-403. doi: 10.1016/j.urology.2015.03.008. PMID: 26099886
  6. Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Non-Clinical Factors Predict Selection of Initial Observation for Renal Cell Carcinoma. Urology. 2015 Aug 17. pii: S0090-4295(15)00738-4. doi: 10.1016/j.urology.2015.06.057. PMID: 26291563
  7. Maurice MJ, Zhu H, Kim SP, Abouassaly R. Increased use of partial nephrectomy to treat high-risk disease. BJU Int. 2015 Aug 25. doi: 10.1111/bju.13262. PMID: 26305770
  8. Kiechle JE, Abouassaly R, Smaldone MC, Shah ND, Dong S, Cherullo EE, Nakamoto D, Zhu H, Cooney MM, Kim SP. National Trends of Local Ablative Therapy among Young Patients with Small Renal Masses in the United States. Urology. 2015 Sep 1. pii: S0090-4295(15)00816-X. doi: 10.1016/j.urology.2015.08.016. PMID: 26341571
  9. Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Increasing Biopsy Utilization for Renal Cell Carcinoma is Closely Associated with Treatment. Urology. 2015 Sep 2. pii: S0090-4295(15)00826-2. doi: 10.1016/j.urology.2015.08.020. PMID: 26342316
  10. Maurice MJ, Abouassaly R, Kim SP, Zhu H. Contemporary Nationwide Patterns of Active Surveillance Use for Prostate Cancer. JAMA Intern Med. 2015 Sep 1;175(9):1569-71. doi: 10.1001/jamainternmed.2015.2835. PMID: 26121305
  11. Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Comorbid Disease Burden is Independently Associated with Higher-Risk Disease at Prostatectomy in Patients Eligible for Active Surveillance. J Urol. 2015 Oct 28. pii: S0022-5347(15)05140-X. doi: 10.1016/j.juro.2015.10.120. PMID: 26519653
  12. Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Nonclinical Factors Predict Selection of Initial Observation for Renal Cell Carcinoma. Urology. 2015 Nov;86(5):892-9. doi: 10.1016/j.urology.2015.06.057. PMID: 26291563
  13. Kiechle JE, Abouassaly R, Gross CP, Dong S, Cherullo EE, Zhu H, Trinh QD, Sun M, Meropol NJ, Hoimes CJ, Ialacci S, Kim SP. Racial Disparities in Partial Nephrectomy Persist Across Hospital Types: Results From a Population-based Cohort. Urology. 2016 Apr;90:69-74. doi: 10.1016/j.urology.2015.10.035. PMID: 26724412
  14. Maurice MJ, Zhu H, Kim SP, Abouassaly R. Robotic prostatectomy is associated with increased patient travel and treatment delay. Can Urol Assoc J. 2016 May-Jun;10(5-6):192-201. PMID: 27713799
  15. Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Comorbid Disease Burden is Independently Associated with Higher Risk Disease at Prostatectomy in Patients Eligible for Active Surveillance. J Urol. 2016 Apr;195(4P1):919-24. doi: 10.1016/j.juro.2015.10.120. PMID: 26519653
  16. Maurice MJ, Zhu H, Kim SP, Abouassaly R. Increased use of partial nephrectomy to treat high-risk disease. BJU Int. 2016 Jun;117(6B):E75-86. doi: 10.1111/bju.13262. PMID: 26305770
  17. Maurice MJ, Zhu H, Kim SP, Abouassaly R. Reexamining the Association Between Positive Surgical Margins and Survival After Partial Nephrectomy in a Large American Cohort. J Endourol. 2016 Jun;30(6):698-703. doi: 10.1089/end.2016.0031. PMID: 26888059
  18. Wang EH, Yu JB, Abouassally R, Meropol NJ, Cooper G, Shah ND, Williams SB, Gonzalez C, Smaldone MC, Kutikov A, Zhu H, Kim SP. Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort. Urology. 2016 Sep;95:88-94. doi: 10.1016/j.urology.2016.06.010. PMID: 27318264
  19. Slopnick EA, Kim SP, Kiechle JE, Gonzalez CM, Zhu H, Abouassaly R. Racial Disparities Differ for African Americans and Hispanics in the Diagnosis and Treatment of Penile Cancer. Urology. 2016 Oct;96:22-28. doi: 10.1016/j.urology.2016.06.048. PMID: 27402373
  20. Maurice MJ, Zhu H, Kim S, Abouassaly R. Survival after partial and radical nephrectomy for high-risk disease: A propensity-matched comparison. Can Urol Assoc J. 2016 Sep-Oct;10(9-10):E282-E289. PMID: 27695581
  21. Bream MJ, Maurice MJ, Altschuler J, Zhu H, Abouassaly R. Increased Use of Cystectomy in Patients 75 and Older: a Contemporary Analysis of Survival and Perioperative Outcomes From the National Cancer Data Base. Urology. 2016 Oct 17. pii: S0090-4295(16)30701-4. doi: 10.1016/j.urology.2016.08.054. [Epub ahead of print] PMID: 27765588
Hui Zhu, MD, ScD

Hui Zhu, MD, ScD

Chief of the Urology Section

University of Washington, VA Puget Sound Health Care System

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