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Munir MM, Rashid Z, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma. Surgery 2024:S0039-6060(24)00309-X. [PMID: 38890100 DOI: 10.1016/j.surg.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/16/2024] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection. METHODS Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival. RESULTS A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001). CONCLUSION Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Rashid Z, Munir MM, Woldesenbet S, Khan MMM, Khalil M, Endo Y, Tsilimigras DI, Dillhoff M, Ejaz A, Pawlik TM. Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer. J Surg Oncol 2024; 129:850-859. [PMID: 38151795 DOI: 10.1002/jso.27571] [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: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M M Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Guideline adherence and implementation of tumor board therapy recommendations for patients with gastrointestinal cancer. J Cancer Res Clin Oncol 2023; 149:1231-1240. [PMID: 35394231 PMCID: PMC9984328 DOI: 10.1007/s00432-022-03991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Although participation in multidisciplinary tumor boards (MTBs) is an obligatory quality criterion for certification, there is scarce evidence, whether MTB recommendations are consistent with consensus guidelines and whether they are followed in clinical practice. Reasons of guideline and tumor board deviations are poorly understood so far. METHODS MTB's recommendations from the weekly MTB for gastrointestinal cancers at the University Cancer Center Leipzig/Germany (UCCL) in 2020 were analyzed for their adherence to therapy recommendations as stated in National German guidelines and implementation within an observation period of 3 months. To assess adherence, an objective classification system was developed assigning a degree of guideline and tumor board adherence to each MTB case. For cases with deviations, underlying causes and influencing factors were investigated and categorized. RESULTS 76% of MTBs were fully adherent to guidelines, with 16% showing deviations, mainly due to study inclusions and patient comorbidities. Guideline adherence in 8% of case discussions could not be determined, especially because there was no underlying guideline recommendation for the specific topic. Full implementation of the MTBs treatment recommendation occurred in 64% of all cases, while 21% showed deviations with primarily reasons of comorbidities and differing patient wishes. Significantly lower guideline and tumor board adherences were demonstrated in patients with reduced performance status (ECOG-PS ≥ 2) and for palliative intended therapy (p = 0.002/0.007). CONCLUSIONS The assessment of guideline deviations and adherence to MTB decisions by a systematic and objective quality assessment tool could become a meaningful quality criterion for cancer centers in Germany.
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Elshami M, Ahmed FA, Kakish H, Hue JJ, Hoehn RS, Rothermel LD, Bajor D, Mohamed A, Selfridge JE, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Trends and disparities in the utilization of systemic chemotherapy in patients with metastatic hepato-pancreato-biliary cancers. HPB (Oxford) 2023; 25:239-251. [PMID: 36411233 DOI: 10.1016/j.hpb.2022.11.003] [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: 05/24/2022] [Revised: 10/12/2022] [Accepted: 11/02/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND We described trends and disparities in utilization of systemic chemotherapy in metastatic hepato-pancreato-biliary (HPB) cancers. METHODS We queried the National Cancer Database for metastatic HPB cancers [hepatocellular carcinoma (HCC), biliary tract cancers (BTC), pancreatic adenocarcinoma (PDAC)]. We used multivariable analysis to examine the factors associated with utilization of systemic chemotherapy. We utilized marginal structural logistic models to estimate the effect of health insurance, facility type, or facility volume on utilization of systemic chemotherapy. RESULTS We identified 162,283 patients with metastatic HPB cancers: 23,923 (14.7%) had HCC, 26,766 (16.5%) had BTC, and 111,594 (68.8%) had PDAC. A total of 37.2% patients with HCC, 55.6% with BTC, and 56.4% with PDAC received chemotherapy. Age ≥70 years and Charlson-Deyo score ≥2 were associated with lower likelihood of receiving chemotherapy across all cancers. Patients with private health insurance had higher receipt of chemotherapy. Receiving treatment at academic facilities had no effect on the receipt of chemotherapy. Treatment of patients with HCC or PDAC at high-volume facilities resulted in higher receipt of chemotherapy. CONCLUSION A significant proportion of patients with metastatic HPB cancers do not receive systemic chemotherapy. Several disparities in administration of chemotherapy for metastatic HPB cancers exist.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Fasih A Ahmed
