Trends in the Care of Locally Advanced Pancreatic Cancer in the Modern Era of Chemotherapy

INTRODUCTION

Current guidelines for treatment for locally advanced pancreatic cancer recommend chemotherapy ± radiation, or radiation alone when multimodal therapy is contraindicated. In a subset of patients, guideline-recommended treatment (GRT) achieves sufficient response to qualify for potentially curative resection. This study evaluated trends in treatment utilization and aimed to identify barriers to GRT.

METHODS

Patients with clinical T4M0 disease in the National Cancer Database from 2010 to 2017 were included. Potential predictors were assessed by relative risk regression with Poisson distribution and compared by log-link function.

RESULTS

In total, 28 056 patients met the criteria. Among 17 059 (67.67%) patients treated primarily with chemotherapy, 41.19% also had radiation and 8.89% went onto resection. Many received no cancer-directed treatment or failed to receive GRT. Another 710 patients had radiation (±surgery) without chemotherapy despite few contraindications to chemotherapy. Over time, patients were more likely to undergo resection after chemotherapy (aRR = 1.58; p < 0.0001) and less likely to have chemoradiation (aRR = 0.78; p < 0.0001) or go untreated (aRR = 0.90; p < 0.0001). Socioeconomic factors (race, education, income, and insurance status) affected the likelihood of receiving chemotherapy and surgery. Median overall survival (OS) was significantly improved for patients treated with chemotherapy and particularly in those patients who went on to receive RT or undergo surgical resection. OS was also longer for patients treated at high-volume academic centers. Patients insured by Medicaid, Medicare, or those without insurance had worse OS.

CONCLUSIONS

Despite improvement over time, many patients go untreated. Clinical factors were influential, but the impact of vulnerable social standing suggests persistent inequity in access to care.

Hospital Accreditation Status and Treatment Differences Among Black Patients With Colon Cancer

Importance

Hospital-level factors, such as hospital type or volume, have been demonstrated to play a role in treatment disparities for Black patients with cancer. However, data evaluating the association of hospital accreditation status with differences in treatment among Black patients with cancer are lacking.

Objective

To evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of guideline-concordant care and mortality among non-Hispanic Black patients with colon cancer.

Design, Setting, and Participants

This population-based cohort study used the National Program of Cancer Registries, which is a multicenter database with data from all 50 states and the District of Columbia, and covers 97% of the cancer population in the US. The participants included non-Hispanic Black patients aged 18 years or older diagnosed with colon cancer between January 1, 2018, and December 31, 2020. Race and ethnicity were abstracted from medical records as recorded by health care facilities and practitioners. The data were analyzed from December 7, 2023, to January 17, 2024.

Exposure

CoC hospital accreditation.

Main Outcome and Measures

Guideline-concordant care was defined as adequate lymphadenectomy during surgery for patients with stages I to III disease or chemotherapy administration for patients with stage III disease. Multivariable logistic regression models investigated associations with receipt of guideline-concordant care and Cox proportional hazards regression models assessed associations with 3-year cancer-specific mortality.

Results

Of 17 249 non-Hispanic Black patients with colon cancer (mean [SD] age, 64.8 [12.8] years; 8724 females [50.6%]), 12 756 (74.0%; mean [SD] age, 64.7 [12.8] years) were treated at a CoC-accredited hospital and 4493 (26.0%; mean [SD] age, 65.1 [12.5] years) at a non-CoC-accredited hospital. Patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals had higher odds of receiving guideline-concordant lymphadenectomy (adjusted odds ratio [AOR], 1.89; 95% CI, 1.69-2.11) and chemotherapy (AOR, 2.31; 95% CI, 1.97-2.72). Treatment at CoC-accredited hospitals was associated with lower cancer-specific mortality for patients with stages I to III disease who received surgery (adjusted hazard ratio [AHR], 0.87; 95% CI, 0.76-0.98) and for patients with stage III disease eligible for chemotherapy (AHR, 0.75; 95% CI, 0.59-0.96).

Conclusions and Relevance

In this cohort study of non-Hispanic Black patients with colon cancer, patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals were more likely to receive guideline-concordant care and have lower mortality risk. These findings suggest that increasing access to high-quality guideline-concordant care at CoC-accredited hospitals may reduce variations in cancer treatment and outcomes for underserved populations.

