Background
The first consensus Merkel cell carcinoma (MCC) staging system was published in 2010. New information on the clinical course prompts review of MCC staging.
Methods
A total of 9387 MCC ...cases from the National Cancer Data Base Participant User File with follow-up and staging data (1998–2012) were analyzed. Prognostic differences based on clinical and pathological staging were evaluated. Survival estimates were compared by disease extent.
Results
Sixty-five percent of cases presented with local disease, whereas 26 and 8 % presented with nodal and distant disease. Disease extent at presentation was predictive of 5-year overall survival (OS) with estimates of 51, 35, and 14 % for local, nodal, and distant disease. Tumor burden at the regional nodal basin was predictive of 5-year OS with estimates of 40 and 27 % for clinically occult and clinically detected nodal disease. For local disease, we confirm improved prognosis when the regional nodal basin was negative by pathological compared with clinical staging. We identified 336 cases with clinically detected nodal disease and unknown primary tumor and showed improved prognosis over cases presenting with concurrent primary tumor (OS estimates of 42 vs. 27 %).
Conclusions
Analysis of a national dataset of MCC cases validates the predictive value of disease extent at presentation. Separation of clinical and pathological stage groups and regrouping of unknown primary tumors are supported by the analysis. The revised staging system provides more accurate prognostication and has been formally accepted by the AJCC staging committee for inclusion in the 8th edition.
Background
Recent attention has focused on the ability to rescue patients from postoperative complications and prevent short-term mortality. However, it is unknown whether patients rescued from ...complications after complex cancer resections have long-term survival outcomes similar to those of patients without complications.
Methods
From 2005 to 2009 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the study identified elderly patients who underwent resection for cancers of the esophagus, lung, or pancreas. The association of risk-adjusted long-term survival with serious complications, minor complications, and no complications was analyzed.
Results
The study included 905 patients with esophageal cancer, 12,395 patients with lung cancer, and 1966 patients with pancreatic cancer. The serious complication rates were respectively 17.4, 9.5 and 11.8 %. The patients with serious complications had lower 5-year survival rates than those with no complications even if they were rescued and survived 30 days (20 vs 43 % for esophagus, 29 vs 54 % for lung, and 10 vs 21 % for pancreas cancer). Even after patients who died within 180 days after surgery were excluded from the analysis, a decrement in risk-adjusted long-term survival was observed among the patients with serious complications after all three procedures. The association between complications and long-term survival was not explained by differences in receipt of adjuvant chemotherapy
Conclusion
Patients who undergo complex cancer resection and experience serious complications have diminished long-term survival, even if they are “rescued” from their complications. This finding persists even when deaths within 6 months after surgery are excluded from the analysis. Metrics of surgical success should consider terms beyond 30 and even 90 days as well as the long-term consequences of surgical complications.
OBJECTIVE:This study aims to determine the publicʼs perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond.
SUMMARY BACKGROUND DATA:With rapid expansion and uptake ...of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The publicʼs perception of telemedicine for an initial surgical consultation has not been previously studied.
METHODS:A 43-question survey assessed respondents’ attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during “normal circumstances.” Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace.
RESULTS:Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that “establishing trust and comfort” was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery.
CONCLUSIONS:The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an in-person interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.
To determine whether preoperatively untreated obstructive sleep apnea (OSA) affects postoperative outcomes.
Cohort study of patients undergoing surgery between July 2012 and September 2013, utilizing ...prospectively collected data from the Michigan Surgical Quality Collaborative. Multivariable regression models were used to compare complication rates between treated and untreated OSA, while adjusting for important patient covariates and clustering within hospitals.
Fifty-two community and academic hospitals in Michigan.
Adult patients undergoing various general or vascular operations were categorized as: (1) no diagnosis or low risk of OSA; (2) documented OSA without therapy or suspicion of OSA; and (3) diagnosis of OSA with treatment (e.g., positive airway pressure).
OSA, preoperatively treated or untreated, was the exposure variable. Postoperative 30-day cardiopulmonary complications including arrhythmias, cardiac arrest, myocardial infarction, unplanned reintubation, pulmonary embolism, and pneumonia were the outcomes of interest.
Of 26,842 patients, 2,646 (9.9%) had a diagnosis or suspicion of OSA. Of those, 1,465 (55.4%) were untreated. Patient and procedural risk factors were evenly balanced between treated and untreated groups. Compared with treated OSA, untreated OSA was independently associated with more cardiopulmonary complications (risk-adjusted rates 6.7% versus 4.0%; adjusted odds ratio aOR = 1.8, P = 0.001), particularly unplanned reintubations (aOR = 2.5, P = 0.003) and myocardial infarction (aOR = 2.6, P = 0.031).
Patients with obstructive sleep apnea (OSA) who are not treated with positive airway pressure preoperatively are at increased risks for cardiopulmonary complications after general and vascular surgery. Improving the recognition of OSA and ensuring adequate treatment may be a strategy to reduce risk for surgical patients with OSA.
The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing recent clinical practice guidelines that have been developed by other professional organizations.
The ...Cancer Care Ontario (CCO) Guideline on Follow-up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer was reviewed by ASCO for methodologic rigor and considered for endorsement.
The ASCO Panel concurred with the CCO recommendations and recommended endorsement, with the addition of several qualifying statements.
Surveillance should be guided by presumed risk of recurrence and functional status of the patient (important within the first 2 to 4 years). Medical history, physical examination, and carcinoembryonic antigen testing should be performed every 3 to 6 months for 5 years. Patients at higher risk of recurrence should be considered for testing in the more frequent end of the range. A computed tomography scan (abdominal and chest) is recommended annually for 3 years, in most cases. Positron emission tomography scans should not be used for surveillance outside of a clinical trial. A surveillance colonoscopy should be performed 1 year after the initial surgery and then every 5 years, dictated by the findings of the previous one. If a colonoscopy was not preformed before diagnosis, it should be done after completion of adjuvant therapy (before 1 year). Secondary prevention (maintaining a healthy body weight and active lifestyle) is recommended. If a patient is not a candidate for surgery or systemic therapy because of severe comorbid conditions, surveillance tests should not be performed. A treatment plan from the specialist should have clear directions on appropriate follow-up by a nonspecialist.
To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was ...considered, as were treatment and use of anticoagulation as a cancer-directed therapy.
A systematic review of the literature published from December 2007 to December 2012 was completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed evidence to determine which recommendations required revision.
Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized controlled trials.
Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low-molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE. Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient education about the signs and symptoms of VTE.
Purpose To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. Methods An ASCO-SSO panel was formed, ...and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. Results Nine new observational studies, two systematic reviews, and an updated randomized controlled trial of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. Recommendations Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (nonulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or < 0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of > 1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher-risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors and details of the reference patient populations are included within the guideline. Additional information is available at www.asco.org/melanoma-guidelines and www.asco.org/guidelineswiki .
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