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Bakkila BF, Kerekes D, Nunez-Smith M, Billingsley KG, Ahuja N, Wang K, Oladele C, Johnson CH, Khan SA. Evaluation of Racial Disparities in Quality of Care for Patients With Gastrointestinal Tract Cancer Treated With Surgery. JAMA Netw Open 2022; 5:e225664. [PMID: 35377425 PMCID: PMC8980937 DOI: 10.1001/jamanetworkopen.2022.5664] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Racial disparities have been demonstrated in many facets of health care, but a comprehensive understanding of who is most at risk for substandard surgical care of gastrointestinal tract cancers is lacking. OBJECTIVE To examine racial disparities in quality of care of patients with gastrointestinal tract cancers. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of patients with gastrointestinal tract cancer included the US population as captured in the National Cancer Database with a diagnosis from January 1, 2004, to December 31, 2017. Participants included 565 124 adults who underwent surgical resection of gastrointestinal tract cancers. Data were analyzed from June 21 to December 23, 2021. EXPOSURES Race and site of cancer. MAIN OUTCOMES AND MEASURES Oncologic standard of care, as defined by negative resection margin, adequate lymphadenectomy, and receipt of indicated adjuvant chemotherapy and/or radiotherapy. RESULTS Among 565 124 adult patients who underwent surgical resection of a gastrointestinal tract cancer, 10.9% were Black patients, 83.5% were White patients, 54.7% were men, and 50.7% had Medicare coverage. The most common age range at diagnosis was 60 to 69 years (28.5%). Longer median survival was associated with negative resection margins (87.3 [IQR, 28.5-161.9] months vs 22.9 [IQR, 8.8-69.2] months; P < .001) and adequate lymphadenectomies (80.7 [IQR, 25.6 to not reached] months vs 57.6 [IQR, 17.7-153.8] months; P < .001). After adjustment for covariates, Black patients were less likely than White patients to have negative surgical margins overall (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and after esophagectomy (OR, 0.71 [95% CI, 0.58-0.87]), proctectomy (OR, 0.71 [95% CI, 0.66-0.76]), and biliary resection (OR, 0.75 [95% CI, 0.61-0.91]). Black patients were also less likely to have adequate lymphadenectomy overall (OR, 0.89 [95% CI, 0.87-0.91]) and after colectomy (OR, 0.89 [95% CI, 0.87-0.92]), esophagectomy (OR, 0.72 [95% CI, 0.63-0.83]), pancreatectomy (OR, 0.90 [95% CI, 0.85-0.96]), proctectomy (OR, 0.93 [95% CI, 0.88-0.98]), proctocolectomy (OR, 0.90 [95% CI, 0.81-1.00]), and enterectomy (OR, 0.71 [95% CI, 0.65-0.79]). Black patients were more likely than White patients not to be recommended for chemotherapy (OR, 1.15 [95% CI, 1.10-1.21]) and radiotherapy (OR, 1.49 [95% CI, 1.35-1.64]) because of comorbidities and more likely not to receive recommended chemotherapy (OR, 1.68 [95% CI, 1.55-1.82]) and radiotherapy (OR, 2.18 [95% CI, 1.97-2.41]) for unknown reasons. CONCLUSIONS AND RELEVANCE These findings suggest that there are significant racial disparities in surgical care of gastrointestinal tract cancers. Black patients are less likely than White patients to receive standard of care with respect to negative surgical margins, adequate lymphadenectomies, and use of adjuvant therapies. Both system- and physician-level reforms are needed to eradicate these disparities in health care.
