1
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Fromer MW, Mouw TJ, Scoggins CR, Egger ME, Philips P, McMasters KM, Martin RCG. Barriers to resection following neoadjuvant chemotherapy for resectable pancreatic adenocarcinoma: A national and local perspective. J Surg Oncol 2024; 130:284-292. [PMID: 38828742 DOI: 10.1002/jso.27697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/26/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) use for pancreatic ductal adenocarcinoma (PDAC) has increased, but some patients never get resection following NAC. METHODS Data from January 2012 to December 2019 for all clinically resectable patients across two health networks were utilized, as well as data from the ACS NCDB registry. Univariate testing, multivariable logistic regression, and survival analyses were employed to evaluate failure to resection after neo-adjuvant chemotherapy. RESULTS Of the 10 007 registry patients eligible for resection, the resected group was younger (64.6 vs. 69.5 years; p < 0.001) and had a slightly lower mean comorbidity index (0.41 vs. 0.45; p < 0.001) than the nonsurgical group. The nonsurgical group was composed of a higher percentage of Black and Hispanic patients (17.5 vs. 13.1%; p < 0.001). After adjusting for age and comorbidities, the factors associated with decreased probability of resection after NAC were evaluation at a community hospital (OR 2.4), Black or Hispanic race (OR 1.6), areas of increased high school drop-out rates (OR 1.4), and lack of private health insurance (OR 1.3). The median overall survival for nonsurgery was markedly worse than the surgical cohort (10.6 vs. 26.6 months; p < 0.001). The most frequent reasons for a lack of definitive resection were operative upstaging to unresectable (39.6%), patient preference (14.5%), progression on NAC (13.2%), deconditioning or comorbidity severity (12.5%), and nonreferral to a surgeon (8.8%). CONCLUSIONS Racial, economic, and educational disparities have a considerable influence on the successful completion of a neoadjuvant approach for resectable PDAC. A comprehensive closed or highly collaborative/communicative multidisciplinary neoadjuvant program is optimal for treatment success and completion.
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Affiliation(s)
- Marc W Fromer
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Tyler J Mouw
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Charles R Scoggins
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Michael E Egger
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Prejesh Philips
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Kelly M McMasters
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
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Tran A, Zheng R, Johnston F, He J, Burns WR, Shubert C, Lafaro K, Burkhart RA. Sociodemographic variation in the utilization of minimally invasive surgical approaches for pancreatic cancer. HPB (Oxford) 2024:S1365-182X(24)02208-1. [PMID: 39033045 DOI: 10.1016/j.hpb.2024.07.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/11/2024] [Accepted: 07/05/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Minimally invasive pancreatic surgery (MIPS), when selectively utilized, has been shown to hasten recovery with outcomes comparable to open approaches, but access may not be equitable. This study explored variation in utilization of MIPS for pancreatic cancer. METHODS The National Cancer Database was queried to identify patients diagnosed with a primary pancreatic neoplasm from 2010 to 2020. Study participants had diagnoses of clinical or pathologic stage 1-3 disease and received curative-intent surgery. Multivariable analyses assessed the association between surgical approach and patient and disease factors. RESULTS Inclusion criteria identified 73,137 patients: 51,408 underwent open surgery and 21,729 received MIPS. In our multivariable analysis, Black race was associated with reduced odds of MIPS (AOR 0.88; p = 0.02), while older age (AOR 1.17; p = 0.01), later year of diagnosis (AOR 1.57; p < 0.001), and private insurance coverage (AOR 1.30; p = 0.05) were associated with increased odds. When patients with adenocarcinoma were analyzed in isolation, disparities in MIPS utilization persisted even when controlling for disease stage. CONCLUSION Sociodemographic factors like age, race, and insurance coverage appear to vary in the utilization of MIPS technologies for the treatment of pancreatic malignancy. Addressing variation with robust mixed methods approaches in the future is proposed to incorporate prospective interventions with highly annotated outcomes for additional study.
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Affiliation(s)
- Andy Tran
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Zheng
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Fabian Johnston
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Christopher Shubert
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Kelly Lafaro
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA.
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Aminpour N, Phan V, Wang H, McDermott J, Valentin M, Mishra A, DeLia D, Noel M, Al-Refaie W. Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers. J Gastrointest Surg 2024:S1091-255X(24)00480-3. [PMID: 38910084 DOI: 10.1016/j.gassur.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND For patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute-designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC. METHODS Maryland's All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC. RESULTS Only 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation. CONCLUSION Patients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.
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Affiliation(s)
- Nathan Aminpour
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Vy Phan
- Georgetown University School of Medicine, Washington, DC, United States
| | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, MD, United States
| | - James McDermott
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Michelle Valentin
- Georgetown University School of Medicine, Washington, DC, United States
| | - Ankit Mishra
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Derek DeLia
- Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ, United States
| | - Marcus Noel
- Department of Medicine, MedStar-Georgetown University Hospital, Washington, DC, United States
| | - Waddah Al-Refaie
- Department of Surgery, Creighton University School of Medicine and CHI Health, Omaha, NE, United States.
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Eaglehouse YL, Darmon S, Gage MM, Shriver CD, Zhu K. Characteristics Associated With Survival in Surgically Nonresected Pancreatic Adenocarcinoma in the Military Health System. Am J Clin Oncol 2024; 47:64-70. [PMID: 37851358 PMCID: PMC10805355 DOI: 10.1097/coc.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVES Pancreatic cancer is often diagnosed at advanced stages with high-case fatality. Many tumors are not surgically resectable. We aimed to identify features associated with survival in patients with surgically nonresected pancreatic cancer in the Military Health System. METHODS We used the Military Cancer Epidemiology database to identify the Department of Defense beneficiaries aged 18 and older diagnosed with a primary pancreatic adenocarcinoma between January 1998 and December 2014 who did not receive oncologic surgery as treatment. We used Cox Proportional Hazard regression with stepwise procedures to select the sociodemographic and clinical characteristics related to 2-year overall survival, expressed as adjusted hazard ratios (aHR) and 95% CIs. RESULTS Among 1148 patients with surgically nonresected pancreatic cancer, sex, race-ethnicity, marital status, and socioeconomic indicators were not selected in association with survival. A higher comorbidity count (aHR 1.30, 95% CI: 1.06-1.59 for 5 vs. 0), jaundice at diagnosis (aHR 1.57, 95% CI: 1.33-1.85 vs. no), tumor grade G3 or G4 (aHR 1.32, 95% CI: 1.05-1.67 vs. G1/G2), tumor location in pancreas tail (aHR 1.49, 95% CI: 1.22-1.83 vs. head) or body (aHR 1.30, 95% CI: 1.04-1.62 vs. head), and metastases were associated with survival. Patients receiving chemotherapy (aHR 0.66, 95% CI: 0.57-0.76) had better survival compared with no treatment. CONCLUSIONS In a comprehensive health system, sociodemographic characteristics were not related to survival in surgically nonresected pancreatic cancer. This implicates access to care in reducing survival disparities in advanced pancreatic cancer and emphasizes the importance of treating patients based on clinical features.
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Affiliation(s)
- Yvonne L. Eaglehouse
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
| | - Sarah Darmon
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
| | - Michele M. Gage
- Departments of Surgery
- Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Craig D. Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- Departments of Surgery
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
- Preventive Medicine & Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences
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5
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Khalaf N, Xu A, Nguyen Wenker T, Kramer JR, Liu Y, Singh H, El-Serag HB, Kanwal F. The Impact of Race on Pancreatic Cancer Treatment and Survival in the Nationwide Veterans Affairs Healthcare System. Pancreas 2024; 53:e27-e33. [PMID: 37967826 PMCID: PMC10883640 DOI: 10.1097/mpa.0000000000002272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Among patients with pancreatic cancer, studies show racial disparities at multiple steps of the cancer care pathway. Access to healthcare is a frequently cited cause of these disparities. It remains unclear if racial disparities exist in an integrated, equal access public system such as the Veterans Affairs healthcare system. METHODS We identified all patients diagnosed with pancreatic adenocarcinoma in the national Veterans Affairs Central Cancer Registry from January 2010 to December 2018. We examined the independent association between race and 3 endpoints: stage at diagnosis, receipt of treatment, and survival while adjusting for sociodemographic factors and medical comorbidities. RESULTS We identified 8529 patients with pancreatic adenocarcinoma, of whom 79.5% were White and 20.5% were Black. Black patients were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. Black patients had 13% higher mortality risk compared with White patients after adjusting for sociodemographic characteristics and medical comorbidities. This difference in mortality was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment. CONCLUSIONS Equal access to healthcare might have reduced but failed to eliminate disparities. Dedicated efforts are needed to understand reasons underlying these disparities in an attempt to close these persistent gaps.
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Affiliation(s)
| | - Ann Xu
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | - Hashem B El-Serag
- From the Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Pothuri V, Zárate Rodriguez JG, Kasting C, Leigh N, Hawkins WG, Sanford DE, Fields RC. Area deprivation and rurality impact overall survival and adjuvant therapy administration in patients with pancreatic ductal adenocarcinoma (PDAC). HPB (Oxford) 2023; 25:1545-1554. [PMID: 37626007 DOI: 10.1016/j.hpb.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND The impact of neighborhood deprivation on outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) is not well-described and represents an area to improve disparities. METHODS We retrospectively queried our prospectively maintained database of patients with PDAC (2014-2022). Patients were grouped by Area Deprivation Index (ADI) and rural-urban commuting area (RUCA) codes. Cox proportional hazards models and logistic regressions were used to investigate effect on overall survival (OS) and adjuvant therapy administration. RESULTS 536 patients were included. High ADI patients (more disadvantaged, n = 184) were more likely to identify as non-Hispanic Black (17.9% vs. 4.8%, p < 0.01) and were more likely to be from rural areas (49.5% vs. 18.5%, p < 0.01). High ADI was independently associated with decreased OS (HR (95% CI): 1.31 (1.01-1.69), p = 0.04). Urban high ADI patients were 3.5 times more likely to receive adjuvant therapy than rural high ADI patients (OR [95% CI]: 3.48 [1.26-9.61], p = 0.02). CONCLUSION Patients from the most disadvantaged neighborhoods have decreased OS. Access to adjuvant therapy likely contributes to this disparity in rural areas. Investigation into sources of this OS disparity and identification of barriers to adjuvant therapy will be crucial to improve outcomes in underserved patients with PDAC.
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Affiliation(s)
- Vikram Pothuri
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | | | - Christina Kasting
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Natasha Leigh
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Dominic E Sanford
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St. Louis, MO 63110, USA.
