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Background: One of the American College of Surgeons Commission on Cancer (ACS CoC) quality measures in colon cancer is receipt of chemotherapy (CT) in Stage III disease within 120 ...days of diagnosis. Minimally invasive surgery (MIS) has been associated with faster recovery times. The aim of this study is to assess whether MIS improves compliance to this metric. Methods: Stage III colon cancer patients 80 years old and younger from 2010 to 2012 were identified in the National Cancer Database. Demographic, tumor and treatment characteristics were evaluated including receipt of CT and surgical approach. Uni- and multi-variate logistic regression was used to assess factors associated with CT compliance. Results: Of the 19,963 patients identified, 14,901(74.6%) were compliant while 5,062 (25.3%) were not. Of the patients who were non-compliant, 956 (4.8%) received CT after 120 days. Surgical approach was significantly different between CT compliant and non-compliant groups (MIS 28% vs 32%,p < 0.000). Uni- and multi-variate analyses identified MIS as a significant factor associated with improved compliance to CT with an OR of 1.31 (95%CI 1.22-1.41). Other factors associated with CT compliance were nodal and tumor stage and treatment in an academic program. Non-compliance was associated with age 50-64 (OR 0.76; 95%CI 0.68-0.86), age 65-79 (OR 0.49; 95%CI 0.43-0.56) and increased co-morbidities (OR 0.60; 95%CI 0.53-0.67). Lack of insurance (OR 0.69; 95%CI 0.58-0.81) or Medicaid (OR 0.54; 95%CI 0.47-0.62) and Medicare (OR 0.69; 95%CI 0.63-0.77) as well as distance to hospital of more than 44 miles were also associated with non-compliance to CT (OR 0.86; 95%CI 0.76-0.97). Conclusions: This is the first study to demonstrate that MIS for Stage III colon cancer improves compliance to receipt of CT within the 120 days. Given the potential survival benefits as a result of adherence to ACS CoC cancer care quality metrics, MIS may benefit patients not only in faster return to recovery but also in improved cancer outcomes.
Older Breast Cancer (BC) survivors are an increased risk of osteoporosis due to natural aging and long-term cancer treatment-related toxicity. It is well known that anti-estrogen therapy (AET), ...especially aromatase inhibitors (AI), is associated with rapid bone loss and thus increases the risk of osteoporosis. This study characterizes patterns and predictors of receiving guideline-recommended bone densitometry (BD) screening at AET initiation.
A retrospective cohort study (1998–2012) of all women ≥65 years of age initiating AET was designed using claims data from Quebec's universal health care. Associations with BD screening were estimated using a generalized estimating equations regression model, adjusting for clustering of patients within physicians.
Among 16,480 women initiating AET, 36.1% received a baseline BD. Among AI users, the rate was 58.4%. In the multivariate analysis, age, lower socioeconomic status, tamoxifen use, lack of periodic health exam and having a general practitioner as the AET prescriber were associated with lower odds of BD screening. In terms of quality of care-related variables, lack of guideline-appropriate radiotherapy (OR: 0.69 (95% CI, 0.57–0.83), or chemotherapy consideration (0.82 (95% CI, 0.71–0.94)) and non-adherence to AET (0.76 (95% CI, 0.68–0.84)) were associated with lower odds of receiving BD screening. Women diagnosed with BC after 2003 had significantly better odds of being screened.
Despite an increase in rates since 2003, BD screening remains suboptimal, especially for women at higher risk of osteoporosis. Coordination of health care and service-delivery monitoring can potentially optimize long-term management of treatment-related toxicity in older BC survivors.
•Older breast cancer survivors are at risk of osteoporosis due to the combined effect of age and treatment-related toxicity.•Anti-estrogen therapy and particularly aromatase inhibitors double the baseline risk of osteoporotic fracture.•Bone densitometry rates are low in older breast cancer survivors; only a third are screened at anti-estrogen therapy start.•Absence of bone density screening is more frequent in women who also encounter other challenges in cancer care quality.•Omitting bone densitometry is more common in older, poorer breast cancer survivors without primary care continuity.•Care coordination and service delivery monitoring can minimize treatment-related toxicity in older breast cancer survivors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
The role of fecal diversion with pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is not well defined.