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Hanna Kakish
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Bajor
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amr Mohamed
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Munir MM, Ruff SM, Endo Y, Lima HA, Alaimo L, Moazzam Z, Shaikh C, Pawlik TM. Does Adjuvant Therapy Benefit Low-Risk Resectable Cholangiocarcinoma? An Evaluation of the NCCN Guidelines. J Gastrointest Surg 2022; 27:511-520. [PMID: 36538255 DOI: 10.1007/s11605-022-05558-9] [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: 10/27/2022] [Accepted: 12/06/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant therapy for patients with resectable cholangiocarcinoma (CCA). The trends in utilization and receipt of adjuvant therapy and its association with overall survival have not been well studied among patients with low-risk CCA. METHODS Patients who received systemic chemotherapy for low-risk CCA after surgical resection (2010-2017) were identified in the National Cancer Database. Low-risk CCA was defined according to NCCN guidelines as patients with R0 margins and negative regional lymph nodes. Multivariable analysis was performed to assess predictors of NCCN guideline concordance and its association with overall survival. RESULTS Among 4519 patients who underwent resection for low-risk CCA, 55.5% (n = 2510) had intrahepatic, 15.0% (n = 680) had perihilar, and 29.4% (n = 1329) had distal cholangiocarcinoma. Adherence to NCCN guidelines increased from 27.7% in 2010 to 41.6% in 2017 (ptrend < 0.001) for low-risk CCA. On multivariable analysis, receipt of NCCN guideline-concordant care was associated with a nearly 15% decrease in mortality hazards (HR 0.86, 95%CI 0.78-0.95, [Formula: see text]). Increased distance travelled (Ref < 12.5 miles, 50-249 miles: OR 0.55, 95%CI 0.49-0.69; ≥ 250 miles: OR 0.41, 95%CI 0.25-0.6), and care in the South (OR 0.78, 95%CI 0.64-0.95) or Midwest (OR 0.66, 95%CI 0.53-0.81) of the United States versus the Northeast was associated with not receiving guideline-concordant care. CONCLUSION Adherence to evidence-based NCCN guidelines was associated with improved survival among low-risk CCA patients. Geographical disparities in the receipt of NCCN guideline-concordant care exist and may influence long-term outcomes among CCA patients.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Samantha M Ruff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Kaslow SR, Ma Z, Hani L, Prendergast K, Vitiello G, Lee AY, Berman RS, Goldberg JD, Correa-Gallego C. Adherence to guidelines at the patient- and hospital-levels is associated with improved overall survival in patients with gastric cancer. J Surg Oncol 2022; 126:479-489. [PMID: 35471731 PMCID: PMC9339461 DOI: 10.1002/jso.26895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/05/2022] [Accepted: 04/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Adherence to evidence-based guidelines in gastric cancer is low. We aimed to evaluate adherence to National Comprehensive Cancer Network (NCCN) Guidelines for gastric cancer at both patient- and hospital-levels and examine associations between guideline adherence and treatment outcomes, including overall survival (OS). METHODS We applied stage-specific, annual NCCN Guidelines (2004-2015) to patients with gastric cancer treated with curative-intent within the National Cancer Database and compared characteristics of patients who did and did not receive guideline-adherent care. Hospitals were evaluated by guideline adherence rate. We identified associations with OS through multivariable Cox regression. RESULTS Of 37 659 patients included, 32% received NCCN Guideline-adherent treatment. OS was significantly associated with both guideline adherence (51 months for patients receiving guideline-adherent treatment vs. 22 for patients receiving nonadherent treatment, p < 0.001). Treatment at a hospital with higher adherence was associated with longer OS (21 months for patients treated at lowest adherence quartile hospitals vs. 37 months at highest adherence quartile hospitals, p < 0.001), regardless of type of treatment received. CONCLUSIONS Guideline-adherent treatment was strongly associated with longer median OS. Guideline adherence should be used as a benchmark for focused quality improvement for physicians taking care of patients with gastric cancer and institutions at large.