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7
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Bohan RP, Riner AN, Herremans KM, Gao H, Szymkiewicz DD, Nassour I, Forsmark CE, Hughes SJ. Impact of Biopsy Attempts, Race, and Access on Time to Initiation of Treatment for Pancreatic Cancer. J Gastrointest Surg 2023; 27:2474-2483. [PMID: 37740146 PMCID: PMC11220574 DOI: 10.1007/s11605-022-05531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/01/2022] [Indexed: 09/24/2023]
Abstract
BACKGROUND Biopsy of suspected pancreatic cancer (PDAC) in surgical candidates is informative however not always necessary. Biopsies impact treatment options as histological diagnosis are presently required for neo-adjuvant therapy, but not surgical resection. We explored the impact of pursuing tissue diagnosis by endoscopic ultrasound (EUS) biopsy on time to treatment in patients with resectable and borderline resectable PDAC. METHODS A retrospective review of surgical patients with ultimately proven PDAC was performed (2011-2021). Milestone dates (cancer suspected, biopsy(ies), surgical or neo-adjuvant treatment) were collected. Mann-Whitney-Wilcoxon tests, Pearson's chi-squared tests, Fisher's exact tests, linear regressions, and Cox proportional hazard models were used for data analysis. RESULTS Among 131 resectable and 58 borderline resectable patients, the borderline resectable group underwent more biopsies (1.2 vs 0.7, p < 0.0001), were more likely to undergo biopsy at tertiary care centers (67.2% vs 30.5%, p < 0.0001), and trended toward longer time to treatment (49 vs 44 days, p = 0.070). Significant increases in days to treatment were seen in patients with Black race (29 days, p = 0.0002) and Medicare insurance (22 days, p = 0.038) and no biopsies at a tertiary care center (10 days, p = 0.039). After adjusting for covariates, additional biopsies significantly delayed treatment (1 biopsy: 21 days, p = 0.0001; 2 biopsies: 44 days, p < 0.0001; 3 biopsies: 68 days, p < 0.0001). CONCLUSIONS EUS biopsy significantly impacts time between suspicion and treatment of PDAC. This may be exacerbated by clinical practices increasingly favoring neo-adjuvant therapy that necessitates biopsy-proven disease. Time to treatment may also be impacted by access to tertiary centers and racial disparities.
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Affiliation(s)
- Riley P Bohan
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA
| | - Andrea N Riner
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA
| | - Kelly M Herremans
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA
| | - Hanzhi Gao
- Department of Biostatistics, University of Florida College of Public Health and Health Professions & College of Medicine, Gainesville, FL, USA
| | - Dominique D Szymkiewicz
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA
| | - Ibrahim Nassour
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA
| | - Chris E Forsmark
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL, 32610, USA.
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Brooks GA, Tomaino MR, Ramkumar N, Wang Q, Kapadia NS, O’Malley AJ, Wong SL, Loehrer AP, Tosteson ANA. Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival. J Natl Cancer Inst 2023; 115:1171-1178. [PMID: 37233399 PMCID: PMC10560598 DOI: 10.1093/jnci/djad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/07/2023] [Accepted: 05/24/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer. METHODS We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression. RESULTS We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26). CONCLUSIONS Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.
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Affiliation(s)
- Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Marisa R Tomaino
- Center for Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | | | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - A James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, NH, USA
| | - Sandra L Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Koerner AS, Thomas AS, Chabot JA, Kluger MD, Sugahara KN, Schrope BA. Associations Between Patient Characteristics and Whipple Procedure Outcomes Before and After Implementation of an Enhanced Recovery After Surgery Protocol. J Gastrointest Surg 2023; 27:1855-1866. [PMID: 37165160 DOI: 10.1007/s11605-023-05693-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/22/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal perioperative care bundle aimed to improve pancreatic surgery outcomes. This work evaluates whether a Whipple ERAS protocol can be safely implemented at a quaternary care center. We also aimed to assess if race and socioeconomic factors are associated with disparities in outcomes in patients undergoing a Whipple ERAS protocol. METHODS A retrospective review identified demographic and clinical data for 458 patients undergoing pancreaticoduodenectomies (PDs) at a single institution from October 2017 to May 2022. Patients were split into two cohorts: pre-ERAS (treated before implementation) and ERAS (treated after). Outcomes included length of stay (LOS), 30-day readmission and mortality rates, and major complications. RESULTS There were 213 pre-ERAS PD patients, and 245 were managed with an ERAS protocol. More ERAS patients had a BMI > 30 (15.5% vs. 8.0%; p = 0.01) and received neoadjuvant chemotherapy (15.5% vs. 4.2%; p < 0.001). ERAS patients had a higher rate of major complications (57.6% vs. 37.6%; p < 0.001). Medicaid patients did not have more complications or longer LOS compared to non-Medicaid patients. On univariate analysis, race/ethnicity or gender was not significantly associated with a higher rate of major complications or prolonged LOS. CONCLUSION A Whipple ERAS protocol did not significantly change LOS, readmissions, or 30-day mortality. Rate of overall complications did not significantly change after implementation, but rate of major complications increased. These outcomes were not significantly impacted by race/ethnicity, gender, tumor staging, or insurance status.
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Affiliation(s)
- Anna S Koerner
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
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10
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Poulson MR, Papageorge MV, LaRaja AS, Kenzik KM, Sachs TE. Socioeconomic Mediation of Racial Segregation in Pancreatic Cancer Treatment and Outcome Disparities. Ann Surg 2023; 278:246-252. [PMID: 35837973 DOI: 10.1097/sla.0000000000005543] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand the mediating effect of socioeconomic factors on the association between residential segregation and racial disparities in pancreatic cancer (PC). BACKGROUND Black patients with PC present at a later stage and have worse mortality than White patients. These disparities have been explained by the level of residential segregation. METHODS Data were obtained from Surveillance, Epidemiology, and End-Results (SEER) and included all Black and White patients who were diagnosed with PC between 2005 and 2015. The primary exposure variable was the Index of Dissimilarity, a validated measure of segregation. County-level socioeconomic variables from the US Census were assessed as mediators. The primary outcomes were advanced stage at diagnosis, surgical resection for localized disease, and overall mortality. Generalized structural equation modeling was used to assess the mediation of each of the socioeconomic variables. RESULTS Black patients in the highest levels of segregation saw a 12% increased risk [relative risk=1.12; 95% confidence interval (CI): 1.08, 1.15] of presenting at an advanced stage, 11% decreased likelihood of undergoing surgery (relative risk=0.89; 95% CI: 0.83, 0.94), and 8% increased hazards of death (hazard ratio=1.08; 95% CI: 1.03, 1.14) compared with White patients in the lowest levels. The Black share of the population, insurance status, and income inequality mediated 58% of the total effect on the advanced stage. Poverty and Black income immobility mediated 51% of the total effect on surgical resection. Poverty and Black income immobility mediated 50% of the total effect on overall survival. CONCLUSIONS These socioeconomic factors serve as intervention points for legislators to address the social determinants inherent to the structural racism that mediate poor outcomes for Black patients.
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Affiliation(s)
- Michael R Poulson
- Department of Surgery, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
| | | | | | - Kelly M Kenzik
- Department of Surgery, Boston Medical Center, Boston, MA
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
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11
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Maduekwe UN, Stephenson BJK, Yeh JJ, Troester MA, Sanoff HK. Identifying patient profiles of disparate care in resectable pancreas cancer using latent class analysis. J Surg Oncol 2023. [PMID: 37095707 DOI: 10.1002/jso.27275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/02/2023] [Accepted: 03/26/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVES: Disparities in pancreas cancer care are multifactorial, but factors are often examined in isolation. Research that integrates these factors in a single conceptual framework is lacking. We use latent class analysis (LCA) to evaluate the association between intersectionality and patterns of care and survival in patients with resectable pancreas cancer. METHODS LCA was used to identify demographic profiles in resectable pancreas cancer (n = 140 344) diagnosed from 2004 to 2019 in the National Cancer Database (NCDB). LCA-derived patient profiles were used to identify differences in receipt of minimum expected treatment (definitive surgery), optimal treatment (definitive surgery and chemotherapy), time to treatment, and overall survival. RESULTS Minimum expected treatment (hazard ratio [HR] 0.69, 95% confidence interval [CI]: 0.65, 0.75) and optimal treatment (HR 0.58, 95% CI: 0.55, 0.62) were associated with improved overall survival. Seven latent classes were identified based on age, race/ethnicity, and socioeconomic status (SES) attributes (zip code-linked education and income, insurance, geography). Compared to the referent group (≥65 years + White + med/high SES), the ≥65 years + Black profile had the longest time-to-treatment (24 days vs. 28 days) and lowest odds of receiving minimum (odds ratio [OR] 0.67, 95% CI: 0.64, 0.71) or optimal treatment (OR 0.76, 95% CI: 0.72, 0.81). The Hispanic patient profile had the lowest median overall survival-55.3 months versus 67.5 months. CONCLUSIONS Accounting for intersectionality in the NCDB resectable pancreatic cancer patient cohort identifies subgroups at higher risk for inequities in care. LCA demonstrates that older Black patients and Hispanic patients are at particular risk for being underserved and should be prioritiz for directed interventions.
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Affiliation(s)
- Ugwuji N Maduekwe
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Epidemiology, Gillings School of Public Health, Chapel Hill, North Carolina, USA
| | - Briana J K Stephenson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jen Jen Yeh
- Department of Surgery, Division of Surgical Oncology & Endocrine Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | - Melissa A Troester
- Department of Epidemiology, Gillings School of Public Health, Chapel Hill, North Carolina, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | - Hanna K Sanoff
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
- Department of Medicine, Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Twohig PA, Butt MU, Gardner TB, Chahal P, Sandhu DS. Racial and Gender Disparities Among Obese Patients With Pancreatic Cancer: A Trend Analysis in the United States. J Clin Gastroenterol 2023; 57:410-416. [PMID: 35324480 DOI: 10.1097/mcg.0000000000001688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/04/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) is the third leading cause of cancer death. Obesity can increase the risk of PC by up to 50%. Studies have shown racial and gender disparities in PC, however, there is a paucity of such information in obese PC patients. AIM The aim of this study was to: (1) evaluate the incidence and prevalence of obesity among PC patients in the United States over the last 15 years, and (2) determine if variation exists in the demographic of obese PC patients over the last 15 years. It is hoped that this information could be used to assist in primary prevention and early detection of PC. METHODS A population-based retrospective analysis in IBM Explorys, a pooled, national, deidentified database of 63 million patients from 300 hospitals in the United States. Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing was performed to analyze trends in obesity among PC. Subgroup analysis for gender, age, race, and mortality rate were assessed. RESULTS The percentage of obese patients with PC increased over the 15-year period (2.5% to 8.5%, P <0.0001). Rates of obesity among PC patients increased among females ( P =0.0004), individuals under age 65 years ( P =0.0002), and all races, but especially for African Americans ( P =0.0007) and those in minority groups. CONCLUSION Awareness of disparities in PC and applying targeted care to those at increased risk are essential to improve future outcomes, including increased health care access and recruitment in research studies for minority groups.