Methods
A retrospective ...review of patients who underwent CRS and HIPEC between 2009 and 2016 was performed to identify those with a pelvic anastomosis (colorectal, ileorectal, or coloanal anastomosis).
Results
The study identified 73 patients who underwent CRS and HIPEC at three different institutions between July 2009 and June of 2016. Of these patients, 32 (44%) underwent a primary anastomosis with a diverting ileostomy, whereas 41 (56%) underwent a primary anastomosis without fecal diversion. The anastomotic leak rate for the no-diversion group was 22% compared with 0% for the group with a diverting ileostomy (
p
< 0.01). The 90-day mortality rate for the no-diversion group was 7.1%. The hospital stay was 14.1 ± 8.0 days in the diversion group compared with 17.9 ± 12.5 days in the no-diversion group (
p
= 0.12). Of those patients with a diverting ileostomy, 68% (
n
= 22) had their bowel continuity restored, 18% of which required a laparotomy for reversal. Postoperative complications occurred for 50% of those who required a laparotomy and for 44% of those who did not require a laparotomy (
p
= 0.84).
Conclusion
Diverting ileostomies in patients with a pelvic anastomosis undergoing CRS and HIPEC are associated with a significantly reduced anastomotic leak rate. Reversal of the diverting ileostomy in this patient population required a laparotomy in 18% of the cases and had an associated morbidity rate of 50%.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Melanoma is an immunogenic cancer with a high response rate to immune checkpoint inhibitors (ICIs). It harbors a high mutation burden compared with other cancers and, as a result, has abundant ...tumor-infiltrating lymphocytes (TILs) within its microenvironment. However, understanding the complex interplay between the stroma, tumor cells, and distinct TIL subsets remains a substantial challenge in immune oncology. To properly study this interplay, quantifying spatial relationships of multiple cell types within the tumor microenvironment is crucial. To address this, we used cytometry time-of-flight (CyTOF) imaging mass cytometry (IMC) to simultaneously quantify the expression of 35 protein markers, characterizing the microenvironment of 5 benign nevi and 67 melanomas. We profiled more than 220,000 individual cells to identify melanoma, lymphocyte subsets, macrophage/monocyte, and stromal cell populations, allowing for in-depth spatial quantification of the melanoma microenvironment. We found that within pretreatment melanomas, the abundance of proliferating antigen-experienced cytotoxic T cells (CD8
CD45RO
Ki67
) and the proximity of antigen-experienced cytotoxic T cells to melanoma cells were associated with positive response to ICIs. Our study highlights the potential of multiplexed single-cell technology to quantify spatial cell-cell interactions within the tumor microenvironment to understand immune therapy responses.
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Background: Laparoscopic-assisted distal pancreatectomy (LDP) has improved perioperative outcomes over open distal pancreatectomy (ODP). Concerns regarding failure to achieve proper ...oncologic resection and compromised survival remain. Methods: Using the National Cancer Database (NCDB), we analyzed patients undergoing distal pancreatectomy for resectable pancreatic adenocarcinoma over a four-year period (2010-2014). Propensity score nearest-neighbor 1:1 matching (PSM) was performed between LDP and ODP patients based on age, sex, race, insurance, hospital volume, comorbidities, T-stage, N-stage, grade, neoadjuvant therapy, adjuvant therapy. Primary outcome was overall survival. Results: Of the 1,947 eligible patients, 605 (31%) underwent LDP. After PSM two well-balanced groups of 544 patients each were analyzed. There was a trend towards improved overall survival (OS) in patients undergoing LDP as compared to ODP (HR: 0.83, 95% CI 0.68-1.0; Median OS 29 vs. 23 months, p = 0.06). Patients undergoing ODP had a higher margin positive rate compared to those undergoing LDP (21.1% vs. 14.9%, p-value = 0.007). Overall conversion rate was 27%. Patients undergoing ODP had comparable outcomes to LDP in regards to median time to chemotherapy (50 vs. 48 days, p-value = 0.96); median nodes examined (12 vs. 12, p-value = 0.61); 30-day mortality (1.6% vs. 1.1%, p-value = 0.43); 90-day mortality (3.5% vs. 2.4%, p-value = 0.28); 30-day readmission rate (8.6% vs. 9.4%, p-value = 0.67). However, the median length of stay was shorter in the LDP group (6 vs. 7 days, p = 0.0001). Conclusions: In the absence of randomized trials, this is the largest comparative study demonstrating LDP as an acceptable alternative ODP, associated with a lower margin positive rate and shorter length of stay, and with no detriment in long term survival.