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Affiliation(s)
| | - Zhongyang Ma
- Division of Biostatistics, Departments of Population Health and Environmental Medicine, NYU Grossman School of Medicine
| | - Leena Hani
- Department of Surgery, NYU Grossman School of Medicine
| | | | | | - Ann Y Lee
- Department of Surgery, NYU Grossman School of Medicine
| | | | - Judith D Goldberg
- Division of Biostatistics, Departments of Population Health and Environmental Medicine, NYU Grossman School of Medicine
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Koh WJ, Anderson BO, Carlson RW. NCCN resource-stratified and harmonized guidelines: A paradigm for optimizing global cancer care. Cancer 2021; 126 Suppl 10:2416-2423. [PMID: 32348572 DOI: 10.1002/cncr.32880] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/08/2023]
Abstract
Clinical practice guidelines in oncology lead to improved outcomes in care. However, the most frequently used guidelines are developed for highly resourced systems. Recognizing the significant and increasing burden of cancer in low- and middle-income countries, the National Comprehensive Cancer Network (NCCN) has developed resource-stratified framework and harmonization processes that allow the NCCN Guidelines to be tailored and optimized for specific geographical areas, resource levels, and settings. The critical need for local expertise and involvement in successful development and uptake is emphasized, and the promise of this collaboration for advancement in oncology programs is illustrated.
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Affiliation(s)
- Wui-Jin Koh
- National Comprehensive Cancer Center, Plymouth Meeting, Pennsylvania
| | - Benjamin O Anderson
- University of Washington School of Medicine, Seattle, Washington.,Breast Health Global Initiative, Seattle, Washington
| | - Robert W Carlson
- National Comprehensive Cancer Center, Plymouth Meeting, Pennsylvania.,Division of Medical Oncology, Stanford University Medical Center, Palo Alto, California.,Stanford Medical Informatics, Stanford University Medical Center, Palo Alto, California
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Wang T, Sun Y, Xiong Z, Wu J, Ding X, Guo X, Shao Y. Association of ST6GAL1 and CYP19A1 polymorphisms in the 3'-UTR with astrocytoma risk and prognosis in a Chinese Han population. BMC Cancer 2021; 21:391. [PMID: 33836687 PMCID: PMC8034180 DOI: 10.1186/s12885-021-08110-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background Astrocytoma is a common type of central nervous system tumor. In this study, we investigated the correlation between ST6GAL1 and CYP19A1 polymorphisms and the risk and prognosis of astrocytoma. Methods A total of 365 astrocytoma patients and 379 healthy controls were genotyped using the Agena MassARRAY system. The correlation between ST6GAL1 and CYP19A1 variants and astrocytoma risk was calculated using logistic regression. The survival rate of patients with astrocytoma was analyzed to evaluate prognosis. Results We found that the ST6GAL1-rs2239611 significantly decreased the risk of astrocytoma in the codominant model (p = 0.044) and dominant model (p = 0.049). In stratified analyses, CYP19A1-rs2255192 might be associated with a higher risk of astrocytoma among the low-grade subgroup under recessive (p = 0.034) and additive (p = 0.030) models. However, CYP19A1-rs4646 had a risk-decreasing effect on the high-grade subgroup in the codominant model (p = 0.044). The results of Cox regression analysis showed that the CYP19A1-rs2239611 and -rs1042757 polymorphisms were significantly correlated with the prognosis of astrocytoma. Conclusion Our results suggest that ST6GAL1 and CYP19A1 genes may be a potential biomarker of genetic susceptibility and prognosis to astrocytoma in the Chinese Han population. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08110-1.
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Affiliation(s)
- Tuo Wang
- Department of Neurosurgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yao Sun
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, 710069, China
| | - Zichao Xiong
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, 710069, China
| | - Jiamin Wu
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, 710069, China
| | - Xiaoying Ding
- Department of Neurosurgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xiaoye Guo
- Department of Neurosurgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yuan Shao
- Department of Otorhinolaryngology Head and Neck Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, 277 YanTa West Road, Xi'an, 710061, Shaanxi, China.