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Affiliation(s)
- Patrick A Twohig
- Department of Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE
- Departments of Internal Medicine
| | - Muhammad U Butt
- Department of Cardiac Electrophysiology, New York University Langone Hospital, New York, NY
| | - Timothy B Gardner
- Department of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Dalbir S Sandhu
- Gastroenterology & Hepatology, MetroHealth Medical Center, Case Western Reserve University
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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13
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Fang HA, Irfan A, Vickers SM, Gbolahan O, Williams GR, Outlaw D, Wang TNT, Dudeja V, Rose JB, Reddy S. Are Lymph Node Metastases Associated With Survival in Black Patients With Pancreatic Cancer? J Surg Res 2023; 284:143-150. [PMID: 36571869 DOI: 10.1016/j.jss.2022.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/12/2022] [Accepted: 11/16/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Despite aggressive surgical care and systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis. Recent studies show that racial disparities in outcome also exist. We sought to investigate the association lymph node (LN) metastases had with survival between Black and White patients with PDAC after resection. METHODS Retrospective analysis of 226 PDAC patients who underwent resection at a single institution from 2010 to 2018 was performed with attention to LN metastasis and patient race. The number of patients who received chemotherapy was also evaluated. RESULTS One Hundred Seventy Five (77.4%) PDAC patients were White and 51 (22.6%) were Black. 130 (59.3%) patients had LN metastasis (LN+). LN+ and LN- groups were similar in race (P = 0.93), sex (P = 0.10) and age at the time of diagnosis (P = 0.45). Patients with LN + disease were more likely to present with larger tumors (3.4 versus 2.8 cm, P = 0.02) and higher T status (P = 0.001). White and Black patients had similar rates of LN metastasis (59% versus 58.8%, P = 1.0). The median survival for LN- Black and White patients were similar (43.2 versus 30.2 mo, P = 0.82). LN + Black patients trended towards receiving more systemic therapy than White LN + patients (55% versus 42%, P = 0.10). The median survival for LN + Black patients was significantly less than LN + White patients (17.5 versus 24.6 mo, P = 0.04). CONCLUSIONS Black LN + PDAC patients have an inferior survival rate after resection when compared to their White counterparts. Our disparity in outcome cannot be solely explained by a difference in systemic treatment. Further investigation is warranted to determine racial differences in tumor biology or response to chemotherapy.
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Affiliation(s)
- Hua Amanda Fang
- School of Medicine, University of Alabama in Birmingham, Birmingham, Alabama; Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama
| | - Ahmer Irfan
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama
| | - Selwyn M Vickers
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama
| | - Olumide Gbolahan
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama; Department of Hematology and Oncology, University of Alabama in Birmingham, Birmingham, Alabama
| | - Grant R Williams
- Department of Hematology and Oncology, University of Alabama in Birmingham, Birmingham, Alabama
| | - Darryl Outlaw
- Department of Hematology and Oncology, University of Alabama in Birmingham, Birmingham, Alabama
| | | | - Vikas Dudeja
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama
| | - J Bart Rose
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama
| | - Sushanth Reddy
- Department of Surgery, Birmingham, University of Alabama in Birmingham, Alabama.
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14
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Paiella S, Azzolina D, Gregori D, Malleo G, Golan T, Simeone DM, Davis MB, Vacca PG, Crovetto A, Bassi C, Salvia R, Biankin AV, Casolino R. A systematic review and meta-analysis of germline BRCA mutations in pancreatic cancer patients identifies global and racial disparities in access to genetic testing. ESMO Open 2023; 8:100881. [PMID: 36822114 PMCID: PMC10163165 DOI: 10.1016/j.esmoop.2023.100881] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Germline BRCA1 and BRCA2 mutations (gBRCAm) can inform pancreatic cancer (PC) risk and treatment but most of the available information is derived from white patients. The ethnic and geographic variability of gBRCAm prevalence and of germline BRCA (gBRCA) testing uptake in PC globally is largely unknown. MATERIALS AND METHODS We carried out a systematic review and prevalence meta-analysis of gBRCA testing and gBRCAm prevalence in PC patients stratified by ethnicity. The main outcome was the distribution of gBRCA testing uptake across diverse populations worldwide. Secondary outcomes included: geographic distribution of gBRCA testing uptake, temporal analysis of gBRCA testing uptake in ethnic groups, and pooled proportion of gBRCAm stratified by ethnicity. The study is listed under PROSPERO registration number #CRD42022311769. RESULTS A total of 51 studies with 16 621 patients were included. Twelve of the studies (23.5%) enrolled white patients only, 10 Asians only (19.6%), and 29 (56.9%) included mixed populations. The pooled prevalence of white, Asian, African American, and Hispanic patients tested per study was 88.7%, 34.8%, 3.6%, and 5.2%, respectively. The majority of included studies were from high-income countries (HICs) (64; 91.2%). Temporal analysis showed a significant increase only in white and Asians patients tested from 2000 to present (P < 0.001). The pooled prevalence of gBRCAm was: 3.3% in white, 1.7% in Asian, and negligible (<0.3%) in African American and Hispanic patients. CONCLUSIONS Data on gBRCA testing and gBRCAm in PC derive mostly from white patients and from HICs. This limits the interpretation of gBRCAm for treating PC across diverse populations and implies substantial global and racial disparities in access to BRCA testing in PC.
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Affiliation(s)
- S Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/Totuccio83
| | - D Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara
| | - D Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova, Italy. https://twitter.com/gregoriDario
| | - G Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/gimalleo
| | - T Golan
- Oncology Institute, Sheba Medical Center at Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - D M Simeone
- Department of Surgery, New York University, New York; Perlmutter Cancer Center, New York University, New York. https://twitter.com/MadameSurgeon
| | - M B Davis
- Department of Surgery and Surgical Oncology, Weill Cornell University, New York; Englander Institute of Precision Medicine, Weill Cornell University, New York, USA. https://twitter.com/MeliD32
| | - P G Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/pvhdfm
| | - A Crovetto
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/crovetto_a
| | - C Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona
| | - R Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/SalviaRobi
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK; Faculty of Medicine, South Western Sydney Clinical School, University of NSW, Liverpool, Australia.
| | - R Casolino
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow.
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15
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Racial disparities in pancreatic cancer clinical trials: Defining the problem and identifying solutions. Adv Cancer Res 2023. [DOI: 10.1016/bs.acr.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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16
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Herremans KM, Riner AN, Charles AM, Balch JA, Vudatha V, Freudenberger DC, Nassour I, Hughes SJ, Trevino JG, Loftus TJ. From bench to bedside: Pursuing equity in precision medicine approaches to pancreatic cancer care. Front Oncol 2022; 12:1086779. [PMID: 36568255 PMCID: PMC9779942 DOI: 10.3389/fonc.2022.1086779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Kelly M. Herremans
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Andrea N. Riner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Angel M. Charles
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jeremy A. Balch
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Vignesh Vudatha
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Devon C. Freudenberger
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Ibrahim Nassour
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Steven J. Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jose G. Trevino
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Tyler J. Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States,*Correspondence: Tyler J. Loftus,
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17
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Alwatari Y, Mosquera CM, Khoraki J, Rustom S, Wall N, Sevdalis AE, Stover W, Trevino JG, Kaplan B. The impact of race/ethnicity on pancreaticoduodenectomy outcomes for pancreatic cancer. J Surg Oncol 2022; 127:99-108. [PMID: 36177773 PMCID: PMC10092121 DOI: 10.1002/jso.27113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/20/2022] [Accepted: 09/19/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the impact of race/ethnicity on surgical outcomes following pancreaticoduodenectomy for pancreatic cancer. METHODS A retrospective review of patients undergoing pancreaticoduodenectomy for adenocarcinoma in the National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2019. Patient and tumor characteristics and 30-day postoperative outcomes were compared. Multivariable logistic and linear regression models were conducted to investigate the relationship between race/ethnicity and surgical outcomes. RESULTS Six thousand five hundred and sixty-two patients were included (84.5% White, 7.9% Black, 3% Hispanic, 4.6% Asian). Larger proportions of Blacks had preoperative American Society of Anesthesiologists class 3 or 4. There were no significant differences in tumor characteristics or operative techniques. A smaller proportion of Asians and Hispanics received neoadjuvant chemotherapy and/or radiation than Blacks and Whites. Relative to White, the Black race was independently associated with postoperative sepsis and reoperation. Both Black and Hispanic race/ethnicity were associated with prolonged intubation and delayed gastric emptying, and minorities races/ethnicities were associated with longer length of hospital stay. Relative to White, Hispanic, and Asian race/ethnicity were independently associated with a lower likelihood of neoadjuvant therapy (NAT) receipt. CONCLUSION In ACS-NSQIP participating hospitals, non-White race/ethnicity was independently associated with adverse outcomes after pancreatic cancer resection. A possible disparity in NAT receipt may exist in Asian and Hispanic patients undergoing surgical resection.
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Affiliation(s)
- Yahya Alwatari
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Jad Khoraki
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Salem Rustom
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Natalie Wall
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Weston Stover
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jose G Trevino
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Brian Kaplan
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
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18
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Jeong SH, Lee HJ, Yun C, Yun I, Jung YH, Kim SY, Lee HS, Jang SI. Healthcare vulnerability disparities in pancreatic cancer treatment and mortality using the Korean National Sample Cohort: a retrospective cohort study. BMC Cancer 2022; 22:925. [PMID: 36030217 PMCID: PMC9419365 DOI: 10.1186/s12885-022-10027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background The gap in treatment and health outcomes after diagnosis of pancreatic cancer is a major public health concern. We aimed to investigate the differences in the health outcomes and treatment of pancreatic cancer patients in healthcare vulnerable and non-vulnerable areas. Methods This retrospective cohort study evaluated data from the Korea National Health Insurance Corporation-National Sample Cohort from 2002 to 2019. The position value for relative comparison index was used to define healthcare vulnerable areas. Cox proportional hazard regression was used to estimate the risk of mortality in pancreatic cancer patients according to healthcare vulnerable areas, and multiple logistic regression was used to estimate the difference in treatment. Results Among 1,975 patients, 279 (14.1%) and 1,696 (85.9%) lived in the healthcare vulnerable and non-vulnerable areas, respectively. Compared with the non-vulnerable area, pancreatic cancer patients in the vulnerable area had a higher risk of death at 3 months (hazard ratio [HR]: 1.33, 95% confidence interval [CI] = 1.06–1.67) and 6 months (HR: 1.23, 95% CI = 1.03–1.48). In addition, patients with pancreatic cancer in the vulnerable area were less likely to receive treatment than patients in the non-vulnerable area (odds ratio [OR]: 0.70, 95% CI = 0.52–0.94). This trend was further emphasized for chemotherapy (OR: 0.68, 95% CI = 0.48–0.95). Conclusion Patients with pancreatic cancer belonging to medically disadvantaged areas receive less treatment and have a higher risk of death. This may be a result of the late diagnosis of pancreatic cancer among these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10027-2.
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Affiliation(s)
- Sung Hoon Jeong
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Hyeon Ji Lee
- Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Choa Yun
- Department of Biostatistics & Computing, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Il Yun
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Yun Hwa Jung
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Soo Young Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Republic of Korea. .,Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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19
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Thomas AS, Sharma RK, Kwon W, Sugahara KN, Chabot JA, Schrope BA, Kluger MD. Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State. J Gastrointest Surg 2022; 26:1647-1662. [PMID: 35501551 DOI: 10.1007/s11605-022-05320-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE We evaluated how race and socioeconomic factors impact access to high-volume surgical centers, treatment initiation, and postoperative care for pancreatic cancer in a state with robust safety net insurance coverage and healthcare infrastructure. METHODS The New York Statewide Planning and Research Cooperative System was analyzed. Patients with pancreatic cancer resected from 2007 to 2017 were identified by ICD and CPT codes. Primary outcomes included surgery at low-volume facilities (< 20 pancreatectomies/year), time to therapy initiation, and time to postoperative surveillance imaging (within 60-180 days after surgery). RESULTS In total, 3312 patients underwent pancreatectomy across 124 facilities. Median age was 67 years (IQR 59, 75) and 55% of patients were male. Most (72.7%) had surgery at high-volume centers. On multivariable analysis, odds ratios for surgery at low-volume centers were increased for Black race (2.21 (95% CI 1.69-2.88)), Asian race (1.64 (95% CI 1.09-2.43)), Hispanic ethnicity (1.68 (95% CI 1.24-2.28)), Medicaid insurance (2.52 (95% CI 1.79-3.56)), no insurance (2.24 (95% CI 1.38-3.61)), lowest income quartile (3.31 (95% CI 2.14-5.32)), and rural zip code (2.49 (95% CI 1.69-3.65)). Patients treated at low-volume centers waited longer to initiate treatment (hazard ratio (HR) 0.91 (95% CI 0.81-1.01)). Black patients underwent the least surveillance imaging (50.4%; p < 0.0001), while Asian (HR 2.04, 95% CI 1.40-2.98)) and Hispanic patients (HR 1.36 (95% CI 1.00-1.84)) were more likely to have surveillance imaging. CONCLUSIONS Race independently affected access to high-volume facilities and surveillance imaging. When considered in light of other accumulating evidence, future efforts might investigate the perceptions and logistical considerations noted by providers and patients alike to identify the etiology of these disparities and then institute corrective measures.