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Affiliation(s)
- Baylee F. Bakkila
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Daniel Kerekes
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kevin G. Billingsley
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Karen Wang
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Carol Oladele
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut
| | - Caroline H. Johnson
- Department of Environmental Health Sciences, Yale School of Public Health, Yale University, New Haven, Connecticut
| | - Sajid A. Khan
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Croghan SM, Matanhelia DM, Foran AT, Galvin DJ. Oncological Outcomes of Open Radical Retropubic Prostatectomy in Ireland: A Single Surgeon's 5-Year Experience. Surg J (N Y) 2018; 4:e226-e234. [PMID: 30574556 PMCID: PMC6261740 DOI: 10.1055/s-0038-1675827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 10/08/2018] [Indexed: 12/17/2022] Open
Abstract
Objectives There is a little published data on the outcomes of radical prostatectomy in the Irish context. We aimed to determine the 5-year oncological results of open radical retropubic prostatectomy (RRP) performed by a single surgeon following appointment. Methods A retrospective review of RRPs performed between 2011 and 2016 was conducted. Patient demographics, preoperative parameters (clinical stage on digital rectal exam, prostate-specific antigen (PSA) levels, biopsy Gleason's score and MRI [magnetic resonance imaging] findings), pathological variables (T-stage, Gleason's score, nodal status, and surgical margin status), and treatment decisions (lymphadenectomy or adjuvant radiotherapy) were recorded. Oncological outcome at last follow-up was ascertained. Results 265 patients underwent RRP between 2011 and 2016. Median age was 62 years (range: 41-74). Mean follow-up was 32.24 months (range: 8-72) months. Pathological disease stage was T2 in 170/265 (64.15%), T3a in 65/265 (24.53%), and T3b in 30/265 (11.32%). Final Gleason's score was upgraded from diagnostic biopsy in 16.35% (43/263) and downgraded in 27% (71/263). Pelvic lymph node dissection was performed in 44.25% (118/265) patients. A positive surgical margin (PSM) was seen in 26/170 (15.2%) patients with T2 disease and in 45/95 (47.37%) patients with T3 disease. Of the 265 patients, 238 (89.81%) were disease-free at last follow-up, of whom 24/238 (10.08%) had received adjuvant and 17/238 (7.14%) received salvage radiotherapy. Adjuvant/salvage treatment was ongoing in 19/265 (7.17%) of patients. Conclusion Good oncological outcomes of RRP in the Irish context are seen in this 5-year review, with the vast majority of patients experiencing biochemical-free survival at most recent follow-up.
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Affiliation(s)
- Stefanie M Croghan
- Department of Urology, The Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | | | - Ann T Foran
- Department of Urology, The Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | - David J Galvin
- Department of Urology, The Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland.,Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin, Ireland.,Department of Urology, St. Vincent's Private Hospital, Elm Park, Dublin, Ireland
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Therapeutic Value of Standard Versus Extended Pelvic Lymph Node Dissection During Radical Prostatectomy for High-Risk Prostate Cancer. Curr Urol Rep 2018; 18:51. [PMID: 28589397 DOI: 10.1007/s11934-017-0696-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Extent of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) remains a subject of debate. Here, we review the literature covering the value of extended PLND (ePLND) during RP for high-risk prostate cancer (PCa) over a standard PLND, with a focus on potential therapeutic advantage. PLND may provide valuable prognostic information to high-risk PCa patients, and incorporating the common iliac and presacral nodes to ePLND templates further improves pathologic nodal staging accuracy. Although increased PLND extent is associated with increased lymphocele/lymphedema rates, it is not associated with increased venous thromboembolism rates. The therapeutic role of ePLND remains uncertain. While recent retrospective studies suggest an increased number of nodes removed within the ePLND template are associated with improved survival outcomes, such retrospective studies cannot completely adjust for the Will Rodgers phenomenon or surgeon-specific factors. Thus, the results of randomized trials are eagerly awaited in this arena.