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Sweigert PJ, Eguia E, Janjua H, Nassoiy SP, Knab LM, Abood G, Kuo PC, Baker MS. Does resection improve overall survival for intrahepatic cholangiocarcinoma with nodal metastases? Surg Open Sci 2020; 2:107-112. [PMID: 32754714 PMCID: PMC7391899 DOI: 10.1016/j.sopen.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 01/25/2023] Open
Abstract
Background The potential benefit of surgical resection of intrahepatic cholangiocarcinoma in patients with locoregionally advanced disease has not been definitively determined. Methods The National Cancer Database was queried to identify patients with clinical evidence of node-positive intrahepatic cholangiocarcinoma. Resected patients were stratified by margin status and lymph node ratio (nodes positive to nodes harvested). Risk of death was determined using Cox regression models and Kaplan-Meier survival functions. Results A total of 1,425 patients with T(any)N1M0 intrahepatic cholangiocarcinoma were identified. Two hundred twelve (14.9%) underwent surgical resection. On multivariable Cox regression, R0 resection afforded a survival benefit regardless of lymph node ratio (lymph node ratio > 0.5: hazard ratio 0.466, 95% confidence interval 0.304–0.715; lymph node ratio ≤ 0.5: hazard ratio 0.444, 95% confidence interval 0.322–0.611), whereas a survival benefit was only seen in R1 patients with lymph node ratio ≤ 0.5 (hazard ratio 0.470, 95% confidence interval 0.316–0.701). On Kaplan-Meier, median survival was 11.6 months with chemotherapy, 15.7 months with R0 resection in lymph node ratio > 0.5, and 22.2 months with R0 resection in lymph node ratio ≤ 0.5 (P < .001). Discussion Margin negative resection is associated with a risk-adjusted survival benefit for patients with clinically N1 intrahepatic cholangiocarcinoma regardless of the degree of regional lymph node involvement.
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Affiliation(s)
- Patrick J. Sweigert
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
- Corresponding author at: Patrick J. Sweigert, MD, Department of Surgery, 2160 S First Ave, Maywood, IL 60153. Tel.: + 1-708-327-2413; fax: + 1-708-327-2813.
| | - Emanuel Eguia
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
| | - Haroon Janjua
- University of South Florida, Department of Surgery, 2 Tampa General Circle, Tampa, FL 33606
| | - Sean P. Nassoiy
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
| | - Lawrence M. Knab
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
| | - Gerard Abood
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
| | - Paul C. Kuo
- University of South Florida, Department of Surgery, 2 Tampa General Circle, Tampa, FL 33606
| | - Marshall S. Baker
- Loyola University Medical Center, Department of Surgery, 2160 S First Ave, Maywood, IL 60153
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Sahara K, Tsilimigras DI, Mehta R, Moro A, Paredes AZ, Lopez-Aguiar AG, Rocha F, Kanji Z, Weber S, Fisher A, Fields R, Krasnick BA, Idrees K, Smith PM, Poultsides GA, Makris E, Cho C, Beems M, Dillhoff M, Maithel SK, Endo I, Pawlik TM. Trends in the Number of Lymph Nodes Evaluated Among Patients with Pancreatic Neuroendocrine Tumors in the United States: A Multi-Institutional and National Database Analysis. Ann Surg Oncol 2019; 27:1203-1212. [PMID: 31838609 DOI: 10.1245/s10434-019-08120-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of routine lymphadenectomy in the surgical treatment of pancreatic neuroendocrine tumors (pNET) remains poorly defined. The objective of the current study was to investigate trends in the number of lymph nodes (LN) evaluated for pNET treatment at a nationwide level. METHODS Patients undergoing surgery for pNET between 2000 and 2016 were identified in the U.S. Neuroendocrine Tumor Study Group (US-NETSG) database as well as the Surveillance, Epidemiology, and End Results (SEER) database. The number of LNs examined was evaluated over time. RESULTS The median number of evaluated LNs increased roughly fourfold over the study period (US-NETSG, 2000: 3 LNs vs. 2016: 13 LNs; SEER, 2000: 3 LNs vs. 2016: 11 LNs, both p < 0.001). While no difference in 5-year OS and RFS was noted among patients who had 1-3 lymph node metastases (LNM) vs. ≥ 4 LNM between 2000-2007 (OS 73.5% vs. 69.9%, p = 0.12; RFS: 64.9% vs. 40.1%, p = 0.39), patients who underwent resection and LN evaluation during the period 2008-2016 had an incrementally worse survival if the patient had node negative disease, 1-3 LNM and ≥ 4 LNM (OS 86.8% vs. 82.7% vs. 74.9%, p < 0.001; RFS: 86.3% vs. 64.7% vs. 50.4%, p < 0.001). On multivariable analysis, a more recent year of diagnosis, pancreatic head tumor location, and tumor size > 2 cm were associated with 12 or more LNs evaluated in both US-NETSG and SEER databases. CONCLUSION The number of LNs examined nearly quadrupled over the last decade. The increased number of LNs examined suggested a growing adoption of the AJCC staging manual recommendations regarding LN evaluation in the treatment of pNET.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Zaheer Kanji