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Affiliation(s)
- Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA.
| | - Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
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20
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Dahiya DS, Inamdar S, Perisetti A, Kichloo A, Singh A, Solanki S, Solanki D, Al-Haddad M. Decreasing length of stay and inpatient mortality associated with pancreatic cancer hospitalizations: A United States national survey from 2008 to 2017. Pancreatology 2022; 22:590-597. [PMID: 35469754 DOI: 10.1016/j.pan.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/30/2022] [Accepted: 04/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic cancer is the third leading cause of cancer death in the United States (US). However, there is paucity of data on pancreatic cancer hospitalizations in the US. METHODS We analyzed the National Inpatient Sample (NIS) to identify all hospitalizations of pancreatic cancer from 2008 to 2017. Hospitalization characteristics, adverse outcomes, and the disease burden on the US healthcare system was highlighted and further analyzed with respect to the US population. P-values ≤0.05 were statistically significant. RESULTS We noted an increase in the total number of pancreatic cancer hospitalizations from 37,123 in 2008 to 37,635 in 2017 (p < 0.0001), but a decline was noted for per million US population from 122 in 2008 to 116 in 2017. The 65-79 age group had the highest hospitalizations with an increasing trend from 41.6% in 2008 to 45.9% in 2017 (p < 0.0001). In 2008, a slight female predominance was noted (51.9 vs 48.1%, p < 0.0001); however, in 2017, a slight male predominance was observed (50.9 vs 49.1%, p < 0.0001). Whites made up a majority of the study population. Furthermore, emergent/urgent hospitalizations (50.7 vs 49.3%, p < 0.0001) were slightly more frequent than elective hospitalizations in 2017. The mean length of stay (LOS) decreased from 8.4 days in 2008 to 7 days in 2017 (p < 0.0001) and the all-cause inpatient mortality decreased from 10.1% in 2008 to 7.6% in 2017 (p < 0.0001). CONCLUSION Although the total number of pancreatic cancer hospitalizations increased, there was a decline for per million US population. Additionally, mean LOS and inpatient mortality decreased between 2008 and 2017.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA.
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA.
| | - Amandeep Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Shantanu Solanki
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA.
| | | | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
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21
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Del Valle JP, Fillmore NR, Molina G, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3194-3202. [PMID: 35006509 DOI: 10.1245/s10434-021-11250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - George Molina
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Fairweather
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiping Wang
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanley W Ashley
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Whang
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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22
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Fonseca AL, Khan H, Mehari KR, Cherla D, Heslin MJ, Johnston FM. Disparities in Access to Oncologic Care in Pancreatic Cancer: A Systematic Review. Ann Surg Oncol 2022; 29:3232-3250. [PMID: 35067789 DOI: 10.1245/s10434-021-11258-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Pancreatic cancer care is complex, and multiple disparities in receipt of therapies have been documented. The authors aimed to conduct a systematic review of the literature to critically assess and summarize disparities in access to oncologic therapies for pancreatic cancer. METHODS A search of PubMed, Scopus, Web of Science, and Cochrane databases were performed for studies reporting disparities in access to oncologic care for pancreatic cancer. Primary research articles published in the United States from 2000 to 2020 were included. Data were independently extracted, and risk of bias was assessed using the modified Newcastle-Ottawa scale. RESULTS The inclusion criteria were met by 47 studies. All the studies used retrospective data, with 70 % involving national database studies, 41 assessing the impact of race/ethnicity, 22 assessing the impact of socioeconomic status, 18 assessing the impact of insurance status, 23 assessing the impact of gender, 26 assessing the impact of age, and 3 assessing the impact of location on the delivery of cancer-directed therapies. Race, socioeconomic status, insurance status, gender, and age- based disparities in receipt of surgical resection, treatment at high-volume facilities and multimodal therapy for resectable pancreatic cancer, receipt of systemic chemotherapy for metastatic cancer, and receipt of expected standard-of-care treatment are reported. CONCLUSION Significant sociodemographic disparities in access to equitable oncologic care exist along the continuum of pancreatic cancer care. Multiple patient, provider, and systemic factors contribute to these disparities. The ongoing study of these disparities is important to elucidate processes that may be targeted to improve access to equitable oncologic care for patients with pancreatic cancer.
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Affiliation(s)
| | - Hamza Khan
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista R Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Deepa Cherla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Kills First CC, Sutton TL, Shannon J, Brody JR, Sheppard BC. Disparities in pancreatic cancer care and research in Native Americans: Righting a history of wrongs. Cancer 2022; 128:1560-1567. [PMID: 35132620 PMCID: PMC10257521 DOI: 10.1002/cncr.34118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/22/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
Disparities in pancreatic cancer incidence and outcomes exist in Native American populations. These disparities are multifactorial, difficult to quantify, and are influenced by historical, socioeconomic, and health care structural factors. The objective of this article was to assess these factors and offer a call to action to overcome them. The authors reviewed published data on pancreatic cancer in Native American populations with a focus on disparities in incidence, outcomes, and research efforts. The historical context of the interactions between Native Americans and the United States health care system was also analyzed to form actionable items to build trust and collaboration. The incidence of pancreatic cancer in Native Americans is higher than that in the general US population and has the worst survival of any major racial or ethnic group. These outcomes are influenced by a patient population with often poor access to high-quality cancer care, historical trauma potentially leading to reduced care utilization, and a lack of research focused on etiologies and comorbid conditions that contribute to these disparities. A collaborative effort between nontribal and tribal leaders and cancer centers is key to addressing disparities in pancreatic cancer outcomes and research. More population-level studies are needed to better understand the incidence, etiologies, and comorbid conditions of pancreatic cancer in Native Americans. Finally, a concerted, focused effort should be undertaken between nontribal and tribal entities to increase the access of Native Americans to high-quality care for pancreatic cancer and other lethal malignancies.
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Affiliation(s)
| | | | | | - Jonathan R. Brody
- OHSU, Department of Surgery, Portland, OR, 97239
- OHSU Brenden-Colson Center for Pancreatic Care, Portland, OR, 97239
| | - Brett C. Sheppard
- OHSU, Department of Surgery, Portland, OR, 97239
- OHSU Brenden-Colson Center for Pancreatic Care, Portland, OR, 97239
- OHSU, Department of Cell, Developmental and Cancer Biology, Knight Cancer Institute, Portland, OR, 97239
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24
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Cantos A, Eguia E, Wang X, Abood G, Knab LM. Impact of sociodemographic factors on outcomes in patients with peritoneal malignancies following cytoreduction and chemoperfusion. J Surg Oncol 2022; 125:1285-1291. [PMID: 35253223 PMCID: PMC9314066 DOI: 10.1002/jso.26843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives Sociodemographic factors have been shown to impact surgical outcomes. However, the effects of these factors on patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are not well known. This study aims to evaluate the impact of sociodemographic factors on patients undergoing CRS/HIPEC. Methods Adult patients at a tertiary center who underwent CRS/HIPEC were evaluated. Perioperative variables were collected and analyzed. A national database was also used to evaluate patients undergoing CRS/HIPEC. Results There were 90 patients who underwent CRS/HIPEC (32% non‐White). There was no statistically significant difference in postoperative complications, length of stay, or discharge disposition based upon race (white vs. non‐White patients), socioeconomic status (SES), or insurance type. Nationally, we found that Black and Hispanic patients were less likely to undergo CRS/HIPEC than Non‐Hispanic white patients (Black: odds ratio [OR]: 0.60, [confidence interval {CI}: 0.39–0.94]; Hispanic: OR: 0.52, [CI: 0.28–0.98]). However, there were no significant differences in postoperative complications based upon race/ethnicity. Conclusion Sociodemographic factors including race, SES, and insurance status did not impact postoperative outcomes in patients undergoing CRS/HIPEC at our single institution. On a national level, Black and Hispanic patients underwent CRS/HIPEC at lower rates compared to white patients.
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Affiliation(s)
- Adriana Cantos
- Department of Surgery Loyola University Chicago Stritch School of Medicine Maywood Illinois USA
| | - Emanuel Eguia
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Xuanji Wang
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Gerard Abood
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Lawrence M. Knab
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
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25
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Abbaszadeh Kasbi A, Ashary MA, Baksh M, Nussbaum S, Attwood K, Gabriel E. Age-related Survival Outcomes for Pancreatic Cancer by Age. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:71-77. [PMID: 35400009 PMCID: PMC8962847 DOI: 10.21873/cdp.10078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/04/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM Pancreatic cancer has a very poor prognosis, though outcomes based on age are not well characterized. The aim of current study was to analyze the survival of patients with pancreatic cancer based on age. PATIENTS AND METHODS Using National Cancer Data Base (NCDB), we determined survival outcome based on age among patients with pancreatic cancer. RESULTS A total of 423,482 patients between 2004 and 2017 were included in the study. Patients aged between 18 and 40-years-old had the worst 3-year survival rate among stage 1 disease. Conversely, patients over 65-years-old had the worst 3-year survival rate and presented with more advanced disease (clinical stages 3 and 4). CONCLUSION Older patients with more advanced disease had worse survival.
