Background
During the height of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries, including oncologic surgeries, were delayed. Little prospective data existed to guide practice, ...and professional surgical societies issued recommendations grounded mainly in common sense and expert consensus, such as medical therapy for early-stage breast and prostate cancer patients. To understand the patient experience of delay in cancer surgery during the pandemic, we interviewed breast and prostate cancer patients whose surgeries were delayed due to the pandemic.
Patients and Methods
Patients with early-stage breast or prostate cancer who suffered surgical postponement at Brigham and Women’s Hospital (BWH) were invited to participate. Semi-structured telephone interviews were conducted with 21 breast and prostate cancer patients. Interviews were transcribed, and qualitative analysis using ground-theory approach was performed.
Results
Most patients reported significant distress due to cancer and COVID. Key themes that emerged included the lack of surprise and acceptance of the surgical delays but endorsed persistent cancer- and delay-related worries. Satisfaction with patient–physician communication and the availability of a delay strategy were key factors in patients’ acceptance of the situation; perceived lack of communication prompted a few patients to seek care elsewhere.
Discussion
The clinical effect of delay in cancer surgery will take years to fully understand, but there are immediate steps that can be taken to improve the patient experience of delays in care, including elicitation of individual patient perspectives and ongoing communication. More work is needed to understand the wider experiences of patients, especially minority, socioeconomically disadvantaged, and uninsured patients, who encounter delays in oncologic care.
Graphical Abstract
Objective
To determine whether patients with Gleason score 5 + 3 = 8 prostate cancer have outcomes more similar to other patients with Gleason score 8 disease or to patients with Gleason score 9 ...disease.
Patients and Methods
The Surveillance, Epidemiology and End Results (SEER) database was used to study 40 533 men diagnosed with N0M0 Gleason score 8 or 9 prostate cancer from 2004 to 2011. Using Gleason score 4 + 4 = 8 as the referent, Fine and Gray competing risks regression analyses modelled the association between Gleason score and prostate cancer‐specific mortality (PCSM).
Results
The 5‐year PCSM rates for patients with Gleason score 4 + 4 = 8, 3 + 5 = 8, 5 + 3 = 8, and 9 disease were 6.3%, 6.6%, 13.5%, and 13.9%, respectively (P < 0.001). Patients with Gleason score 5 + 3 = 8 or 9 disease had up to a two‐fold increased risk of PCSM (adjusted hazard ratio AHR 1.89, 95% confidence interval CI 1.50–2.38, P < 0.001; and AHR 2.17, 95% CI 1.99–2.36, P < 0.001, respectively) compared with the referent group of patients (Gleason score 4 + 4 = 8). There was no difference in PCSM between patients with Gleason score 5 + 3 = 8 vs 9 disease (P = 0.25).
Conclusions
Gleason score 8 disease represents a heterogeneous entity with PCSM outcomes distinguishable by the primary Gleason pattern. The PCSM of Gleason score 3 + 5 = 8 and Gleason 4 + 4 = 8 disease are similar, but patients with Gleason score 5 + 3 = 8 have a risk of PCSM that is twice as high as other patients with Gleason score 8 disease and should be considered to have a similar poor prognosis as patients with Gleason score 9 disease. Such patients should be allowed onto trials seeking the highest‐risk patients in which to test novel aggressive treatment strategies.
Abstract Background Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally ...invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. Objective Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. Design, setting, and participants As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP ( n = 11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients ( n = 7389). Intervention All patients underwent RARP or ORP. Measurements We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score–matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Results and limitations Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score–matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio OR: 0.34; 95% confidence interval CI, 0.28–0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31–0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77–0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26–0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. Conclusions RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.
Background
Obesity is associated with poor surgical outcomes and disparity in access-to-care. There is a lack of quality data on the effect of body mass index (BMI) on perioperative outcomes. ...Accordingly, we sought to determine the procedure specific, independent-effect of BMI on 30-day perioperative outcomes in patients undergoing major surgery.
Methods
Participants included individuals undergoing one of 16 major surgery (cardiovascular, orthopedic, oncologic;
n
= 141,802) recorded in the ACS-NSQIP (2005–2011). Outcomes evaluated included complications, blood transfusion, length-of-stay (LOS), re-intervention, readmission, and perioperative mortality. Multivariable-regression models assessed the independent-effect of BMI on outcomes.
Results
Nearly, 74 % of patients had a BMI disturbance; the majority being overweight (35.3 %) or obese (29.8 %). Morbidly obese patients constituted a small but significant proportion of the patients (5.7 %;
n
= 8067). In adjusted-analyses, morbidly obese patients had significantly increased odds of wound complications in 15 of the examined procedures, of renal complications after 6-procedures, of thromboembolism after 5-procedures, of pulmonary, septic and UTI complications after 2-procedures, and of cardiovascular complications after CABG. Conversely, obese/overweight patients, except for increased odds of wound complications after select procedures, had significantly decreased odds of perioperative mortality, prolonged-LOS and blood transfusion relative to normal BMI patients after 4, 8, and 9 of the examined procedures.
Conclusions
The prevalence of BMI derangements in surgical patients is high. The effect of BMI on outcomes is procedure specific. Patients with BMI between 18.5 and 40-kg/m
2
at time of surgery fare equally well with regard to complications and mortality. However, morbidly obese patients are at-risk for postsurgical complications and targeted preoperative-optimization may improve outcomes and attenuate disparity in access-to-care.