Nipple-sparing mastectomy (NSM) remains controversial in patients with high-risk breast cancer. The objective of this study was to assess surgical and oncologic outcomes of NSM and to evaluate ...associations of outcomes with high-risk features.
A retrospective review was conducted of all NSM cases performed for breast cancer at 2 academic cancer centers between January 2013 and August 2018.
Of the 175 patients who underwent NSM, 13 (7.4%) had locally advanced breast cancer (LABC), 52 (29.2%) had previous neoadjuvant chemotherapy, 21 (12.0%) had previous radiation therapy, 40 (22.8%) received postmastectomy radiation, 27 (15.4%) had de-epithelialized skin reduction, and 13 (7.4%) had free nipple grafting. The median duration of follow-up was 24 months. Nipple necrosis (4 cases; 2.2%) was associated with previous radiation (9.5%; P = .018), skin reduction (11.1%; P = .001), and nipple grafting (15.4%; P = .001). The nipple–areolar complex margin (NAC) was involved with invasive disease in 1 case. Local recurrence occurred in 8 cases (4.6%), with 1 in-NAC recurrence. Overall survival was 98.3%, and disease-free survival (DFS) was 88.6%. LABC was associated with worse DFS (hazard ratio, 4.28; P = .011), with all 4 recurrences being distant.
Previous radiation, skin reduction, and nipple grafting are associated with an increased risk of NAC necrosis. None of these should be considered absolute contraindications, but patients should be counseled appropriately. Although LABC is associated with worse DFS, relapses are systemic. Longer follow-up is needed to establish oncologic safety in unselected breast cancer patients.
In this series of nipple-sparing mastectomy cases, previous radiation, de-epithelialized skin-reduction and free-nipple grafting are associated with increased risk of nipple necrosis. Locally advanced disease was associated with an increased risk of systemic rather than local relapse. High-risk patients should be counseled appropriately.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background In order to decrease cost and increase healthcare quality there is an ongoing effort to reduce readmissions after complex operations. The timing and severity of post-discharge ...complications after hepatectomy need to be better defined. Methods All patients undergoing liver resection at a single institution from Jan 2009–Jun 2015 were included. Complications were scored using the comprehensive complication index (CCI). Multivariate analysis is performed using logistic regression. Receiver operating characteristics (ROCs) were analyzed to optimize the Readmission Risk Index (RRI). Results Of the 258 patients that met the inclusion criteria, 26 (10%) were readmitted within 30 days of discharge after hepatectomy. On multivariate analysis age ≥68 years (OR 3.76; 95% CI 1.47–9.63, p = 0.006), CCI ≥ 15 (OR 3.65; 95% CI 1.39–9.56, p = 0.008), maximum temperature within 48 h of discharge (OR 3.02; 95% CI 1.17–7.75, p = 0.022) and white blood cell count ≥10.2 billion cells/L within 48 h of discharge (OR 2.88; 95% CI 1.04–8, p = 0.043) were independent predictors of 30-day readmission. These variables were used to develop the RRI (ROC area 0.80; 95% CI 0.70–0.9, p < 0.001). Conclusion The CCI and pre-discharge variables can help identify individuals at risk of readmission. Readmission risk reduction efforts should focus on this subset of patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Disparities in health care have an adverse effect on the outcome of disadvantaged patients with cancer. Patients may be at a disadvantage because of geographic isolation; insurance status; or racial, ...ethnic, or other factors. In this article, we examine how disparities affect the care of patients with sarcoma in the United States, Canada, and the Asia-Pacific region. Because of the rarity of sarcomas and their challenging diagnosis and complex treatment patterns, some professional or national guidelines stipulate that patients with sarcoma should be treated at centers of expertise by multidisciplinary teams. This recommendation, based on published evidence, is not always applicable because of various sociopolitical or patient-related factors. We are proposing solutions to overcome these obstacles in a practical and patient-centered way while acknowledging that disparities exist among countries as well as within any country.
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