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Affiliation(s)
- Ali Abbaszadeh Kasbi
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
| | - Mohammed Ali Ashary
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
| | - Mizba Baksh
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
| | - Samuel Nussbaum
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
| | - Kristopher Attwood
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
| | - Emmanuel Gabriel
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic in Florida, Jacksonville, FL, U.S.A
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26
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Powers BD, Fulp W, Dhahri A, DePeralta DK, Ogami T, Rothermel L, Permuth JB, Vadaparampil ST, Kim JK, Pimiento J, Hodul PJ, Malafa MP, Anaya DA, Fleming JB. The Impact of Socioeconomic Deprivation on Clinical Outcomes for Pancreatic Adenocarcinoma at a High-volume Cancer Center: A Retrospective Cohort Analysis. Ann Surg 2021; 274:e564-e573. [PMID: 31851004 PMCID: PMC7272283 DOI: 10.1097/sla.0000000000003706] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the impact of a granular measure of SED on pancreatic surgical and cancer-related outcomes at a high-volume cancer center that employs a standardized clinic pathway. SUMMARY OF BACKGROUND DATA Prior research has shown that low socioeconomic status leads to less treatment and worse outcomes for PDAC. However, these studies employed inconsistent definitions and categorizations of socioeconomic status, aggregated individual socioeconomic data using large geographic areas, and lacked detailed clinicopathologic variables. METHODS We conducted a retrospective cohort study of 1552 PDAC patients between 2008 and 2015. Patients were stratified using the area deprivation index, a validated dataset that ranks census block groups based on SED. Multivariable models were used in the curative surgery cohort to predict the impact of SED on (1) grade 3/4 Clavien-Dindo complications, (2) initiation of adjuvant therapy, (3) completion of adjuvant therapy, and (4) overall survival. RESULTS Patients from high SED neighborhoods constituted 29.9% of the cohort. Median overall survival was 28 months. The rate of Clavien-Dindo grade 3/4 complications was 14.2% and completion of adjuvant therapy was 65.6%. There was no evidence that SED impacted surgical evaluation, receipt of curative-intent surgery, postoperative complications, receipt of adjuvant therapy or overall survival. CONCLUSIONS Although nearly one-quarter of curative-intent surgery patients were from high SED neighborhoods, this factor was not associated with measures of treatment quality or survival. These observations suggest that treatment at a high-volume cancer center employing a standardized clinical pathway may in part address socioeconomic disparities in pancreatic cancer.
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Affiliation(s)
- Benjamin D. Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - William Fulp
- Department of Biometrics and Biostatistics, Moffitt Cancer Center, Tampa, Florida
| | - Amina Dhahri
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Luke Rothermel
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jennifer B. Permuth
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Jose Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Pamela J. Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Mokenge P. Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Daniel A. Anaya
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
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27
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Chu QD, Hsieh MC, Gibbs JF, Wu XC. Social determinants of health associated with poor outcome for rural patients following resected pancreatic cancer. J Gastrointest Oncol 2021; 12:2567-2578. [PMID: 35070388 PMCID: PMC8748046 DOI: 10.21037/jgo-20-583] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 06/08/2021] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND The impact of rurality on outcome for patients who had resected pancreatic ductal adenocarcinoma (PDAC) is unclear. We hypothesize that poor outcomes for rural patients are associated with adverse social determinants of health (SDoH). The objective of this study is to assess the difference in overall survival (OS) of PDAC patients between rural, urban, and contributing factors. METHODS A cohort of 25,536 patients diagnosed with stage I-III pancreatic adenocarcinoma from 2003 to 2011 and underwent resection were evaluated from the National Cancer Database. Socioeconomic/demographic, clinicopathological, and treatment variables were compared between rural and urban residences. The 5-year OS was calculated using the Kaplan-Meier method. The Cox regression model was used to assess factors associated with OS. P value <0.05 was considered significant. RESULTS In univariate analysis, the rural residence was a predictor of poor OS. The 5-year OS for rural (N=4,389) and urban (N=21,147) was 18.8% (95% CI: 17.4-20.2%) and 22.3% (95% CI: 21.6-22.9%; P<0.0001), respectively. The risk of all causes of death was 10.3% higher (P<0.0001) in rural than urban patients. In multivariable analysis, rurality was not an independent predictor of OS (P=0.407). Independent predictors of worse OS included adverse social determinants of health associated with the rural population and these included a low income (P<0.0001), low education level (P<0.01), low insurance status (P<0.01), and treatment at a low-volume facility (P<0.0001). CONCLUSIONS Rural/urban outcome disparities for resected stage I-III pancreatic cancer outcome can be explained by adverse social determinants of health associated with rural population.
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Affiliation(s)
- Quyen D. Chu
- Departments of Surgery, LSU Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry & Epidemiology and School of Public Health at LSU Health Sciences-New Orleans, New Orleans, Louisiana, USA
| | - John F. Gibbs
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry & Epidemiology and School of Public Health at LSU Health Sciences-New Orleans, New Orleans, Louisiana, USA
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28
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Torres MB, Dixon MEB, Gusani NJ. Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography. Surg Oncol Clin N Am 2021; 31:43-54. [PMID: 34776063 DOI: 10.1016/j.soc.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third leading cause of cancer deaths in the United States. Black patients with pancreatic cancer experience higher incidence and increased mortality. Although racial biologic differences exist, socioeconomic status, insurance type, physician bias, and patient beliefs contribute to the disparities in outcomes observed among patients who are Black, indigenous, and people of color.
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Affiliation(s)
- Madeline B Torres
- General Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Avenue MC H149, Hershey, PA 17033, USA. https://twitter.com/MadelineBTorres
| | - Matthew E B Dixon
- Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, 500 University Avenue MC H070, Hershey, PA 17036, USA. https://twitter.com/mebdixon
| | - Niraj J Gusani
- Section of Surgical Oncology, Baptist MD Anderson Cancer Center, 1301 Palm Avenue, Jacksonville, FL 32207, USA.
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29
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Pastrana Del Valle J, Mahvi DA, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer. J Surg Oncol 2021; 125:646-657. [PMID: 34786728 DOI: 10.1002/jso.26748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/03/2021] [Accepted: 10/25/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy. METHODS The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ2 test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis. RESULTS Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity. CONCLUSIONS Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Mahvi
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark Fairweather
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jiping Wang
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thomas E Clancy
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stanley W Ashley
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard D Urman
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward E Whang
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason S Gold
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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30
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Papageorge MV, Evans DB, Tseng JF. Health Care Disparities and the Future of Pancreatic Cancer Care. Surg Oncol Clin N Am 2021; 30:759-771. [PMID: 34511195 DOI: 10.1016/j.soc.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.
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Affiliation(s)
- Marianna V Papageorge
- Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Collamore - C500, Boston, MA 02118, USA. https://twitter.com/MPapageorge_MD
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Wilwaukee, WI 53226, USA. https://twitter.com/@DougEvans2273
| | - Jennifer F Tseng
- Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Collamore - C500, Boston, MA 02118, USA.
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31
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Gurney J, Stanley J, McLeod M, Koea J, Jackson C, Sarfati D. Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016. JCO Glob Oncol 2021; 6:766-774. [PMID: 32511067 PMCID: PMC7328125 DOI: 10.1200/go.20.00028] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE While cancer survival is improving across most developed nations, those improvements are not shared equally within their population. Using high-quality national data, we have reviewed the extent to which cancer survival inequities are persisting for indigenous Māori compared with non-Māori New Zealanders and the extent to which these disparities are driven by deprivation, comorbidity, and stage of disease. METHODS Incident cases of cancer (2007-2016) were extracted from the New Zealand Cancer Registry and linked to mortality and hospitalization data. Descriptive, Kaplan-Meier, and Cox regression methods were used to compare survival outcomes between Māori and non-Māori. RESULTS Māori continue to have poorer survival than non-Māori for 23 of the 24 most common causes of Māori cancer death, with the extent of this disparity ranging from 12% to 156%. The magnitude of these disparities varies according to deprivation, comorbidity, and stage. Of note, there was a tendency for survival disparities to be largest among those with no comorbidity. CONCLUSION Māori continue to experience substantial cancer survival inequities. These observations are in keeping with reports from previous decades, which suggest that these disparities persist despite heightened attention. Reduction of the cancer burden on Māori and achievement of equitable survival outcomes require us to prevent cancer for Māori where we can, diagnose Māori patients early when we cannot, and once diagnosed, deliver equitable care to Māori patients at each step along the treatment path.
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Affiliation(s)
- Jason Gurney
- Cancer and Chronic Conditions Research Group, Department of Public Health, University of Otago, Wellington, New Zealand
| | - James Stanley
- Cancer and Chronic Conditions Research Group, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Melissa McLeod
- Cancer and Chronic Conditions Research Group, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jonathan Koea
- Waitemata District Health Board, Auckland, New Zealand
| | - Chris Jackson
- Southern District Health Board, Dunedin, New Zealand.,Cancer Society of New Zealand, Wellington, New Zealand
| | - Diana Sarfati
- Cancer and Chronic Conditions Research Group, Department of Public Health, University of Otago, Wellington, New Zealand
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Permuth JB, Vyas S, Li J, Chen DT, Jeong D, Choi JW. Comparison of Radiomic Features in a Diverse Cohort of Patients With Pancreatic Ductal Adenocarcinomas. Front Oncol 2021; 11:712950. [PMID: 34367997 PMCID: PMC8339963 DOI: 10.3389/fonc.2021.712950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/05/2021] [Indexed: 12/20/2022] Open
Abstract
Background Significant racial disparities in pancreatic cancer incidence and mortality rates exist, with the highest rates in African Americans compared to Non-Hispanic Whites and Hispanic/Latinx populations. Computer-derived quantitative imaging or “radiomic” features may serve as non-invasive surrogates for underlying biological factors and heterogeneity that characterize pancreatic tumors from African Americans, yet studies are lacking in this area. The objective of this pilot study was to determine if the radiomic tumor profile extracted from pretreatment computed tomography (CT) images differs between African Americans, Non-Hispanic Whites, and Hispanic/Latinx with pancreatic cancer. Methods We evaluated a retrospective cohort of 71 pancreatic cancer cases (23 African American, 33 Non-Hispanic White, and 15 Hispanic/Latinx) who underwent pretreatment CT imaging at Moffitt Cancer Center and Research Institute. Whole lesion semi-automated segmentation was performed on each slice of the lesion on all pretreatment venous phase CT exams using Healthmyne Software (Healthmyne, Madison, WI, USA) to generate a volume of interest. To reduce feature dimensionality, 135 highly relevant non-texture and texture features were extracted from each segmented lesion and analyzed for each volume of interest. Results Thirty features were identified and significantly associated with race/ethnicity based on Kruskal-Wallis test. Ten of the radiomic features were highly associated with race/ethnicity independent of tumor grade, including sphericity, volumetric mean Hounsfield units (HU), minimum HU, coefficient of variation HU, four gray level texture features, and two wavelet texture features. A radiomic signature summarized by the first principal component partially differentiated African American from non-African American tumors (area underneath the curve = 0.80). Poorer survival among African Americans compared to Non-African Americans was observed for tumors with lower volumetric mean CT [HR: 3.90 (95% CI:1.19–12.78), p=0.024], lower GLCM Avg Column Mean [HR:4.75 (95% CI: 1.44,15.37), p=0.010], and higher GLCM Cluster Tendency [HR:3.36 (95% CI: 1.06–10.68), p=0.040], and associations persisted in volumetric mean CT and GLCM Avg Column after adjustment for key clinicopathologic factors. Conclusions This pilot study identified several textural radiomics features associated with poor overall survival among African Americans with PDAC, independent of other prognostic factors such as grade. Our findings suggest that CT radiomic features may serve as surrogates for underlying biological factors and add value in predicting clinical outcomes when integrated with other parameters in ongoing and future studies of cancer health disparities.