Dynamic volume-outcome association for esophagectomies: Do current volume thresholds still apply?

BACKGROUND

It is unknown if the current minimum case volume recommendation of 20 cases per year per hospital is applicable to contemporary practice.

METHODS

Patients undergoing esophageal resection between 2005 and 2015 were identified in the National Cancer Database. High, medium, and low-volume hospital strata were defined by quartiles. Adjusted odds ratios and adjusted 30-day mortality between low-, medium-, and high-volume hospitals were calculated using logistic regression analyses and trended over time.

RESULTS

Only 1.1% of hospitals had ≥20 annual cases. The unadjusted 30-day mortality for esophagectomy was 3.8% overall. Unadjusted and adjusted 30-day mortality trended down for all three strata between 2005 and 2015, with disproportionate decreases for low-volume and medium-volume versus high-volume hospitals. By 2015, adjusted 30-day mortality was similar in medium- and high-volume hospitals (odds ratio 1.35, 95% confidence interval 0.96-1.91). For hospitals with 20 or more annual cases the adjusted 30-day mortality was 2.7% overall. To achieve this same 30-day mortality the minimum volume threshold had lowered to 7 annual cases by 2015.

CONCLUSION

Only 1.1% of hospitals meet current volume recommendations for esophagectomy. Differential improvements in postoperative mortality at low- and medium- versus high-volume hospitals have led to 7 cases in 2015 achieving the same adjusted 30-day mortality as 20 cases in the overall cohort. Lowering volume thresholds for esophagectomy in contemporary practice would potentially increase the proportion of hospitals able to meet volume standards and increase access to quality care without sacrificing quality.

Measuring and addressing health equity: an assessment of cancer center designation requirements

PURPOSE

By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements.

METHODS

We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes.

RESULTS

ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment.

CONCLUSION

Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Comparison of Capture Rates of the National Cancer Database Across Race and Ethnicity

Importance

The National Cancer Database (NCDB) is an invaluable and widely used resource for cancer research, but the current state of representation of different racial and ethnic groups compared with the United States Cancer Statistics (USCS) database is unknown.

Objective

To examine whether Hispanic and American Indian or Alaska Native individuals have lower representation in the NCDB compared with the USCS database.

Design, Setting, and Participants

This multicenter, retrospective cohort study assessed individuals diagnosed with breast, colorectal, lung, and prostate cancer from January 1, 2004, to December 31, 2006, and January 1, 2017, to December 31, 2019, in the NCDB and USCS databases. Data analysis was performed from September 2022 to October 2023.

Exposure

Time.

Main Outcomes and Measures

The primary outcome was the absolute percentage change (APC) in capture rate across the study period.

Results

The cohort included 5 175 007 individuals (0.50% American Indian or Alaska Native, 3.10% Asian or Pacific Islander, 12.01% Black, 6.58% Hispanic, and 77.81% White) who were diagnosed with breast, colorectal, lung, and prostate cancer. Capture rates were the lowest for individuals who were Hispanic (40.83% in 2004-2006 and 54.75% in 2017-2019; P < .001) or American Indian or Alaska Native (20.72% in 2004-2006 and 41.41% in 2017-2019; P < .001). The APCs were positive for both racial categories across all 4 cancers. However, overall APCs for Hispanic individuals (13.92%) remained lower than the overall APCs of White individuals (22.23%; P < .001). The APCs were greater for American Indian or Alaska Native individuals than for White individuals for prostate (14.68% vs 11.57%) and breast (21.61% vs 17.90%) cancer (P < .001), but the APCs for American Indian or Alaska Native individuals were lower than for White individuals for lung cancer (24.54% vs 33.03%; P < .001).

Conclusions and Relevance

In this cohort study of individuals diagnosed with cancer in the NCDB, Hispanic and American Indian or Alaska Native individuals diagnosed with breast, colorectal, lung, and prostate cancer were undercaptured in the NCDB, but their representation improved over time. Increased study is needed to determine where these populations predominantly seek cancer care.

Understanding Variation in In-hospital Mortality After Major Surgery in the United States

OBJECTIVES

We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US).

BACKGROUND

The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown.

STUDY DESIGN

Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each.

RESULTS

Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups.

CONCLUSIONS

Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM.

