In panel A, cubic spline regression modeled a 1-unit increase in the number of days the declaration lasted and the overall survival, adjusted for sex, race/ethnicity, income, geographic region, health insurance, comorbidities, tumor size, tumor spread to lymph nodes, facility type, driving distance to facility, receipt of concomitant chemotherapy, number of treatment sessions (fractions) received, and radiation treatment start month and year (2004-2009 and 2010-2014). Only the 1734 patients who were affected by a hurricane disaster declared during radiation treatment were included in this analysis. The solid line represents the relative risk and the dotted lines represent 95% CIs.
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Nogueira LM, Sahar L, Efstathiou JA, Jemal A, Yabroff KR. Association Between Declared Hurricane Disasters and Survival of Patients With Lung Cancer Undergoing Radiation Treatment. JAMA. 2019;322(3):269–271. doi:10.1001/jama.2019.7657
Natural disasters, such as hurricanes, can interrupt the provision of oncology care.1 Radiotherapy is particularly vulnerable because it requires dependable electrical power and daily treatment.2 Disruptions are especially concerning for patients undergoing treatment for locally advanced non–small cell lung cancer (NSCLC)2 because treatment delays as little as 2 days negatively affect survival.3
We investigated whether hurricane disasters occurring during radiotherapy were associated with poorer survival for patients with NSCLC.
Patients undergoing definitive radiotherapy for nonoperative locally advanced NSCLC between 2004 and 2014 were selected from the hospital-based National Cancer Database, which captures approximately 70% of all cases in the United States and requires hospitals to have 90% annual follow-up of living patients.4 All patients had at least 1 year of follow-up for vital status (up to December 31, 2015). Disaster declarations were identified from the Federal Emergency Management Agency for 2004 to 2014.5
Exposed patients were undergoing radiation treatment when a hurricane disaster was declared for the facility’s area between the date when radiotherapy started and the date when radiotherapy ended. They were propensity score–matched6 to unexposed patients, who completed treatment at the same facility at times when no disaster was declared, on radiotherapy start month, sex, age, stage, tumor spread to lymph nodes, and zip code–level median income quintile. Pearson χ2 or t tests were used to compare groups.
Overall survival was defined as the interval between age at diagnosis and age at death or last contact. Multivariable Cox proportional hazards modeling included an indicator variable for hurricane disaster declared during radiotherapy, sex, race/ethnicity, income, geographic region, health insurance, comorbidities, tumor size, tumor spread to lymph nodes, facility type, driving distance to facility, receipt of concomitant chemotherapy, number of treatment sessions (fractions) received, and radiotherapy start month and year (2004-2009 and 2010-2014). Proportionality assumption, tested using Schoenfeld residuals, was met. Restricted cubic spline regression flexibly modeled the association between the number of days disaster declarations lasted and survival. Statistical significance was set at a 2-sided α = .05. All analyses were performed using SAS version 9.4. This study was granted exempt review by the institutional review board at the Morehouse School of Medicine.
There were 1934 patients who had a hurricane disaster declared during radiation treatment and 129 080 who completed radiation treatment in the absence of a disaster declaration, with 1734 in the exposed group and 1734 in the unexposed group after matching characteristics were balanced (Table). The 101 disaster declarations lasted between 1 and 69 days.
The median observation time was 15 months. For the exposed group, the total number of deaths was 1408, mean survival time was 29 months, and 5-year survival estimate was 14.5%. For the unexposed group, the total number of deaths was 1331, mean survival time was 31 months, and 5-year survival estimate was 15.4%. Patients affected by a hurricane disaster had longer radiation treatment durations (66.9 vs 46.2 days; P < .001) and significantly worse overall survival than matched unexposed patients in both crude (hazard ratio [HR] for death, 1.11 [95% CI, 1.02-1.22]; P = .02) and adjusted (HR, 1.19 [95% CI, 1.07-1.32]; P = .001) analyses. The adjusted relative risk for death increased with the length of the disaster declaration (Figure, A), reaching 1.27 (95% CI, 1.12-1.44) for disasters lasting 27 days. The association became nonsignificant after 30 days, but only 19 declarations lasted that long (Figure, B).
Having a hurricane disaster declared during radiotherapy was associated with worse overall survival in patients with locally advanced NSCLC. Longer declarations were associated with worse survival.
Strengths of this study include a large national sample with detailed sociodemographic, clinical, and treatment information and adequate follow-up periods. Limitations include lack of information about smoking history, performance status, treatment toxicity, reasons for or exact dates of treatment breaks, and other hurricane disaster–associated factors (eg, displacement, mental health status, physical functioning).
Because data on other potentially explanatory factors are lacking, the relative contribution of treatment delay to the observed association cannot be quantified. However, treatment delay is one of the few hurricane-related disruptions that can be prevented. Because no recommended correction for radiotherapy delays exists,3 strategies for identifying patients, arranging for transferring treatment, and eliminating patient out-of-network insurance charges should be considered in disaster mitigation planning. Research is needed to evaluate other types of natural disasters, diseases, and treatments.
Accepted for Publication: May 15, 2019.
Corresponding Author: Leticia M. Nogueira, PhD, Surveillance and Health Services Research Program, American Cancer Society, 250 Williams St, Atlanta, GA 30067 (firstname.lastname@example.org).
Author Contributions: Dr Nogueira had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Nogueira, Yabroff.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Nogueira, Sahar, Yabroff.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Nogueira.
Other - geospatial visualization and analysis: Sahar.
Conflict of Interest Disclosures: Dr Efstathiou reported receiving personal fees from Blue Earth Diagnostics, Taris Biomedical, Janssen, Bayer Healthcare, Genentech, and EMD Serono/Pfizer outside the submitted work. All authors conducted this study as part of the intramural research program at the American Cancer Society or contributed their time.
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