Abstract Background More than a decade since its inception, the benefits and cost efficiency of robot-assisted radical prostatectomy (RARP) continue to elicit controversy. Objective To compare ...outcomes and costs between RARP and open RP (ORP). Design, setting, and participants A cohort study of 629 593 men who underwent RP for localized prostate cancer at 449 hospitals in the USA from 2003 to 2013, using the Premier Hospital Database. Intervention RARP was ascertained through a review of the hospital charge description master for robotic supplies. Outcome measures and statistical analysis Outcomes were 90-d postoperative complications (Clavien), blood product transfusions, operating room time (ORT), length of stay (LOS), and direct hospital costs. Propensity-weighted regression analyses accounting for clustering by hospitals and survey weighting ensured nationally representative estimates. Results and limitations RARP utilization rapidly increased from 1.8% in 2003 to 85% in 2013 ( p < 0.001). RARP patients ( n = 311 135) were less likely to experience any complications (odds ratio OR 0.68, p < 0.001) or prolonged LOS (OR 0.28, p < 0.001), or to receive blood products (OR 0.33, p = 0.002) compared to ORP patients ( n = 318 458). The adjusted mean ORT was 131 min longer for RARP ( p = 0.002). The 90-d direct hospital costs were higher for RARP (+$4528, p < 0.001), primarily attributed to operating room and supplies costs. Costs were no longer signficantly different between ORP and RARP among the highest-volume surgeons (≥104 cases/yr; +$1990, p = 0.40) and highest-volume hospitals (≥318 cases/yr; +$1225, p = 0.39). Limitations include the lack of oncologic characteristics and the retrospective nature of the study. Conclusions Our contemporary analysis reveals that RARP confers a perioperative morbidity advantage at higher cost. In the absence of large randomized trials because of the widespread adoption of RARP, this retrospective study represents the best available evidence for the morbidity and cost profile of RARP versus ORP. Patient summary In this large study of men with prostate cancer who underwent either open or robotic radical prostatectomy, we found that robotic surgery has a better morbidity profile but costs more.
Objectives: Accurate tumor identification during partial nephrectomy is essential for successful tumor control. Intraoperative laparoscopic ultrasonography is useful for tumor localization, but the ...ultrasound probe is controlled by the assistant rather than the surgeon. We evaluated our initial experience using a robotic ultrasound probe that is controlled by the console surgeon.
Methods: Partial nephrectomy was carried out in 22 consecutive patients between November 2010 and March 2011. A robotic ultrasound probe under console surgeon control was used in all the cases. All patients had at least 1 year follow up.
Results: Mean patient age was 59 years and mean tumor size was 2.7 cm. There were six hilar tumors (27%) and 21 (95%) endophytic tumors. Mean R.E.N.A.L. nephrometry score was 6.9 (range 6–9). Mean operative time was 205.7 min and mean warm ischemia time was 17.9 min (range 6–28 min). All patients had negative tumor margins and were free of disease recurrence at a mean follow up of 13 months.
Conclusion: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure.
There is limited data on the prevalence and mortality of venous thromboembolism (VTE) following oncologic surgery.
To evaluate the trends, factors, and mortality of VTE following major cancer ...surgery.
Patients undergoing colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, or prostatectomy were identified retrospectively using the Nationwide Inpatient Sample between January 1, 1999, and December 30, 2009, resulting in a weighted estimate of 2,508,916 patients.
Venous thromboembolism following major cancer surgery was assessed according to date, patient, and hospital characteristics. The determinants of in-hospital VTE were evaluated using logistic regression analysis.
Venous thromboembolism showed an estimated annual percentage increase of 4.0% (95% CI, 2.9% to 5.1%), which contrasts with a 2.4% (95% CI, -4.3% to -0.5%) annual decrease in mortality in VTE after major cancer surgery. In multivariate logistic regression analysis, older age (odds ratio OR, 1.03; P < .001), female sex (OR, 1.25; P < .001), black race (vs white; OR, 1.56; P < .001), Charlson comorbidity index score of 3 or more (OR, 1.85; P < .001), and Medicaid (vs private insurance; OR, 2.04; P < .001), Medicare (OR, 1.39; P < .001), and uninsured (OR, 1.49; P < .001) status were associated with an increased risk of VTE. Conversely, other (nonwhite and nonblack) race (OR, 0.75; P < .001) was associated with a lower risk of VTE. Among hospital characteristics, urban location (OR, 1.32; P < .001) and teaching status (OR, 1.08; P = .01) were associated with greater odds of VTE. Patients with vs without VTE experienced 5.3-fold greater odds of mortality.
During our study period, VTE events following major cancer surgery increased in frequency; however, associated VTE mortality decreased. Changing VTE detection guidelines and better management of this condition may explain our findings.
Secondary data analysis has become increasingly common in health services research, specifically comparative effectiveness research. While a comprehensive study of the techniques and methods for ...secondary data analysis is a wide-ranging topic, we sought to perform a descriptive study of some key methodological issues related to secondary data analyses and to provide a basic summary of techniques to address them.
In this study, we first address common issues seen in analysis of secondary datasets, and limitations of datasets with respect to bias. We cover some strategies for handling missing or incomplete data and a basic summary of three statistical approaches that can be used to address the problem of bias.
While it is unrealistic for surgeon scientists to aspire to the depth of knowledge of professional statisticians or data scientists, it is important for researchers and clinicians reading to understand some of the common pitfalls and issues when using secondary data to investigate clinical questions. Ultimately, the choice of analytical technique and the particular data sets used should be dictated by the research question and hypothesis being tested. Transparency about data handling and statistical techniques are vital elements of secondary data analysis.
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