Travel distances to care have increased substantially with centralization of complex cancer procedures at high-volume centers. We hypothesize that longer travel distances are associated with higher ...rates of postoperative readmission and poorer outcomes.
SEER-Medicare patients with bladder, lung, pancreas, or esophagus cancer who were diagnosed in 2001 to 2007 and underwent extirpative surgery were included. Readmission rates and survival were calculated using Kaplan-Meier functions. Multivariable negative binomial models were used to examine factors associated with readmission.
Four thousand nine hundred forty cystectomies, 1,573 esophagectomies, 20,362 lung resections, and 2,844 pancreatectomies were included. Thirty- and 90-day readmission rates ranged from 13% to 29% and 23% to 43%, respectively, based on tumor type. Predictors of readmission were discharge to somewhere other than home, longer length of stay, comorbidities, higher stage at diagnosis, and longer travel distance (P < .001 for each). Patients who lived farther from the index hospital also had increased emergency room visits and were more likely to be readmitted to a hospital other than the index hospital (P < .001). Of readmitted patients, 31.9% were readmitted more than once. Long-term survival was worse and costs of care higher for patients who were readmitted (P < .001 for all).
The burden of readmissions after major cancer surgery is high, resulting in substantially poorer patient outcomes and higher costs. Risk of readmission was most strongly associated with length of stay and discharge destination. Travel distance also has an impact on patterns of readmission. Interventions targeted at higher risk individuals could potentially decrease the population burden of readmissions after major cancer surgery.
The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly ...centralized and that this centralization has resulted in increased travel burden for patients.
Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled.
Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization.
There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.
Advances in Rectal Cancer Surgery Stitzenberg, Karyn B.; Barnes, Emilie
Clinical colorectal cancer,
March 2022, 2022-03-00, 20220301, Letnik:
21, Številka:
1
Journal Article
Recenzirano
Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local ...recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities.
Background
Surgical resection provides the only potentially curative treatment of pancreatic cancer. Neoadjuvant chemotherapy and/or radiation (NAT) is used to downstage patients with borderline ...resectable tumors. The objective of this study was to examine the postoperative morbidity and mortality of NAT after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA).
Methods
Using the American College of Surgeons‐National Surgical Quality Improvement Project Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA from 2014 to 2015. Patients were grouped by receipt of NAT 90 days before PD. Bivariable and multivariable analyses was used to compare postoperative outcomes.
Results
A total of 3748 patients with PDA underwent PD; 926 (24.7%) received NAT. Those in the NAT group had more major vein resections, and longer operating times (all P < 0.001). On pathologic staging, those in the NAT group had smaller tumors (T1, 10.9% vs 5.1%; P < 0.001) and fewer nodes positive (N0, 49% vs 28%; P < 0.001). There were no differences in 30‐day postoperative mortality or overall complications. On multivariable analysis, patients who received NAT had a lower likelihood of pancreatic fistula (OR, 0.67; P < 0.001).
Conclusion
NAT does not increase the overall postoperative morbidity or mortality of PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.
Neoadjuvant chemoradiation for stage II/III rectal cancer results in up to 49% of patients with a clinical complete response. As a result, many have questioned whether surgery can be omitted for this ...group of patients. Currently, there is insufficient evidence for chemoradiation only, or nonoperative management (NOM), to support its adoption. Despite this, anecdotal evidence suggests there is a trend toward increased use of NOM. Our objective was to examine the use of NOM for rectal cancer over time, as well as the patient- and facility-level factors associated with its use.
We included all incident cases of invasive, nonmetastatic rectal adenocarcinoma reported to the National Cancer Database from 1998 to 2010. We performed univariate and multivariate analyses to assess for NOM use over time, as well as associated patient- and facility-level factors.
A total of 146,135 patients met the inclusion criteria: 5,741 had NOM and 140,394 had surgery with or without additional therapy. From 1998 to 2010, NOM doubled, from 2.4% to 5% of all cases annually. Patients who were black (adjusted odds ratio AOR, 1.71; 95% CI, 1.57 to 1.86), uninsured (AOR, 2.35; 95% CI, 2.08 to 2.65) or enrolled in Medicaid (AOR, 2.10; 95% CI, 1.90 to 2.33), or treated at low-volume facilities (AOR, 1.53; 95% CI, 1.42 to 1.64) were more likely to receive NOM than were patients who were white, privately insured, and treated at a high-volume facility, respectively.
NOM demonstrates promise for the treatment of rectal cancer; currently, however, the most appropriate strategy is to pursue this approach with well-informed patients in the context of a clinical trial. We observed evidence of increasing NOM use, with this increase occurring more frequently in black and uninsured/Medicaid patients, raising concern that increased NOM use may actually represent increasing disparities in rectal cancer care rather than innovation. Further studies are needed to assess survival differences by treatment strategy.
Although most general surgeons receive comparable training leading to Board certification, the services they provide in practice may be highly variable. Progressive specialization is the voluntary ...narrowing of scope of practice from the breadth of skills acquired during training; it occurs in response to patient demand, rapid growth of medical knowledge, and personal factors. Progressive specialization is increasingly linked to fellowship training, which generally abruptly narrows a surgeon’s scope of practice. This study examines progressive specialization by evaluating trends in fellowship training among general surgeons.