Structural Racism, Lifestyle Behaviors, and Obesity-related Cancers among Black and Hispanic/Latino Adults in the United States: A Narrative Review

One in three adults in the United States has obesity; a chronic disease that is implicated in the etiology of at least 14 cancers. Cancer is the leading cause of death among U.S. Hispanic/Latino adults and the second most common cause of death, after cardiovascular disease, for Black adults. Our country's legacy in overt discrimination (e.g., slavery, segregation) generated inequities across all spheres in which people function as defined by the socioecological model-biological, individual, community, structural-and two of the many areas in which it manifests today are the disproportionate burden of obesity and obesity-related cancers in populations of color. Inequities due to environmental, social, and economic factors may predispose individuals to poor lifestyle behaviors by hindering an individual's opportunity to make healthy lifestyles choices. In this review, we examined the evidence on obesity and the lifestyle guidelines for cancer prevention in relation to cancer risk and outcomes for Black and Hispanic/Latino adults. We also discussed the role of structural and societal inequities on the ability of these two communities to adopt and maintain healthful lifestyle behaviors in accordance with the lifestyle guidelines for cancer prevention and control.

Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival

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.

Socioeconomic Mediation of Racial Segregation in Pancreatic Cancer Treatment and Outcome Disparities

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.

Impact of Cancer Care Regionalization on Patient Volume

BACKGROUND

Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs).

METHODS

This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution.

RESULTS

The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299).

CONCLUSIONS

The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.

The impact of race/ethnicity and county-level upward economic mobility on textbook outcomes in hepatopancreatic surgery

BACKGROUND

The impact of upward economic mobility and race/ethnicity on achieving quality metrics such as textbook outcomes remains ill-defined. As such, we sought to define the impact of race and county-level upward economic mobility on the ability to achieve a textbook outcome among patients undergoing hepatic and pancreatic surgery.

METHODS

Patients who underwent hepatic or pancreatic procedures between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The primary outcomes of interest were textbook outcome and its components.

RESULTS

Among 35,403 patients, 17,923 (50.6%) patients were classified as living in a low upward economic mobility county, whereas 17,480 (49.4%) lived in a high upward economic mobility county. Furthermore, 32,981 (93.1%) patients were White, and 2,422 (6.8%) were Black. Overall, a textbook outcome was achieved in 45.6% of patients (n = 16,139), with textbook outcome most likely in patients from a high upward economic mobility county compared with a low upward economic mobility county (low: 44.6% vs high: 46.6%, P < .001). On multivariable analysis, patients in a low upward economic mobility county had 6% lower odds of achieving a textbook outcome compared with a high upward economic mobility county (odds ratio 0.94, 95% confidence interval 0.90-0.98). Furthermore, Black patients were less likely to achieve a textbook outcome (odds ratio 0.91, 95% confidence interval 0.84-0.99) and had 17% and 15% higher odds of developing a complication (odds ratio 1.17, 95% confidence interval 1.07-1.28) and extended length of stay (odds ratio 1.15, 95% confidence interval 1.05-1.27), respectively. Within races, White patients in a high upward economic mobility county had 7% higher odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 1.07, 95% confidence interval 1.02-1.12), although no such effect was observed in Black patients (odds ratio 0.94, 95% confidence interval 0.77-1.15). Furthermore, Black patients in a high upward economic mobility county had similar odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 0.92, 95% confidence interval 0.77-1.09).

CONCLUSION

These results highlight the differential impact of upward economic mobility and race on postoperative outcomes. Due to the health care implications of socioeconomic status, future policy initiatives should target economic mobility as a means to ensure greater health care equity.

Rural-urban survival disparities for patients with surgically treated lung cancer

BACKGROUND

Nonsmall-cell lung cancer (NSCLC) is a common diagnosis among patients living in rural areas and small towns who face unique challenges accessing care. We examined differences in survival for surgically treated rural and small-town patients compared to those from urban and metropolitan areas.

METHODS

The National Cancer Database was used to identify surgically treated NSCLC patients from 2004 to 2016. Patients from rural/small-town counties were compared to urban/metro counties. Differences in patient clinical, sociodemographic, hospital, and travel characteristics were described. Survival differences were examined with Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

The study included 366 373 surgically treated NSCLC patients with 12.4% (n = 45 304) categorized as rural/small-town. Rural/small-town patients traveled farther for treatment and were from areas characterized by lower income and education(all p < 0.001). Survival probabilities for rural/small-town patients were worse at 1 year (85% vs. 87%), 5 years (48% vs. 54%), and 10 years (26% vs. 31%) (p < 0.001). Travel distance >100 miles (hazard ratio [HR] = 1.11, 95% confidence interval [CI]: 1.07-1.16, vs. <25 miles) and living in a rural/small-town county (HR = 1.04, 95% CI: 1.01-1.07) were associated with increased risk for death.