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Affiliation(s)
- Jennifer B Permuth
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States.,Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Shraddha Vyas
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Jiannong Li
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Daniel Jeong
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States.,Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Jung W Choi
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
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Louie AD, Nwaiwu CA, Rozenberg J, Banerjee D, Lee GJ, Senthoor D, Miner TJ. Providing Appropriate Pancreatic Cancer Care for People Experiencing Homelessness: A Surgical Perspective. Am Soc Clin Oncol Educ Book 2021; 41:1-9. [PMID: 33929879 DOI: 10.1200/edbk_100027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
People experiencing homelessness are particularly vulnerable when diagnosed with pancreatic cancer. Patients with lower socioeconomic status have worse outcomes from pancreatic cancer as the result of disparities in access to treatment and barriers to navigation of the health care system. Patients with lower socioeconomic status, or who are vulnerably housed, are less likely to receive surgical treatment even when it is recommended by National Comprehensive Cancer Network guidelines. This disparity in access to surgical care explains much of the gap in pancreatic cancer outcomes. There are many factors that contribute to this disparity in surgical management of pancreatic cancer in people experiencing homelessness. These include a lack of reliable transportation, feeling unwelcome in the medical setting, a lack of primary care and health insurance, and implicit biases of health care providers, including racial bias. Solutions that focus on rectifying these problems include utilizing patient navigators, addressing implicit biases of all health care providers and staff, creating an environment that caters to the needs of patients experiencing homelessness, and improving their access to insurance and regional support networks. Implementing these potential solutions all the way from the individual provider to national safety nets could improve outcomes for patients with pancreatic cancer who are experiencing homelessness.
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Affiliation(s)
- Anna D Louie
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
| | - Chibueze A Nwaiwu
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Supporting Underrepresented Research to Generate Equity (SURGE) Lab Collaborators, Warren Alpert Medical School of Brown University, Providence, RI
| | - Julia Rozenberg
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Debolina Banerjee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Gillian J Lee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Dewahar Senthoor
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Thomas J Miner
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
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Pancreatic Cancer Surgery Following Emergency Department Admission: Understanding Poor Outcomes and Disparities in Care. J Gastrointest Surg 2021; 25:1261-1270. [PMID: 32378096 PMCID: PMC7644583 DOI: 10.1007/s11605-020-04614-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 04/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes. STUDY DESIGN The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008-2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status. RESULTS A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all p < .0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%, p < .0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%, p < .0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%, p < .0001) and had higher mortality (7.4% vs. 3.5%, p < .0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43-0.70)). CONCLUSION Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.
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Gravesteijn B, Krijkamp E, Busschbach J, Geleijnse G, Helmrich IR, Bruinsma S, van Lint C, van Veen E, Steyerberg E, Verhoef K, van Saase J, Lingsma H, Baatenburg de Jong R. Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:648-657. [PMID: 33933233 PMCID: PMC7933792 DOI: 10.1016/j.jval.2020.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/29/2020] [Accepted: 12/13/2020] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Coronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. METHODS A cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. RESULTS Given the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). CONCLUSION Expected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.
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Affiliation(s)
- Benjamin Gravesteijn
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline Krijkamp
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Jan Busschbach
- Department of Medical Psychology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Geert Geleijnse
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabel Retel Helmrich
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sophie Bruinsma
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Céline van Lint
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ernest van Veen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kees Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan van Saase
- Department of Internal Medicine - Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rob Baatenburg de Jong
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Reid TD, Shrestha R, Stone L, Gallaher J, Charles AG, Strassle PD. Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients. Surgery 2021; 170:1039-1046. [PMID: 33933283 DOI: 10.1016/j.surg.2021.03.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/01/2021] [Accepted: 03/22/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND While ostomies for diverticulitis are often intended to be temporary, ostomy reversal rates can be as low as 46%. There are few comprehensive studies evaluating the effects of socioeconomic status as a disparity in ostomy reversal. We hypothesized that among the elderly Medicare population undergoing partial colectomy for diverticulitis, lower socioeconomic status would be associated with reduced reversal rates. METHODS Retrospective cohort study using a 20% representative sample of Medicare beneficiaries >65 years old with diverticulitis who received ostomies between January 1, 2010, to December 31, 2017. We evaluated the effect of neighborhood socioeconomic status, measured by the Social Deprivation Index, on ostomy reversal within 1 year. Secondary outcomes were complications and mortality. RESULTS Of 10,572 patients, ostomy reversals ranged from 21.2% (low socioeconomic status) to 29.8% (highest socioeconomic status), with a shorter time to reversal among higher socioeconomic status groups. Patients with low socioeconomic status were less likely to have their ostomies reversed, compared with the highest socioeconomic status group (hazard ratio 0.83, 95% confidence interval 0.74-0.93) and were more likely to die (hazard ratio 1.21, 95% confidence interval 1.10-1.33). When stratified by race/ethnicity and socioeconomic status, non-Hispanic White patients at every socioeconomic status had a higher reversal rate than non-Hispanic Black patients (White patients 32.0%-24.8% vs Black patients 19.6%-14.7%). Socioeconomic status appeared to have a higher relative impact among non-Hispanic Black patients. CONCLUSION Among Medicare diverticulitis patients, ostomy reversal rates are low. Patients with lower socioeconomic status are less likely to undergo stoma reversal and are more likely to die; Black patients are least likely to have an ostomy reversal.
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Affiliation(s)
- Trista D Reid
- The University of North Carolina-Chapel Hill, Department of Surgery, Chapel Hill, NC.
| | - Riju Shrestha
- The University of North Carolina-Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC
| | - Lucas Stone
- The University of North Carolina-Chapel Hill, Department of Surgery, Chapel Hill, NC
| | - Jared Gallaher
- The University of North Carolina-Chapel Hill, Department of Surgery, Chapel Hill, NC
| | - Anthony G Charles
- The University of North Carolina-Chapel Hill, Department of Surgery, Chapel Hill, NC
| | - Paula D Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health
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Municipality and Adjusted Gross Income Influence Outcome of Patients Diagnosed with Pancreatic Cancer in a Newly Developed Cancer Center in Mercer County New Jersey, USA, a Single Center Study. Cancers (Basel) 2021; 13:cancers13071498. [PMID: 33805136 PMCID: PMC8037458 DOI: 10.3390/cancers13071498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022] Open
Abstract
Socioeconomic status (SES) correlates directly to ZIP code. Mercer County is not atypical as a collection of a dozen municipalities with a suburban/metropolitan population of 370,430 in the immediate vicinity of a major medical center. The purpose of this study for Mercer County, New Jersey, USA is to determine whether a patient's ZIP code is related to the outlook of pancreatic cancer defined as staging at diagnosis, prevalence, overall survival, type of insurance, and recurrence. Our hypothesis was that specific variables such as socio-economic status or race could be linked to the outcome of patients with pancreatic cancer. We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer in 1998-2018. We selected 339 subjects by ZIP code, representing the plurality of the cases in our catchment area. The outcome variable was overall survival; predictor variables were socio-economic status (SES), recurrence, insurance, type of treatment, gender, cancer stage, age, and race. We converted ZIP code to municipality and culled data using adjusted gross income (AGI, FY 2017). Comparative statistical analysis was performed using chi-square tests for nominal and ordinal variables, and a two-way ANOVA test was used for continuous variables; the p-value was set at 0.05. Our analysis confirmed that overall survival was significantly higher for Whites and for individuals who live in a municipality with a high SES. Tumor stage at the time of diagnosis was not different among race and SES; however, statistically significant differences for race or SES existed in the type of treatment received, with disparities found in those who received radiation therapy and surgery but not chemotherapy. The data may point to a lack of access to specific care modalities that subsequently may lead to lower survival in an underserved population. Access to care, optimal nutritional status, overall fitness, and co-morbidities could play a major role and confound the results. Our study suggests that low SES has a negative impact on overall pancreatic cancer survival. Surgery for pancreatic cancer should be appropriately decentralized to those community cancer centers that possess the expertise and the infrastructure to carry out specialized treatments regardless of race, ethnicity, SES, and insurance.
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Permuth JB, Dezsi KB, Vyas S, Ali KN, Basinski TL, Utuama OA, Denbo JW, Klapman J, Dam A, Carballido E, Kim DW, Pimiento JM, Powers BD, Otto AK, Choi JW, Chen DT, Teer JK, Beato F, Ward A, Cortizas EM, Whisner SY, Williams IE, Riner AN, Tardif K, Velanovich V, Karachristos A, Douglas WG, Legaspi A, Allan BJ, Meredith K, Molina-Vega MA, Bao P, St. Julien J, Huguet KL, Green L, Odedina FT, Kumar NB, Simmons VN, George TJ, Vadaparampil ST, Hodul PJ, Arnoletti JP, Awad ZT, Bose D, Jiang K, Centeno BA, Gwede CK, Malafa M, Judge SM, Judge AR, Jeong D, Bloomston M, Merchant NB, Fleming JB, Trevino JG. The Florida Pancreas Collaborative Next-Generation Biobank: Infrastructure to Reduce Disparities and Improve Survival for a Diverse Cohort of Patients with Pancreatic Cancer. Cancers (Basel) 2021; 13:809. [PMID: 33671939 PMCID: PMC7919015 DOI: 10.3390/cancers13040809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Well-annotated, high-quality biorepositories provide a valuable platform to support translational research. However, most biorepositories have poor representation of minority groups, limiting the ability to address health disparities. Methods: We describe the establishment of the Florida Pancreas Collaborative (FPC), the first state-wide prospective cohort study and biorepository designed to address the higher burden of pancreatic cancer (PaCa) in African Americans (AA) compared to Non-Hispanic Whites (NHW) and Hispanic/Latinx (H/L). We provide an overview of stakeholders; study eligibility and design; recruitment strategies; standard operating procedures to collect, process, store, and transfer biospecimens, medical images, and data; our cloud-based data management platform; and progress regarding recruitment and biobanking. Results: The FPC consists of multidisciplinary teams from fifteen Florida medical institutions. From March 2019 through August 2020, 350 patients were assessed for eligibility, 323 met inclusion/exclusion criteria, and 305 (94%) enrolled, including 228 NHW, 30 AA, and 47 H/L, with 94%, 100%, and 94% participation rates, respectively. A high percentage of participants have donated blood (87%), pancreatic tumor tissue (41%), computed tomography scans (76%), and questionnaires (62%). Conclusions: This biorepository addresses a critical gap in PaCa research and has potential to advance translational studies intended to minimize disparities and reduce PaCa-related morbidity and mortality.
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Affiliation(s)
- Jennifer B. Permuth
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Kaleena B. Dezsi
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Shraddha Vyas
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Karla N. Ali
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Toni L. Basinski
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Ovie A. Utuama
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Jason W. Denbo
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jason Klapman
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Aamir Dam
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Estrella Carballido
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jose M. Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Benjamin D. Powers
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Amy K. Otto
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33612, USA;
| | - Jung W. Choi
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.C.); (D.J.)