Because no database exists that tracks trainees from medical school matriculation through entrance into the workforce, data from multiple sources were compiled to assess the impact of progressive specialization. Trends in overall number of trainees, match rates, and proportion of international medical graduates were analyzed.
The proportion of general surgeons pursuing fellowship training has increased from > 55% to > 70% since 1992. The introduction of fellowship opportunities in newer content areas, such as breast surgery and minimally invasive surgery, accounts for some of the increase. Meanwhile, interest in more traditional subspecialties (ie, thoracic and vascular surgery) is declining.
Progressive specialization confounds workforce projections. Available databases provide only an estimate of the extent of progressive specialization. When surgeons complete fellowships, they narrow the spectrum of services provided. Consequently, as the phenomenon of progressive specialization evolves, a larger surgical workforce will be needed to provide the breadth of services encompassed by the primary components of general surgery.
Background
Guidelines recommend extended venous thromboembolism (VTE) prophylaxis for high‐risk populations undergoing major abdominal cancer operations. Few studies have evaluated extended VTE ...prophylaxis in the Medicare population who are at higher risk due to age.
Methods
We performed a retrospective study using a 20% random sample of Medicare claims, 2012–2017. Patients ≥65 years with an abdominal cancer undergoing resection were included. Primary outcome was the proportion of patients receiving new extended VTE prophylaxis prescriptions at discharge. Secondary outcomes included postdischarge VTE and hemorrhagic events.
Results
The study included 72 983 patients with a mean age of 75. Overall, 8.9% of patients received extended VTE prophylaxis. This proportion increased (7.2% in 2012, 10.6% in 2017; p < 0.001). Incidence of postdischarge hemorrhagic events was 1.0% in patients receiving extended VTE prophylaxis and 0.8% in those who did not. The incidence of postdischarge VTE events was 5.2% in patients receiving extended VTE prophylaxis and 2.4% in those who did not.
Conclusion
Adherence to guideline‐recommended extended VTE prophylaxis in high‐risk patients undergoing major abdominal cancer operations is low. The higher rate of VTE in the prophylaxis group may suggest we captured some therapeutic anticoagulation, which would mean the actual rate of thromboprophylaxis is lower than reported herein.
Standard of care treatment for most stage I rectal cancers is total mesorectal excision (TME). Given the morbidity associated with TME, local excision (LE) for early-stage rectal cancer has been ...explored. This study examines practice patterns and overall survival (OS) for early-stage rectal cancer.
All patients in the National Cancer Data Base diagnosed with rectal cancer from 1998 to 2010 were initially included. Use of LE versus proctectomy and use of adjuvant radiation therapy were compared over time. Adjusted Cox proportional hazards models were used to compare OS based on treatment.
LE was used to treat 46.5% of patients with T1 and 16.8% with T2 tumors. Use of LE increased steadily over time (P < .001). LE was most commonly used for women, black patients, very old patients, those without private health insurance, those with well-differentiated tumors, and those with T1 tumors. Proctectomy was associated with higher rates of tumor-free surgical margins compared with LE (95% v 76%; P < .001). Adjuvant radiation therapy use decreased over time independent of surgical procedure or T stage. For T2N0 disease, patients treated with LE alone had significantly poorer adjusted OS than those treated with proctectomy alone or multimodality therapy.
Guideline-concordant adoption of LE for treatment of low-risk stage I rectal cancer is increasing. However, use of LE is also increasing for higher-risk rectal cancers that do not meet guideline criteria for LE. Treatment with LE alone is associated with poorer long-term OS. Additional studies are warranted to understand the factors driving increased use of LE.
Background
The association between procedure volume and clinical outcomes has led many to advocate centralization of cancer procedures at high-volume centers (HVCs). Regional studies show practice ...patterns changing with increasing centralization of esophageal and pancreatic procedures at HVCs but little change for colorectal procedures. We hypothesize that similar trends are occurring nationwide.
Methods
Secondary data analysis was performed by means of the National Inpatient Sample. We examined trends in hospital procedure volume from 1999 to 2007 for all extirpative esophageal, pancreatic, and colorectal cancer procedures. Survey-weighted multivariate logistic regressions were used to examine the likelihood of surgery at a low-volume center (LVC) over time as well as to determine sociodemographic factors associated with surgery at LVCs.
Results
A total of 351,164 cases met the inclusion criteria (6,345 esophagus, 17,658 pancreas, 255,753 colon, 71,408 rectum). The likelihood of surgery at a LVC in 2007 compared to 1999 was as follows: esophagus odds ratio OR 0.42 (95% confidence interval 95% CI, 0.34, 0.53), pancreas OR 0.40 (95% CI, 0.35, 0.46), colon OR 0.88 (95% CI, 0.85, 0.91), rectum OR 0.83 (95% CI, 0.78, 0.89). Admission through an emergency department was associated with a higher likelihood of surgery at a LVC, even after adjusting for clinical and sociodemographic factors. Volume was also associated with race and payer; black patients and the uninsured were particularly likely to remain at LVCs.
Conclusions
Practice patterns have changed substantially to follow national recommendations for centralization of complex cancer surgery. Despite this, disparities remain with regard to access to HVCs.
PDF
