BACKGROUND
This study evaluates the independent association of Medicaid expansion on stage of presentation among patients of Black and White race with colorectal (CRC), breast, or non‐small cell lung ...cancer (NSCLC).
METHODS
A cohort study of patients with CRC, breast cancer, or NSCLC (2009–2017) in the National Cancer Database was performed. Difference‐in‐differences (DID) analysis was used to compare changes in tumor stage at diagnosis between Medicaid expansion (MES) and non‐expansion states (non‐MES) before and after expansion. Predictive margins were calculated by race, year, and insurance status to account for effect heterogeneity. Stage migration was determined by measuring the combined proportional increase in stage I and decrease in stage IV disease at diagnosis.
RESULTS
Black patients gained less Medicaid coverage than White patients (6.0% vs 13.1%, p < 0.001) after expansion. Among Black and White patients, there was a shift towards increased early‐stage diagnosis (DID 3.5% and 3.5%, respectively; p < 0.001) and decreased late‐stage diagnosis (DID White: −3.5%; Black −2.5%; p < 0.001) in MES compared to non‐MES following expansion. Overall stage migration was greater for White compared to Black patients with CRC (10.3% vs. 5.1%) and NSCLC (8.1% vs. 6.7%) after expansion. Stage migration effects in patients with breast cancer were similar by race (White 4.8% vs. Black 4.5%).
CONCLUSION
An increased proportion of Black and White patients residing in Medicaid expansion states presented with earlier stage cancer following Medicaid expansion. However, because the proportion of Black patients is higher in non‐expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.
Both Black and White patients residing in Medicaid expansion states presented with colorectal, breast, and non‐small cell lung cancer at earlier stages following expansion. However, because the proportion of Black patients is higher in non‐expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.
Abstract
Background
The purpose of this study was to determine the association between race and long-term cancer outcomes (recurrence and overall survival) within a population of US patients with ...locoregional colorectal cancer (CRC).
Methods
A cohort study of primary patient data merged with the National Cancer Database as part of a Commission on Cancer Special Study was performed. The study population was a random sample of patients undergoing surgery for stage I to III CRC between years 2006 and 2007 with 5 years of follow-up. Propensity-weighted multivariable Cox regression was performed with pooled results to yield statistical inferences. Prespecified sensitivity analysis was performed only for patients who received guideline concordant care (GCC) of primary CRC. All statistical tests were 2-sided.
Results
The study population included 8176 patients, 9.9% (n = 811) Black and 90.1% (n = 7365) White. Black patients were more likely to be uninsured or underinsured, have lower household income, and lower educational status (all P < .001). Rates of GCC were higher among Black vs White patients with colon cancer (76.9% vs 72.6%, P = .02), and Black and White patients with rectal cancer were treated with radiation at similar rates (69.1% vs 66.6%, P = .64). Black race was independently associated with increased risk of recurrence (hazard ratio HR = 1.48, 95% confidence interval CI = 1.26 to 1.73) and mortality (HR = 1.37, 95% CI = 1.18 to 1.59). In sensitivity analysis of only patients who received GCC, observed effects for recurrence (HR = 1.51, 95% CI = 1.27 to 1.79) and overall survival (HR = 1.40, 95% CI = 1.18 to 1.66) persisted.
Conclusions
Despite higher rates of GCC for CRC, Black patients experience a higher risk of recurrence and mortality compared with White patients.
Background
Colorectal cancer (CRC) often recurs in the peritoneum, although the pattern of peritoneal recurrence (PR) has received less attention. We sought to describe the presentation and risk ...factors for PR following CRC resection.
Methods
We performed a cohort study of patients undergoing resection of Stage I–III CRC from 2006 to 2007 using merged data from a Commission on Cancer Special Study and the National Cancer Database. We estimated the timing, method of detection, and risk factors for isolated PR.
Results
Here, 8991 patients were included and isolate PR occurred in 77 (0.9%) patients. The median time to PR was 16.2 months (intrquartile range = 9.3–28.0 months) and most patients were identified via new symptoms (36.4%). Pathologic factors associated with increased odds of PR included higher T stage (T3 vs. T2, odds ratio OR = 4.8, 95% confidence interval CI = 1.5–15.7), N stage (N1 vs. N0, OR = 2.00, CI = 1.1–3.7), and signet ring (OR = 8.2, CI = 3.0–22.3) or mucinous histology (OR = 2.6, CI = 1.5–4.7).
Conclusions
The majority of PR was detected within 18 months and few were identified by surveillance. Advanced T/N stage and signet ring/mucinous histology were associated with increased odds of PR.
Neoadjuvant chemoradiotherapy for rectal cancer is associated with improved local control and may result in complete tumor response. Associations between tumor response and disease control following ...radical resection should be established before tumor response is used to evaluate treatment strategies. The purpose of this study was to assess and compare oncologic outcomes associated with the degree of pathologic response after chemoradiotherapy.
All patients with locally advanced (cT3-4 or cN+ by endorectal ultrasonography, computed tomography, or magnetic resonance imaging) rectal carcinoma diagnosed from 1993 to 2008 at our institution and treated with preoperative chemoradiotherapy and radical resection were identified, and their records were retrospectively reviewed. The median radiation dose was 50.4 Gy with concurrent chemotherapy. Recurrence-free survival (RFS), distant metastasis (DM), and local recurrence (LR) rates were compared among patients with complete (ypT0N0), intermediate (ypT1-2N0), or poor (ypT3-4 or N+) response by using Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression.