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (D.-T.C.); (J.K.T.)
| | - Jamie K. Teer
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (D.-T.C.); (J.K.T.)
| | - Francisca Beato
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Alina Ward
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Elena M. Cortizas
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | | | - Iverson E. Williams
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
| | - Andrea N. Riner
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
| | - Kenneth Tardif
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Vic Velanovich
- Tampa General Hospital, University of South Florida, Tampa, FL 33606, USA; (V.V.); (A.K.)
| | - Andreas Karachristos
- Tampa General Hospital, University of South Florida, Tampa, FL 33606, USA; (V.V.); (A.K.)
| | - Wade G. Douglas
- Division of Surgery, Tallahassee Memorial Healthcare, Department of Clinical Sciences, College of Medicine, Florida State University, Tallahassee, FL 32308, USA;
| | - Adrian Legaspi
- Center for Advanced Surgical Oncology at Palmetto General Hospital, Tenet Healthcare Palmetto General, Hialeah, FL 33016, USA;
| | - Bassan J. Allan
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Kenneth Meredith
- Department of Gastrointestinal Oncology, Brian Jellison Cancer Institute, Sarasota Memorial Hospital, Sarasota, FL 34239, USA;
| | | | - Philip Bao
- Department of Surgical Oncology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA;
| | - Jamii St. Julien
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Kevin L. Huguet
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Lee Green
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Folakemi T. Odedina
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA;
| | - Nagi B. Kumar
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Vani N. Simmons
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Thomas J. George
- Division of Oncology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
- Office of Community Outreach, Engagement, and Equity, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Pamela J. Hodul
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - J. Pablo Arnoletti
- Center for Surgical Oncology, Advent Health Orlando, Orlando, FL 32804, USA;
| | - Ziad T. Awad
- Surgery, University of Florida-Jacksonville, Jacksonville, FL 32209, USA;
| | - Debashish Bose
- Surgical Oncology, University of Florida-Orlando, Orlando, FL 32806, USA;
| | - Kun Jiang
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.J.); (B.A.C.)
| | - Barbara A. Centeno
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.J.); (B.A.C.)
| | - Clement K. Gwede
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Sarah M. Judge
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.J.); (A.R.J.)
| | - Andrew R. Judge
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.J.); (A.R.J.)
| | - Daniel Jeong
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.C.); (D.J.)
| | - Mark Bloomston
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Nipun B. Merchant
- Department of Surgical Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jose G. Trevino
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
- Division of Surgical Oncology, Department of Surgery, School of Medicine, Virginia Commonwealth University, Richmond, VA 23219, USA
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Mitsakos AT, Dennis SO, Parikh AA, Snyder RA. Thirty-day complication rates do not differ by race among patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. J Surg Oncol 2021; 123:970-977. [PMID: 33497474 DOI: 10.1002/jso.26383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to receive multimodality treatment and have worse survival compared to White patients. However, little is known regarding racial differences in postoperative outcomes. The primary aim of this study was to determine if 30-day complication rates following pancreaticoduodenectomy (PD) differ by race. METHODS A retrospective cohort study of patients who underwent PD for PDAC from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific data set was performed. Primary outcomes were 30-day pancreas-specific and overall major complications. RESULTS A total of 6936 patients were identified, including 91.4% (N = 6337) White and 8.6% (N = 599) Black. Pathologic stage and rates of neoadjuvant therapy were similar among Whites and Blacks. Rates of pancreas-specific (23.9% vs. 23.1%, p = .88) and major postoperative complications (39.2% vs. 39.9%, p = .55) were similar between Whites and Blacks. By multivariable regression analysis, there was no association between race and odds of pancreas-specific complications (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.89-1.37) or overall major complications (OR 1.13, 95% CI 0.95-1.36). CONCLUSIONS Among patients undergoing PD for PDAC, Black race is not associated with increased pancreas-specific or overall 30-day postoperative complications. Short-term postoperative outcomes do not appear to explain the increase in pancreatic cancer mortality among Black patients.
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Affiliation(s)
- Anastasios T Mitsakos
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Samuel O Dennis
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Alexander A Parikh
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Rebecca A Snyder
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA.,Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
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40
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Zavala VA, Bracci PM, Carethers JM, Carvajal-Carmona L, Coggins NB, Cruz-Correa MR, Davis M, de Smith AJ, Dutil J, Figueiredo JC, Fox R, Graves KD, Gomez SL, Llera A, Neuhausen SL, Newman L, Nguyen T, Palmer JR, Palmer NR, Pérez-Stable EJ, Piawah S, Rodriquez EJ, Sanabria-Salas MC, Schmit SL, Serrano-Gomez SJ, Stern MC, Weitzel J, Yang JJ, Zabaleta J, Ziv E, Fejerman L. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer 2021; 124:315-332. [PMID: 32901135 PMCID: PMC7852513 DOI: 10.1038/s41416-020-01038-6] [Citation(s) in RCA: 459] [Impact Index Per Article: 153.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA-African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA.
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Affiliation(s)
- Valentina A Zavala
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Paige M Bracci
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - John M Carethers
- Departments of Internal Medicine and Human Genetics, and Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Luis Carvajal-Carmona
- University of California Davis Comprehensive Cancer Center and Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
- Genome Center, University of California Davis, Davis, CA, USA
| | | | - Marcia R Cruz-Correa
- Department of Cancer Biology, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Melissa Davis
- Division of Breast Surgery, Department of Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Adam J de Smith
- Center for Genetic Epidemiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Julie Dutil
- Cancer Biology Division, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Jane C Figueiredo
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rena Fox
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kristi D Graves
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Scarlett Lin Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Andrea Llera
- Laboratorio de Terapia Molecular y Celular, IIBBA, Fundación Instituto Leloir, CONICET, Buenos Aires, Argentina
| | - Susan L Neuhausen
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Lisa Newman
- Division of Breast Surgery, Department of Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
- Interdisciplinary Breast Program, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Tung Nguyen
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Julie R Palmer
- Slone Epidemiology Center at Boston University, Boston, MA, USA
| | - Nynikka R Palmer
- Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Eliseo J Pérez-Stable
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Sorbarikor Piawah
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Erik J Rodriquez
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Stephanie L Schmit
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Silvia J Serrano-Gomez
- Grupo de investigación en biología del cáncer, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Mariana C Stern
- Departments of Preventive Medicine and Urology, Keck School of Medicine of USC, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey Weitzel
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jovanny Zabaleta
- Department of Pediatrics and Stanley S. Scott Cancer Center LSUHSC, New Orleans, LA, USA
| | - Elad Ziv
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Laura Fejerman
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
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Abdel-Rahman O. Impact of socioeconomic status on presentation, treatment and outcomes of patients with pancreatic cancer. J Comp Eff Res 2020; 9:1233-1241. [PMID: 33275039 DOI: 10.2217/cer-2020-0079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective: To assess the impact of socioeconomic status (SES) on the patterns of care and outcomes of patients with pancreatic cancer. Materials & methods: Surveillance, Epidemiology and End Results specialized SES registry has been accessed and patients with pancreatic cancer diagnosed (2000-2015) were evaluated. The following SES variables were included: employment percentage, percent of people above the poverty line, percent of people identified as working-class, educational level, median rent, median household value and median household income. Within this SES registry, patients were classified according to their census-tract SES into three groups (where group-1 represents the lowest SES category and group-3 represents the highest SES category). Multivariable logistic regression analysis was used to assess the impact of SES on access to surgical resection and multivariable Cox regression analysis was used to assess the impact of SES on pancreatic cancer-specific survival. Kaplan-Meier survival estimates were also used to compare overall survival (OS) outcomes according to SES. Results: A total of 83,902 pancreatic cancer patients were included in the current analysis. Within multivariable logistic regression analysis among patients with a localized/regional disease, patients with lower SES were less likely to undergo surgical resection for pancreatic cancer (odds ratio: 0.719; 95% CI: 0.673-0.767; p < 0.001). Among patients with a localized/regional disease who underwent surgical resection, patients with higher SES have better OS (median OS for group-3: 20.0 vs 17.0 months for group-1; p < 0.001). Moreover, patients with lower SES have worse pancreatic cancer-specific survival compared with patients with higher SES: (hazard ratio for group-1 vs group-3: 1.212; 95% CI: 1.135-1.295; p < 0.001). Conclusion: Poor neighborhood SES is associated with more advanced disease at presentation, less probability of surgical resection and even poorer outcomes after surgical resection.
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Affiliation(s)
- Omar Abdel-Rahman
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton T6G 1Z2, AB, Canada
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42
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Segel JE, Hollenbeak CS, Gusani NJ. Rural‐Urban Disparities in Pancreatic Cancer Stage of Diagnosis: Understanding the Interaction With Medically Underserved Areas. J Rural Health 2020; 36:476-483. [DOI: 10.1111/jrh.12498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Joel E. Segel
- Department of Health Policy and Administration Pennsylvania State University University Park Pennsylvania
- Penn State Cancer Institute Hershey Pennsylvania
- Department of Public Health Sciences Pennsylvania State University Hershey Pennsylvania
| | - Christopher S. Hollenbeak
- Department of Health Policy and Administration Pennsylvania State University University Park Pennsylvania
- Department of Public Health Sciences Pennsylvania State University Hershey Pennsylvania
- Department of Surgery Penn State College of Medicine Hershey Pennsylvania
| | - Niraj J. Gusani
- Penn State Cancer Institute Hershey Pennsylvania
- Department of Public Health Sciences Pennsylvania State University Hershey Pennsylvania
- Department of Surgery Penn State College of Medicine Hershey Pennsylvania
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43
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Molina G, Clancy TE, Tsai TC, Lam M, Wang J. Racial Disparity in Pancreatoduodenectomy for Borderline Resectable Pancreatic Adenocarcinoma. Ann Surg Oncol 2020; 28:1088-1096. [PMID: 32651695 DOI: 10.1245/s10434-020-08717-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies have found racial disparity in pancreatectomies for resectable pancreatic adenocarcinoma. The aim of this study was to investigate if racial disparities were worse in the performance of pancreaticoduodenectomy for borderline resectable pancreatic adenocarcinoma. METHODS This study used the National Cancer Database (2004-2016) and included patients with non-metastatic and head of the pancreas borderline resectable pancreatic adenocarcinoma. Multivariable, Poisson regression models with robust standard errors evaluated the relative risk (RR) of undergoing a pancreaticoduodenectomy among non-White patients (Black, Asian, and non-White Hispanic) compared with White patients. A Poisson regression model with hospital fixed effects was performed to evaluate if findings were due to within-hospital or between-hospital variation. Interaction between race and neoadjuvant therapy was also evaluated. RESULTS There were 15,482 patients (median age 68 years, interquartile range 60-76 years; 48.6% male) with borderline resectable pancreatic adenocarcinoma who were predominantly White (84.3%, n = 13,058; non-White, 15.7%, n = 2424). Overall, 18.4% (n = 2853) had a pancreatic resection. Non-White patients had a significantly lower likelihood of undergoing a pancreatic resection for borderline resectable pancreatic adenocarcinoma when compared with White patients (RR 0.75, 95% confidence interval 0.68-0.83; p < 0.001). These findings persisted in the hospital fixed-effects model. In the interaction analysis, there were no significant differences in the likelihood of pancreatic resection if patients received neoadjuvant therapy. CONCLUSIONS Non-White patients were 25% less likely to undergo a pancreatic resection for borderline resectable pancreatic adenocarcinoma compared with White patients. This racial disparity was due to variation in care within-hospitals and disappeared if non-White patients were treated with neoadjuvant therapy.