CONCLUSIONS

Rural and small-town patients with surgically treated NSCLC had worse survival outcomes compared to urban and metropolitan patients.

Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State

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.

Disparities in access to surgery for glioblastoma multiforme at high-volume Commission on Cancer-accredited hospitals in the United States

OBJECTIVE

Although it has been shown that surgery for glioblastoma (GBM) at high-volume facilities (HVFs) may be associated with better postoperative outcomes, the use of such hospitals may not be equally distributed. The authors aimed to evaluate racial and socioeconomic differences in access to surgery for GBM at high-volume Commission on Cancer (CoC)-accredited hospitals.

METHODS

The National Cancer Database was queried for patients with GBM that was newly diagnosed between 2004 and 2015. Patients who received no surgical intervention or those who received surgical intervention at a site other than the reporting facility were excluded. Annual surgical case volume was calculated for each hospital, with volume ≥ 90th percentile defined as an HVF. Multivariable logistic regression was performed to identify patient-level predictors for undergoing surgery at an HVF. Furthermore, multiple subgroup analyses were performed to determine the adjusted odds ratio of the likelihood of undergoing surgery at an HVF in 2016 as compared to 2004 for each patient subpopulation (by age, race, sex, educational group, etc.).

RESULTS

A total of 51,859 patients were included, with 10.7% (n = 5562) undergoing surgery at an HVF. On multivariable analysis, Hispanic White patients (OR 0.58, 95% CI 0.49-0.69, p < 0.001) were found to have significantly lower odds of undergoing surgery at an HVF (reference = non-Hispanic White). In addition, patients from a rural residential location (OR 0.55, 95% CI 0.41-0.72, p < 0.001; reference = metropolitan); patients with nonprivate insurance status (Medicare [OR 0.78, 95% CI 0.71-0.86, p < 0.001], Medicaid [OR 0.68, 95% CI 0.60-0.78, p < 0001], other government insurance [OR 0.68, 95% CI 0.52-0.86, p = 0.002], or who were uninsured [OR 0.61, 95% CI 0.51-0.72, p < 0.001]); and lower-income patients ($50,354-$63,332 [OR 0.68, 95% CI 0.63-0.74, p < 0.001], $40,227-$50,353 [OR 0.84, 95% CI 0.76-0.92, p < 0.001]; reference = ≥ $63,333) were also found to be significantly associated with a lower likelihood of surgery at an HVF. Subgroup analyses revealed that elderly patients (age ≥ 65 years), both male and female patients and non-Hispanic White patients, and those with private insurance, Medicare, metropolitan residential location, median zip code-level household income in the first and second quartiles, and educational attainment in the first and third quartiles had increased odds of undergoing surgery at an HVF in 2016 compared to 2004 (all p ≤ 0.05). On the other hand, patients with other governmental insurance, patients with a rural residence, and those from a non-White racial category did not show a significant difference in odds of surgery at an HVF over time (all p > 0.05).

CONCLUSIONS

The present analysis from the National Cancer Database revealed significant disparities in access to surgery at an HVF for GBM within the United States. Furthermore, there was evidence that these racial and socioeconomic disparities may have widened between 2004 and 2016. The findings should assist health policy makers in the development of strategies for improving access to HVFs for racially and socioeconomically disadvantaged populations.

Centralisation of surgery for complex cancer diseases: A scoping review of the evidence base on pancreatic cancer

BACKGROUND

Centralisation of cancer surgery is a commonly applied healthcare strategy worldwide. This study aimed to detail the design of centralisation policies, to shed light on the implications of such policies in real practice and to describe the different perspectives taken to deal with difficulties that emerged, taking pancreatic cancer as an example of a complex cancer disease requiring surgery.

METHODOLOGY

A scoping review was conducted using the MEDLINE database. We systematically searched for eligible studies published between January 2000 and December 2018.

