Declining cancer surgery represents a conflict between patients' rights to autonomy and providers’ perspectives of best practice. We hypothesize that, among patients with nonmetastatic lung cancer, ...patient demographics would be associated with different rates of declination of lung cancer surgery.
Patients with nonmetastatic lung cancer from 2004 to 2018 in the National Cancer Database were identified. Patients were categorized into two groups based on surgical treatment: surgical resection and declined surgery. Patient characteristics were compared using bivariate and multivariate models to identify factors associated with surgical declination. Additionally, we performed subgroup analyses of cT1N0M0 patients with no comorbidities. Survival analysis done using multivariate cox analysis and Kaplan-Meier survival analysis.
478,757 patients were identified. In a multivariate model, declining surgery was associated with increased age (odds ratio 1.09, 1.09-1.10), non-Hispanic Black race (odds ratio 1.95, 1.73-2.21), nonprivate insurance, and lower Socioeconomic Status. In a subgroup of cT1N0M0 patients with no comorbidities, declining surgery was associated with increasing age, non-Hispanic Black race, nonprivate insurance, and socioeconomic status. Patient's that declined surgery demonstrated lower overall survival when compared to patients that underwent surgical resection (5 y overall survival: declined surgery 40% versus underwent resection 72%, P < 0.001).
Although early-stage lung cancer is potentially curable, many patients decline guideline-based surgery, and have worse overall survival. There are social and economic factors associated with patients declining lung cancer surgery. Providers have an ethical responsibility to understand the basis of patient's decision to decline recommended surgery and address endemic disparities related to race and access to care.
Postoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The ...purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF.
The TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months (“early”) and 12-24 months postop (“chronic”). Propensity matching was performed to reduce bias between cohorts.
We identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003).
Postoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.
To determine whether discriminatory performance of a computational risk model in classifying pulmonary lesion malignancy using demographic, radiographic, and clinical characteristics is superior to ...the opinion of experienced providers. We hypothesized that computational risk models would outperform providers.
Outcome of malignancy was obtained from selected patients enrolled in the NAVIGATE trial (NCT02410837). Five predictive risk models were developed using an 80:20 train-test split: univariable logistic regression model based solely on provider opinion, multivariable logistic regression model, random forest classifier, extreme gradient boosting model, and artificial neural network. Area under the receiver operating characteristic curve achieved during testing of the predictive models was compared to that of prebiopsy provider opinion baseline using the DeLong test with 10,000 bootstrapped iterations.
The cohort included 984 patients, 735 (74.7%) of which were diagnosed with malignancy. Factors associated with malignancy from multivariable logistic regression included age, history of cancer, largest lesion size, lung zone, and positron-emission tomography positivity. Testing area under the receiver operating characteristic curve were 0.830 for provider opinion baseline, 0.770 for provider opinion univariable logistic regression, 0.659 for multivariable logistic regression model, 0.743 for random forest classifier, 0.740 for extreme gradient boosting, and 0.679 for artificial neural network. Provider opinion baseline was determined to be the best predictive classification system.
Computational models predicting malignancy of pulmonary lesions using clinical, demographic, and radiographic characteristics are inferior to provider opinion. This study questions the ability of these models to provide additional insight into patient care. Expert clinician evaluation of pulmonary lesion malignancy is paramount.
The incidence of esophageal cancer has increased faster than that of most cancers. Evidence from other malignant neoplasms suggests that diabetic patients have a worse response to multimodality ...therapy. We hypothesized that diabetic patients with esophageal cancer will have a decreased response to neoadjuvant chemotherapy and radiation therapy compared with nondiabetic patients.
A retrospective study of The Society of Thoracic Surgeons General Thoracic Surgery Database identified all patients who had an esophagectomy after neoadjuvant therapy for esophageal cancer between 2012 and 2019. Patients were compared on the basis of the presence of diabetes. A pathologic complete response (pCR) was defined as ypT0 N0. The χ
and Wilcoxon rank sum tests were used to compare patients' demographic and clinical characteristics between those with and those without diabetes. Multivariable logistic regression was used to evaluate the predictors of response to neoadjuvant therapy.
Of the 9171 patients who met inclusion criteria, 2011 (22%) patients were diabetic and 7160 (78%) patients were nondiabetic. Patients with diabetes were older, more likely to be male, and more likely to have all comorbidities. Univariate analysis revealed that diabetic patients were less likely to have pCR (16% vs 18%; P = .026). Although multivariable analysis showed a trend toward diabetic patients' having lower odds of achieving pCR, diabetes was not independently associated with pCR (odds ratio, 0.89; 95% CI, 0.78-1.01; P = .075).
Diabetic patients may be less likely than nondiabetic patients to achieve pCR after neoadjuvant treatment of esophageal cancer. This suggests the need for further exploration as diabetic patients with esophageal cancer can potentially benefit from different treatment paradigms compared with their nondiabetic counterparts.
Objective
Minimally invasive lung resection (MILR) is underutilized in the United States. Under the Affordable Care Act (ACA), 39 states adopted Medicaid expansion, while 12 did not. Although ...Medicaid expansion has been associated with improved access to cancer care, its effect on utilization of MILR is unclear. We hypothesize that MILR would increase in Medicaid expansion states.