In all, 725 patients were classified by tumor response: complete (131; 18.1%), intermediate (210; 29.0%), and poor (384; 53.0%). Age, sex, cN stage, and tumor location were not related to tumor response. Tumor response (complete v intermediate v poor) was associated with 5-year RFS (90.5% v 78.7% v 58.5%; P < .001), 5-year DM rates (7.0% v 10.1% v 26.5%; P < .001), and 5-year LR only rates (0% v 1.4% v 4.4%; P = .002).
Treatment response to neoadjuvant chemoradiotherapy among patients with locally advanced rectal cancer undergoing radical resection is an early surrogate marker and correlate to oncologic outcomes. These data provide guidance with response-stratified oncologic benchmarks for comparisons of novel treatment strategies.
Aim
As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative‐intent ...resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long‐term outcomes following robotic extended resection for colorectal cancer.
Method
We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short‐ and long‐term outcomes, using the Kaplan–Meier method to analyse overall and recurrence‐free survival.
Results
Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three‐year overall survival was 88% and median progression‐free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years.
Conclusion
Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer.
Purpose
We evaluated clinical features and survival outcomes among patients with signet ring and mucinous histologies of colorectal adenocarcinoma by using data from the National Cancer Data Base ...(NCDB).
Methods
Patients aged 18–90 years with colorectal adenocarcinoma diagnosed between 1998 and 2002 were identified from the NCDB. Site-stratified (colon vs. rectum) survival analysis was performed by multivariate relative survival adjusted for multiple clinicopathologic and treatment variables.
Results
The study included 244,794 patients: 25,546 (10%) with mucinous, 2,260 (1%) with signet ring, and 216,988 (89%) with nonmucinous, non–signet ring adenocarcinoma. Mucinous and signet ring cancers were more frequently right-sided (60% and 62%, respectively) than were nonmucinous, non–signet ring adenocarcinomas (42%,
P
< 0.001). Signet ring histology was associated with a higher stage (
P
< 0.001), and 77.2% of signet ring tumors were high-grade lesions, compared with 20% of mucinous and 17% of non–signet ring, nonmucinous adenocarcinomas (
P
< 0.001). After adjustment for covariates, signet ring histology was independently associated with higher risk of death hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33–1.51, and HR 1.57, CI 1.38–1.77, for tumors located in the colon and rectum, respectively. Mucinous tumors of the rectum (HR 1.22, CI 1.16–1.29), but not the colon (HR 1.03, CI 1.00–1.06), were associated with increased risk of death.
Conclusions
Signet ring cell adenocarcinomas of the colon and rectum and mucinous adenocarcinomas of the rectum are associated with poorer survival. These aggressive histologic variants of colorectal adenocarcinoma should be targeted for research initiatives to improve outcomes.
Certain bacteria demonstrate the ability to target and colonize the tumor microenvironment, a characteristic that positions them as innovative carriers for delivering various therapeutic agents in ...cancer therapy. Nevertheless, our understanding of how bacteria adapt their physiological condition to the tumor microenvironment remains elusive. In this work, we employed liquid chromatography-tandem mass spectrometry to examine the proteome of
colonized in murine tumors. Compared to
cultivated in the rich medium, we found that
colonized in tumors notably upregulated the processes related to ferric ions, including the enterobactin biosynthesis and iron homeostasis. This finding indicated that the tumor is an iron-deficient environment to
. We also found that the colonization of
in the tumor led to an increased expression of lipocalin 2 (LCN2), a host protein that can sequester the enterobactin. We therefore engineered
in order to evade the nutritional immunity provided by LCN2. By introducing the IroA cluster, the
synthesizes the glycosylated enterobactin, which creates steric hindrance to avoid the LCN2 sequestration. The IroA-
showed enhanced resistance to LCN2 and significantly improved the anti-tumor activity in mice. Moreover, the mice cured by the IroA-
treatment became resistant to the tumor re-challenge, indicating the establishment of immunological memory. Overall, our study underscores the crucial role of bacteria's ability to acquire ferric ions within the tumor microenvironment for effective cancer therapy.
Background
Several factors can affect the risk of recurrence after curative resection of colorectal cancer (CRC). We aimed to develop a risk model for recurrence after definitive treatment of Stage ...I–III CRC using data from a nationally representative database and to develop an individualized web-based risk calculator.
Methods
A random sample of patients who underwent resection for Stage I–III CRC between 2006 and 2007 at Commission on Cancer (CoC) accredited centers were included. Primary data regarding first recurrence was abstracted from medical records and merged with the National Cancer Database. Multivariable cox regression analysis was used to test for factors associated with cancer recurrence, stratified by stage. Model performance was tested by c statistic and calibration plots. Hazard Ratios were utilized to develop an individualized web-based recurrence prediction tool.
Results
A total of 8249 patients from 1175 CoC centers were included. Of these, 1656 (20.1%) patients had a recurrence during 5 years of follow-up. Median time to recurrence was 16 months. The final predictive models displayed excellent discrimination and calibration with concordance indexes of 0.7. The online calculator included 12 variables, including tumor site, stage, time since surgery, and surveillance intensity. Output is displayed numerically and graphically with an icon array.
Conclusions
Using primarily abstracted recurrence data from a random sample of patients treated for CRC at CoC accredited centers across the United States, we successfully created an individualized CRC recurrence risk assessment tool. This web-based calculator can be used by physicians and patients in shared decision making to guide management discussions.
Trial Registration
ClinicalTrials.gov Registration Number: NCT02217865.
PDF