RESULTS

In the 33 included studies, centralisation of pancreatic cancer surgery was implemented through three different models: designated hospitals, definition of minimum volumes per provider, and/or recommendations included in protocols and national guidelines. The presence of highly advanced technology and infrastructures, the availability of extensive service coverage and advanced care processes based on expert multidisciplinary teams, and higher caseloads were identified as key components of centralisation policy.

CONCLUSIONS

Centralisation models for pancreatic cancer surgery showed that having expert centres where the care process is comprehensively guided is a foundational policy approach. External quality assessment and the accreditation of centres and professionals performing complex surgical procedures are levers that may positively impact the effectiveness of the measure. POLICY SUMMARY: while we found different experiences and three models of centralisation, all of them were guided by the will to positively impact on pancreatic cancer patients' access to expert care. Clinical research might be able to make progress in the coming years and perhaps contribute to reversing a critical situation of high mortality and growing incidence. However, policymakers must optimise health system responses considering current resources, as suggested by the recommendations proposed in the framework of the EU initiative Bratislava Statement for pancreatic cancer care.

Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume?

BACKGROUND

How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.

METHODS

A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.

RESULTS

We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).

CONCLUSIONS

This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.

Racial Disparities in Surgery for Malignant Bowel Obstruction

BACKGROUND

Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO.

METHODS

This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates.

RESULTS

Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients.

CONCLUSIONS

This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.

Long-term effect of hospital volume on the postoperative prognosis of 158,618 patients with esophageal squamous cell carcinoma in China

Background

The impact of hospital volume on the long-term survival of esophageal squamous cell carcinoma (ESCC) has not been well assessed in China, especially for stage I-III stage ESCC. We performed a large sample size study to assess the relationships between hospital volume and the effectiveness of ESCC treatment and the hospital volume value at the lowest risk of all-cause mortality after esophagectomy in China.

Aim

To investigate the prognostic value of hospital volume for assessing postoperative long-term survival of ESCC patients in China.

Methods

The date of 158,618 patients with ESCC were collected from a database (1973-2020) established by the State Key Laboratory for Esophageal Cancer Prevention and Treatment, the database includes 500,000 patients with detailed clinical information of pathological diagnosis and staging, treatment approaches and survival follow-up for esophageal and gastric cardia cancers. Intergroup comparisons of patient and treatment characteristics were conducted with the X² test and analysis of variance. The Kaplan-Meier method with the log-rank test was used to draw the survival curves for the variables tested. A Multivariate Cox proportional hazards regression model was used to analyze the independent prognostic factors for overall survival. The relationship between hospital volume and all-cause mortality was assessed using restricted cubic splines from Cox proportional hazards models. The primary outcome was all-cause mortality.

Results

In both 1973-1996 and 1997-2020, patients with stage I-III stage ESCC who underwent surgery in high volume hospitals had better survival than those who underwent surgery in low volume hospitals (both P<0.05). And high volume hospital was an independent factor for better prognosis in ESCC patients. The relationship between hospital volume and the risk of all-cause mortality was half-U-shaped, but overall, hospital volume was a protective factor for esophageal cancer patients after surgery (HR<1). The concentration of hospital volume associated with the lowest risk of all-cause mortality was 1027 cases/year in the overall enrolled patients.

Conclusion

Hospital volume can be used as an indicator to predict the postoperative survival of ESCC patients. Our results suggest that the centralized management of esophageal cancer surgery is meaningful to improve the survival of ESCC patients in China, but the hospital volume should preferably not be higher than 1027 cases/year.

Core tip

Hospital volume is considered to be a prognostic factor for many complex diseases. However, the impact of hospital volume on long-term survival after esophagectomy has not been well evaluated in China. Based on a large sample size of 158,618 ESCC patients in China spanning 47 years (1973-2020), We found that hospital volume can be used as a predictor of postoperative survival in patients with ESCC, and identified hospital volume thresholds with the lowest risk of death from all causes. This may provide an important basis for patients to choose hospitals and have a significant impact on the centralized management of hospital surgery.

Rural-Urban Differences in Esophagectomy for Cancer

Introduction

Patients who are disadvantaged socioeconomically or live in rural areas may not pursue surgery at high-volume centers where outcomes are better for some complex procedures. The objective of this study was to compare rural and urban patient differences directly by location of residence and outcomes after undergoing esophagectomy for cancer.

Methods

An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) database was performed, capturing adult patients with esophageal cancer who underwent esophagectomy. Patients were stratified into rural or urban groups by the National Center for Health Statistics Urban-Rural Classification Scheme. Demographics, hospital variables, and outcomes were compared.