Methods
The National Cancer Database was queried for adult patients from 2010 to 2018 with cT1/2N0M0 non-small cell lung cancer who received surgical resection by wedge, segmentectomy, or lobectomy. Patients were grouped by whether they received care in a state without Medicaid expansion vs expansion in January 2014. The outcome of interest was MILR (defined as video-assisted or robotic-assisted thoracoscopy) relative to open. Multivariable difference in differences (DID) cross-sectional analysis was used to estimate the average treatment effect (ATE) of Medicaid expansion.
Results
There were 41,439 patients who met inclusion criteria: 20,446 (49.3%) in expansion states and 20,993 (50.7%) in non-expansion states. Multivariable DID analysis showed that Medicaid expansion was associated with an increase in Medicaid insurance type with an ATE of 7.4% (95% CI 7.1-7.7%, P = .002). Medicaid expansion was also associated with increased MILR utilization in unadjusted analysis (10,278/20,446 (50.3%) vs 9,953/20,993 (47.4%), p < .001) and in multivariable DID analysis (ATE 0.6%, 95% CI 0.3-0.8%, P = .008).
Conclusions
Although Medicaid expansion was associated with increased utilization of MILR for early stage lung cancer, the treatment effect was modest. This suggests that barriers in access to MILR are larger than simply access to care.
Monitoring for Recurrence After Esophagectomy Chang, Carolyn; Linden, Philip A; Jiang, Boxiang ...
The Annals of thoracic surgery,
07/2022, Letnik:
114, Številka:
1
Journal Article
Recenzirano
Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal ...cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival.
A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy.
During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047).
SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.
Lymphadenectomy is routinely performed during surgical resection of nonsmall cell lung cancer (NSCLC). Lymph node yield and number of nodal stations sampled are important prognostic markers viewed as ...surrogates of surgical quality. The purpose of this study was to identify factors associated with these quality metrics after resection of NSCLC.
We identified NSCLC patients undergoing resection at a single institution from 2010 to 2021. Cases were matched to detailed pathologist reports, which included lymph node yield and number of stations sampled. Demographic and clinical characteristics were analyzed individually using unadjusted linear regression to identify factors associated with lymph node yield and number of stations sampled. Multivariable linear regression analyses were performed to evaluate the same end points, using covariates determined through stepwise-backwards selection.
The study cohort included 836 patients. Multivariable regression demonstrated that male sex, history of cardiothoracic surgery, and individual pathologist were independently associated with lymph node yield. Among 18 pathologists, interpathologist coefficients with respect to lymph node yield varied from −5.61 to 11.25. Multivariable regression demonstrated White race and history of cardiothoracic surgery to be independently associated with number of nodal stations sampled, as well as individual surgeon and pathologist.
Lymph node yield and number of nodal stations sampled after NSCLC resection may vary based on patient demographic and clinical characteristics, as well as institutional factors. These factors should be accounted for when using these metrics as markers of surgical quality and prognosis of NSCLC.
The synthesis and characterization of heptagon‐embedded polycyclic aromatic compounds are essential for understanding the effect of negative curvature on carbon allotropes such as fullerenes and ...graphenes that have applications in functional organic materials. However, owing to the synthetic difficulties in functionalizing and embedding seven‐membered rings, these strain‐challenged structures are relatively unexplored. We report here the synthesis, characterization, and properties of a triarylamine core bridged with ethano chains at the 2,2’‐positions. In doing so, we provide access to the first heterocycle containing three fused heptagon rings with a nitrogen at its core (BATA‐NHAc). X‐ray crystallographic analysis and DFT calculations revealed a remarkably strained structure wherein two of the bridged aryl units approach coplanarity, while the third ring is twisted out of plane at 70°. UV‐vis and emission spectroscopies identify red‐shifted absorption and concentration‐dependent emission profiles, respectively, as a result of the unique conformation and self‐assembly properties of BATA‐NHAc. Furthermore, cyclic voltammetry shows a decrease in the oxidation potential for BATA‐NHAc in comparison to the non‐bridged analog. This study opens new avenues in understanding the structure–property relationships of curved π‐aromatics and the construction of π‐frameworks of increasing complexity.
A strain on the properties: A 7,7,7circulene analog, azatriseptane, has been synthesized, and its highly strained structure confirmed by X‐ray crystallography and computational studies. The distortion of the typical propeller‐like conformation that is observed for triarylamine significantly affects the π‐electronics as well as the inherent self‐assembly properties of these bridged systems.
Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of ...nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC.
In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery.
Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 confidence interval 1.60-2.11; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001).
This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.
A previous meta-analysis (Van der Linden et al., Psychol Bull 143:36–52, 2017) showed that the General Factor of Personality (GFP) overlaps with ability as well as trait emotional intelligence (EI). ...The correlation between trait EI and the GFP was so high (
ρ
=
0
.88) in that meta-analysis that these two may be considered virtually identical constructs. The present study builds on these findings by examining whether the strong phenotypic correlation between the GFP and trait EI has a genetic component. In a sample of monozygotic and dizygotic twins, the heritability estimates for the GFP and trait EI were 53 and 45%, respectively. Moreover, there was a strong genetic correlation of
r
= .90 between the GFP and trait EI. Additional analyses suggested that a substantial proportion of the genetic correlations reflects non-additive genetic effects (e.g., dominance and epistasis). These findings are discussed in light of evolutionary accounts of the GFP.
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