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Al-Mazrou AM, Baser O, Kiran RP. The effect of hospital familiarity with complex procedures on overall healthcare burden. Am J Surg 2018; 216:204-212. [PMID: 29395028 DOI: 10.1016/j.amjsurg.2018.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/04/2018] [Accepted: 01/14/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to evaluate variations in prolonged outcome after proctectomy based on hospital volume. STUDY DESIGN From the Premier Perspective database (2012-2014), hospital volumes for proctectomy of benign and malignant conditions were classified as low, intermediate and high. Hospitals were grouped into tertiles. Impact of procedure volume on in-hospital as well as 90-day post-discharge complications, length of stay, discharge destination and costs was evaluated. RESULTS Of 9306 proctectomy procedures, 6960 occurred at high, 1695 at intermediate and 651 at low volume hospitals. After adjustment, high volume institutions were associated with lower in-hospital surgical complications while low volume centers had higher ninety-day post-discharge medical and surgical complications (p < .05 for all). High volume centers had a shorter hospital stay while the need for extended care facility was higher in low volume centers (p < .05 for all). Healthcare costs were higher for low volume hospitals. CONCLUSION These data suggest that variations in outcomes and costs after complex procedures such as proctectomy exist and are related to institutional familiarity with a procedure.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
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Henríquez I, Rodríguez-Antolín A, Cassinello J, Gonzalez San Segundo C, Unda M, Gallardo E, López-Torrecilla J, Juarez A, Arranz J. Consensus statement on definition, diagnosis, and management of high-risk prostate cancer patients on behalf of the Spanish Groups of Uro-Oncology Societies URONCOR, GUO, and SOGUG. Clin Transl Oncol 2017; 20:392-401. [PMID: 28785912 DOI: 10.1007/s12094-017-1726-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/26/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Prostate cancer (PCa) is the most prevalent malignancy in men and the second cause of mortality in industrialized countries. METHODS Based on Spanish Register of PCa, the incidence of high-risk PCa is 29%, approximately. In spite of the evidence-based beneficial effect of radiotherapy and androgen deprivation therapy in high-risk PCa, these patients (pts) are still a therapeutic challenge for all specialists involved, in part due to the absence of comparative studies to establish which of the present disposable treatments offer better results. RESULTS Nowadays, high-risk PCa definition is not well consensual through the published oncology guides. Clinical stage, tumour grade, and number of risk factors are relevant to be considered on PCa prognosis. However, these factors are susceptible to change depending on when surgical or radiation therapy is considered to be the treatment of choice. Other factors, such as reference pathologist, different diagnosis biopsy schedules, surgical or radiotherapy techniques, adjuvant treatments, biochemical failures, and follow-up, make it difficult to compare the results between different therapeutic options. CONCLUSIONS This article reviews important issues concerning high-risk PCa. URONCOR, GUO, and SOGUG on behalf of the Spanish Groups of Uro-Oncology Societies have reached a consensus addressing a practical recommendation on definition, diagnosis, and management of high-risk PCa.
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Affiliation(s)
- I Henríquez
- Radiation Oncology Department, Hospital Universitario of Sant Joan, Institute d'Investigació Sanitaria Pere Virgili (IISPV), Josep Laporte 2, 43204, Reus, Spain.
| | | | - J Cassinello
- Medical Oncology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | - M Unda
- Urology Department, Hospital Barakaldo, Bilbao, Spain
| | - E Gallardo
- Medical Oncology Department, Hospital Parc Taulí, Sabadell, Spain
| | | | - A Juarez
- Urology Department, Hospital Cádiz, Andalucía, Spain
| | - J Arranz
- Medical Oncology Department, Hospital Gregorio Marañón, Madrid, Spain
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Modi PK, Bock M, Kim S, Singer EA, Parikh RR. Utilization of Pelvic Lymph Node Dissection for Patients With Low-Risk Prostate Cancer Treated With Robot-Assisted Radical Prostatectomy. Clin Genitourin Cancer 2017; 15:e1001-e1006. [PMID: 28558990 DOI: 10.1016/j.clgc.2017.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/19/2017] [Accepted: 05/03/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Pelvic lymph node dissection (PLND) is not recommended for low-risk prostate cancer (PCa) patients. However, the rate of PLND in this population is unknown. METHODS We queried the National Cancer Data Base for PCa patients who underwent robot-assisted radical prostatectomy from 2010 to 2013 and stratified them by D'Amico risk classification. We identified the frequency of PLND in low-risk patients and identified factors associated with receipt of PLND. Further, we determined the number of lymph nodes evaluated (quality) and proportion of patients with detected nodal metastatic disease (utility) in each risk group. RESULTS Of 51,971 patients with low-risk PCa who underwent robot-assisted radical prostatectomy, 19,059 (36.7%) received PLND. Predictors of PLND in low-risk patients included rural residence (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.009-1.327), treatment at an academic center (OR, 1.492; 95% CI 1.188-1.874), and high-volume facility (OR, 1.327; 95% CI, 1.078-1.633). The mean number of lymph nodes obtained in low-risk patients was lower than in intermediate/high-risk patients (4.74 vs. 5.86, P < .0001). Lymph node positivity was identified in 0.4% of low-risk patients and 4.6% of intermediate/high-risk patients. CONCLUSION While PLND is not recommended for low-risk PCa by clinical practice guidelines, it was performed frequently (36.7%) in a large hospital-based data set. PLND in this population was of lower quality (nodal yield) and had less utility of detecting nodal metastatic disease than PLND in intermediate/high-risk PCa. Treatment at a high-volume or academic center was associated with increased use of PLND. Reasons for the variation in practice patterns should be investigated to improve the value of PCa care.