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Affiliation(s)
- George Molina
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thomas E Clancy
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thomas C Tsai
- Division of General and Gastrointestinal Surgery, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Miranda Lam
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA. .,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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44
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Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. Lancet 2020; 395:2008-2020. [PMID: 32593337 DOI: 10.1016/s0140-6736(20)30974-0] [Citation(s) in RCA: 1340] [Impact Index Per Article: 335.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
Pancreatic cancer is a highly fatal disease with a 5-year survival rate of approximately 10% in the USA, and it is becoming an increasingly common cause of cancer mortality. Risk factors for developing pancreatic cancer include family history, obesity, type 2 diabetes, and tobacco use. Patients typically present with advanced disease due to lack of or vague symptoms when the cancer is still localised. High quality computed tomography with intravenous contrast using a dual phase pancreatic protocol is typically the best method to detect a pancreatic tumour and to determine surgical resectability. Endoscopic ultrasound is an increasingly used complementary staging modality which also allows for diagnostic confirmation when combined with fine needle aspiration. Patients with pancreatic cancer are often divided into one of four categories based on extent of disease: resectable, borderline resectable, locally advanced, and metastatic; patient condition is also an important consideration. Surgical resection represents the only chance for cure, and advancements in adjuvant chemotherapy have improved long-term outcomes in these patients. Systemic chemotherapy combinations including FOLFIRINOX (5-fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nab-paclitaxel remain the mainstay of treatment for patients with advanced disease. Data on the benefit of PARP inhibition as maintenance therapy in patients with germline BRCA1 or BRACA2 mutations might prove to be a harbinger of advancement in targeted therapy. Additional research efforts are focusing on modulating the pancreatic tumour microenvironment to enhance the efficacy of the immunotherapeutic strategies.
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Affiliation(s)
- Jonathan D Mizrahi
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rishi Surana
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Rachna T Shroff
- Division of Hematology and Oncology, Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA.
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45
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Seyedin S, Luu C, Stabile BE, Lee B. Effect of Socioeconomic Status on Surgery for Pancreatic Adenocarcinoma. Am Surg 2020. [DOI: 10.1177/000313481207801026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Survival for pancreatic cancer remains poor. Surgical resection remains the only chance for cure. The intent of this study was to investigate the role of socioeconomic status (SES) on resection rates for pancreatic adenocarcinoma. The National Cancer Institute's Surveillance, Epidemiology, and End results database was used to identify patients with pancreatic adenocarcinoma. Disease was deemed resectable or unresectable based on the extent of disease code. Median family income was used as a SES variable to compare patients who underwent resection with those who did not. Median family income was organized into three categories based on definitions from the national census: less than $34,680 (low income), $34,680 to $48,650 (middle), and greater than $48,650 (high income). A total of 5,908 patients with potentially resectable disease were included. A total of 3,331 patients did not have a surgical resection despite having resectable disease. Subgroup analysis of income status revealed that patients with a low or middle income were less likely to have a resection when compared with those with high income (33.0 vs 39.9 vs 45.8%, P = 0.0001). Multivariate analysis revealed that low and middle SES and race were significant predictors of resection. Ongoing study of access to health care may help define the means to eliminate the disparities in the care of patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Steven Seyedin
- From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Carrie Luu
- From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Bruce E. Stabile
- From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Byrne Lee
- From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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46
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Ethnic and racial disparities of pancreatic adenocarcinoma in Florida. HPB (Oxford) 2020; 22:735-743. [PMID: 31601507 DOI: 10.1016/j.hpb.2019.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/18/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial disparities are known to negatively impact survival in patients with pancreatic adenocarcinoma. However, data regarding the Hispanic ethnicity are scarce in the pancreatic cancer literature. Therefore, the aim of this study is to analyze whether race and ethnicity are independent predictors of survival in patients with pancreatic adenocarcinoma in Florida. METHODS A retrospective study was performed utilizing all patients diagnosed with pancreatic adenocarcinoma between 1983 and 2013 in the Florida Cancer Data System (FCDS). Statistical analysis was performed using Cox proportional hazard regression models, and Kaplan-Meier survival analysis. RESULTS Of 36,756 patients identified with pancreatic adenocarcinoma in the FCDS, 9.1% were Hispanic and 91% were non-Hispanic. Ethnicity was associated with improved survival among Hispanics compared to non-Hispanics (HR 0.86, 95% CI 0.82-0.90, both p = 0.001). Furthermore, 90% of patients were White, and 9% were Black. Compared to Whites, Blacks had a significantly decreased survival (HR 1.07, 95% CI 1.03-1.13, p = 0.003). CONCLUSION In Florida patients with pancreatic adenocarcinoma, Hispanic ethnicity is associated with improved survival compared to Non-Hispanics. Additionally, Blacks present at an earlier age and later stage of diagnosis with worse survival compared to Whites and Others.
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47
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Riner AN, Underwood PW, Yang K, Herremans KM, Cameron ME, Chamala S, Qiu P, George TJ, Permuth JB, Merchant NB, Trevino JG. Disparities in Pancreatic Ductal Adenocarcinoma-The Significance of Hispanic Ethnicity, Subgroup Analysis, and Treatment Facility on Clinical Outcomes. Cancer Med 2020; 9:4069-4082. [PMID: 32285629 PMCID: PMC7300394 DOI: 10.1002/cam4.3042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/07/2020] [Accepted: 03/18/2020] [Indexed: 12/12/2022] Open
Abstract
Background Disparities exist among patients with pancreatic ductal adenocarcinoma (PDAC). Non‐White race is regarded as a negative predictor of expected treatment and overall survival. Data suggest that Academic Research Programs (ARP) provide better outcomes for minorities, but ethnic/minority outcomes are underreported. We hypothesize that outcomes among racially/ethnically diverse PDAC patients may be influenced by treatment facility. Methods The National Cancer Database was used to identify 170,327 patients diagnosed with PDAC between 2004 and 2015. Cox proportional‐hazard regression was used to compare survival between race/ethnic groups across facilities. Results In unadjusted models, compared to non‐Hispanic Whites (NHW), non‐Hispanic Blacks (NHB) had the worst overall survival (HR = 1.05, 95%CI: 1.03‐1.06, P < .001) and Hispanics had the best overall survival (HR = 0.92, 95%CI: 0.90‐0.94, P < .001). After controlling for socioeconomic and clinical covariates, NHB (HR = 0.95, 95%CI: 0.93‐0.96, P < .001) had better overall survival compared to NHW, and Hispanics continued to have the best comparative outcomes (HR = 0.84, 95%CI: 0.82‐0.86, P < .001). Among Hispanics, Dominicans and South/Central Americans lived the longest, at 10.25 and 9.82 months, respectively. The improved survival in Hispanics was most pronounced at ARP (HR = 0.80, 95%CI: 0.77‐0.84, P < .001) and Integrated Network Cancer Programs (HR = 0.78, 95%CI: 0.73‐0.84, P < .001). NHB had improved survival over NHW at Comprehensive Community Care Programs (HR = 0.96, 95%CI: 0.93‐0.98, P = .002) and ARP (HR = 0.96, 95%CI: 0.94‐0.98, P = .001), which was influenced by income, education, and surgical resection. Conclusion Survival was improved at ARP for all populations. Hispanics had the best comparative overall survival. NHB had improved overall survival at higher volume centers, but this was dependent upon income, education, and surgical resection.
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Affiliation(s)
- Andrea N Riner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Patrick W Underwood
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kai Yang
- Department of Biostatistics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kelly M Herremans
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Miles E Cameron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Srikar Chamala
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peihua Qiu
- Department of Biostatistics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jennifer B Permuth
- Departments of Cancer Epidemiology and Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nipun B Merchant
- Department of Surgery, University of Miami College of Medicine, Miami, FL, USA
| | - Jose G Trevino
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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49
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Tavakkoli A, Singal AG, Waljee AK, Elmunzer BJ, Pruitt SL, McKey T, Rubenstein JH, Scheiman JM, Murphy CC. Racial Disparities and Trends in Pancreatic Cancer Incidence and Mortality in the United States. Clin Gastroenterol Hepatol 2020; 18:171-178.e10. [PMID: 31202981 DOI: 10.1016/j.cgh.2019.05.059] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/23/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic cancer is one of the few cancers in the United States that is increasing in incidence. Little is known about racial disparities in incidence and mortality. We characterized racial disparities in pancreatic cancer incidence and mortality in different locations, time periods, age groups, and disease stages. METHODS We obtained data on the incidence of pancreatic cancer from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program of cancer registries from 2001 through 2015 on incidence, demographics, tumor characteristics, and population estimates for all 50 states and the District of Columbia. We obtained data on mortality from pancreatic cancer from the National Center for Health Statistics during the same time period. We plotted incidence rates by 10-year age group (30-39 years through 70-79 years and 80 years or older) separately for white and black patients. We calculated incidence and mortality rate ratios with 95% CIs for categories of age and race. To determine racial disparities, we calculated incidence rate ratios (IRR) for black vs white patients and mortality rate ratios by state. RESULTS Disparities in pancreatic cancer incidence and mortality in black vs white patients decreased over 5-year time periods from 2001 through 2015. However, among all age groups, from 2001 through 2015, pancreatic cancer incidence and mortality were higher among blacks than whites (incidence, 24.7 vs 19.4 per 100,000; IRR, 1.28; 95% CI, 1.26-1.29; mortality, 23.3 vs 18.4 per 100,000; IRR, 1.27; 95% CI, 1.26-1.28). Black patients had a higher incidence of distant pancreatic cancer (IRR, 1.32; 95% CI, 1.31-1.34) and a lower incidence of local cancer. Incidence increased in whites and blacks of younger age groups and was most prominent among persons 30-39 years old. Incidence increased by 57% among younger whites (IRR, 1.70; 95% CI, 1.43-2.02) and by 44% among blacks (IRR, 1.47; 95% CI, 1.01-2.15) from 2001 through 2015. Mortality remained stable among blacks and slightly increased among whites during this time period. CONCLUSIONS In the United States, there are racial disparities in pancreatic incidence and mortality that vary with location, patient age, and cancer stage. Further research is needed to identify factors associated with increasing incidence and persistence of racial disparities in pancreatic cancer.
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Affiliation(s)
- Anna Tavakkoli
- Department of Internal Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas.
| | - Amit G Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Akbar K Waljee
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - B Joseph Elmunzer
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas Texas
| | - Thomas McKey
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas
| | - Joel H Rubenstein
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - James M Scheiman
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia
| | - Caitlin C Murphy
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas Texas
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50
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Abstract
Purpose: Pancreatic cancer remains a major health concern; in the next 2 years, it will become the second leading cause of cancer deaths in the United States. Health disparities in the treatment of pancreatic cancer exist across many disciplines, including race and ethnicity, socioeconomic status (SES), and insurance. This narrative review discusses what is known about these disparities, with the goal of highlighting targets for equity promoting interventions. Methods: We performed a narrative review of health disparities in pancreatic cancer spanning greater than ten areas, including epidemiology, treatment, and outcome, using the PubMed NIH database from 2000 to 2019 in the Unites States. Results: African Americans (AAs) tend to present at diagnosis with later stage disease. AAs and Hispanics have lower rates of surgical resection, are more likely to be treated at low volume hospitals, and often experience higher rates of morbidity and mortality compared to white patients, although control for confounders is often limited. Insurance and SES also factor into the delivery of treatment for pancreatic cancer. Conclusion: Disparities by race and SES exist in the diagnosis and treatment of pancreatic cancer that are largely driven by race and SES. Improved understanding of underlying causes could inform interventions.
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Affiliation(s)
- Marcus Noel
- Department of Medicine Hematology and Oncology Division, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Kevin Fiscella
- Department of Medicine Hematology and Oncology Division, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
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