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander Fisher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, WI, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, WI, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Paula M Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | | | | | - Cliff Cho
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Association Between Travel Distance, Hospital Volume, and Outcomes Following Resection of Cholangiocarcinoma. J Gastrointest Surg 2019; 23:944-952. [PMID: 30815777 DOI: 10.1007/s11605-019-04162-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of the current study was to characterize the association between travel distance/hospital volume relative to outcomes following resection of cholangiocarcinoma. METHODS Patients were identified using the 2004-2015 National Cancer Database and stratified into quartiles according to travel distance/hospital volume. Multivariable regression models were utilized to examine the impact of travel distance and hospital volume on quality-of-care metrics and overall survival. RESULTS Among 5125 patients, the majority of patients had T1/2 (N = 2006, 41.1%) and N0 disease (N = 2498, 50.9%). Median hospital quartile surgical volumes in cases/year were low volume (LV) 6, intermediate low volume (ILV) 7, intermediate high volume (IHV) 12, and high volume (HV) 24 cases/year. Median travel distance quartiles in miles were short travel (ST) 2.7, intermediate short travel (IST) 7.9, intermediate long travel (ILT) 18.9, and long travel (LT) 84.7. Longer travel distances were associated with better overall survival, as every 10 miles was associated with a 2% decrease in mortality (p = 0.02). Differences in quality-of-care metrics were largely mediated through travel distance. CONCLUSIONS Travel distance and hospital volume were associated with certain quality-of-care metrics among patients with cholangiocarcinoma. After controlling for hospital volume and travel distance simultaneously, only travel distance was associated with decreased risk of mortality.
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12
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Spolverato G, Bagante F, Tsilimigras D, Ejaz A, Cloyd J, Pawlik TM. Management and outcomes among patients with mixed hepatocholangiocellular carcinoma: A population-based analysis. J Surg Oncol 2018; 119:278-287. [PMID: 30554420 DOI: 10.1002/jso.25331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND We sought to define the management of mixed hepatocellular carcinoma-intrahepatic cholangiocarcinoma (HCC-ICC) as well as characterize short- and long-term outcomes of patients with mixed HCC-ICC. METHODS Patients diagnosed with HCC-ICC, HCC, or ICC between 2004 and 2015 were identified from the National Cancer Data Base using the International Classification of Diseases for Oncology codes. Short- and long-term outcomes were assessed using univariate and multivariate analyses. RESULTS Among 174 454 patients, 86.8% had HCC, 12.1% ICC, and 1.1% HCC-ICC. The incidence of lymphadenectomy was 55.6% among ICC patients vs 15.1% and 34.2% for HCC and HCC-ICC patients, respectively (P < 0.001). A 90-day mortality was comparable among patients with HCC (9.1%), ICC (8.8%), and HCC-ICC (10.5%) (all P > 0.2). While 42.0% of ICC patients received adjuvant chemotherapy, adjuvant chemotherapy among HCC and HCC-ICC patients was 13.1% and 27.4%, respectively (P < 0.001). A 5-year survival was 43.5% (95% CI, 42.5-44.5), 33.3% (95% CI, 31.4-35.3), 34.4% (95% CI, 29.1-39.8) for HCC, ICC, and HCC-ICC patients, respectively. CONCLUSION Patients who underwent resection of mixed HCC-ICC had a prognosis that was comparable to ICC, yet worse than HCC. Utilization of lymphadenectomy and adjuvant therapy were low. HCC-ICC remains a rare disease with a guarded prognosis that should be treated in a multidisciplinary setting.
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Affiliation(s)
- Gaya Spolverato
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Surgery, University of Verona, Verona, Italy
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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