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Affiliation(s)
- Parth K Modi
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Megan Bock
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Sinae Kim
- Biometrics Division, Department of Biostatistics, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
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Mitsinikos E, Abdelsayed GA, Bider Z, Kilday PS, Elliott PA, Banapour P, Chien GW. Does the Level of Assistant Experience Impact Operative Outcomes for Robot-Assisted Partial Nephrectomy? J Endourol 2016; 31:38-42. [PMID: 27806631 DOI: 10.1089/end.2016.0508] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. MATERIALS AND METHODS All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and operative outcomes (WIT, estimated blood loss, operative time (OT), positive margin rate, length of stay (LOS), postoperative glomerular filtration rate, and readmission rate). RESULTS Of the 170 patients captured, 162 had R.E.N.A.L. nephrometry score and WIT: 112 from teaching hospitals and 50 from nonteaching hospitals. Patient characteristics were equivalent between both cohorts with the exception of the R.E.N.A.L. score, which was higher (6.3 vs 5.7, p = 0.046) in the teaching hospitals cohort. Regarding operative outcomes, we noted an overall increase in LOS by 1 day (p = 0.001) and OT by 16 minutes (p = 0.011) in the teaching hospitals. CONCLUSION We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.
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Affiliation(s)
- Emmanuel Mitsinikos
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | - George A Abdelsayed
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | - Zoe Bider
- 2 Department of Research & Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Patrick S Kilday
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | - Peter A Elliott
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | - Pooya Banapour
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
| | - Gary W Chien
- 1 Department of Urology, Kaiser Permanente Los Angeles Medical Center , Los Angeles, California
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Craft PS. Improving quality in prostate cancer. Med J Aust 2016; 204:290. [DOI: 10.5694/mja16.00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/26/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Paul S Craft
- The Canberra Hospital, Canberra, ACT
- Australian National University, Canberra, ACT
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Pelvic lymph node dissection in prostate cancer: indications, extent and tailored approaches. Urologia 2015; 84:9-19. [PMID: 26689534 DOI: 10.5301/uro.5000139] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2015] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study is to review the current literature concerning the indication of pelvic lymph node dissection (PLND), its extent and complications in prostate cancer (PCa) staging, the available tools, and the future perspectives to assess the risk of lymph node invasion (LNI). METHODS A literature review was performed using the Medline, Embase, and Web of Science databases. The search strategy included the terms pelvic lymph nodes, PLND, radical prostatectomy, prostate cancer, lymph node invasion, biochemical recurrence, staging, sentinel lymph node dissection, imaging, and molecular markers. RESULTS PLND currently represents the gold standard for nodal staging in PCa patients. Available imaging techniques are characterized by poor accuracy in the prediction of LNI before surgery. On the contrary, an extended PLND (ePLND) would result into proper staging in the majority of the cases. Several models based on preoperative disease characteristics are available to assess the risk of LNI. Although ePLND is not associated with a substantial risk of severe complications, up to 10% of the men undergoing this procedure experience lymphoceles. Concerns over potential morbidity of ePLND led many authors to investigate the role of sentinel lymph node dissection in order to prevent unnecessary ePLND. Finally, the incorporation of novel biomarkers in currently available tools would improve our ability to identify men who should receive an ePLND. CONCLUSIONS Nowadays, the most informative tools predicting LNI in PCa patients consist in preoperative clinical nomograms. Sentinel lymph node dissection still remains experimental and novel biomarkers are needed to identify patients at a higher risk of LNI.
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