Results

A total of 2,877 patients undergoing esophagectomy for esophageal cancer were captured by the database, with 228 (7.92%) rural and 2,575 (89.50%) urban patients. The rural and urban groups had no differences in age, race, and insurance status, and shared many common comorbidities. Major outcomes of mortality (3.95% versus 4.27%, p = 0.815) and length of stay (15.75 ± 13.22 vs. 15.55 ± 14.91 days, p = 0.828) were similar for both rural and urban patients. There was a trend for rural patients to more likely be discharged home (35.96% vs. 29.79%, OR 0.667 [95% CI 0.479 – 0.929]; p = 0.0167).

Conclusions

This retrospective administrative database study indicated that rural and urban patients received equivalent postoperative care after undergoing esophagectomy. The findings were reassuring as there did not appear to be a disparity in major outcomes depending on the location of residence, but further studies are necessary to assure equitable treatment for rural patients.

Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography

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.

The role of education on Cancer amenable mortality among non-Hispanic blacks & non-Hispanic whites in the United States (1989-2018)

Background

Cancer mortality in the U.S. has fallen in recent decades; however, individuals with lower levels of education experienced a smaller decline than more highly educated individuals. This analysis aimed to measure the influence of education lower than a high school diploma, on cancer amenable mortality among Non-Hispanic Whites (NHW) and Non-Hispanic Blacks (NHB) in the U.S. from 1989 to 2018.

Methods

We analyzed data from 8.2 million death certificates of men and women who died from cancer between 1989 and 2018. We examined 5-year and calendar period intervals, as well as annual percent changes (APC). APC was adjusted for each combination of sex, educational level, and race categories (8 models) to separate the general trend from the effects of age.

Results

Our study demonstrated an increasing mortality gap between the least and the most educated NHW and NHB males and females who died from all cancers combined and for most other cancer types included in this study. The gap between the least and the most educated was broader among NHW males and females than among NHB males and females, respectively, for most malignancies.

Conclusions

In summary, we reported an increasing gap in the age-adjusted cancer mortality among the most and the least educated NHW and NHB between 25 and 74 years of age. We demonstrated that although NHB exhibited the greatest age-adjusted mortality rates for most cancer locations, the gap between the most and the least educated was shown for NHW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08633-7.

Disparities in Access to High-Volume Surgeons Within High-Volume Hospitals for Hysterectomy

OBJECTIVE

To examine access to high-volume surgeons in comparison with low-volume surgeons who perform hysterectomies within high-volume hospitals and to compare perioperative morbidity and mortality between high-volume and low-volume surgeons within these centers.

METHODS

Women who underwent hysterectomy in New York State between 2000 and 2014 at a high-volume (top quartile by volume) hospital were included. Surgeons were classified into quartiles based on average annual hysterectomy volume. Multivariable models were used to determine characteristics associated with treatment by a low-volume surgeon in comparison with a high-volume surgeon and to estimate the association between physician volume, and morbidity and mortality.

RESULTS

A total of 300,586 patients cared for by 5,505 surgeons at 59 hospitals were identified. Women treated by low-volume surgeons, in comparison with high-volume surgeons, were more often Black (19.4% vs 14.3%; adjusted odds ratio [aOR] 1.26; 95% CI 1.09-1.46) and had Medicare insurance (20.6% vs 14.5%; aOR 1.22; 95% CI 1.04-1.42). Low-volume surgeons were more likely to perform both emergent-urgent procedures (26.1% vs 6.4%; aOR 3.91; 95% CI 3.26-4.69) and abdominal hysterectomy, compared with minimally invasive hysterectomy (77.8% vs 54.7%; aOR 1.91; 95% CI 1.62-2.24). Compared with patients cared for by high-volume surgeons, those operated on by low-volume surgeons had increased risk of a complication (31.0% vs 10.3%; adjusted risk ratios [aRR] 1.84; 95% CI 1.71-1.98) and mortality (2.2% vs 0.2%; aRR 3.04; 95% CI 2.20-4.21). In sensitivity analyses, differences in morbidity and mortality remained for emergent-urgent procedures, elective operations, cancer surgery, and noncancer procedures.

CONCLUSION

Socioeconomic disparities remain in access to high-volume surgeons within high-volume hospitals for hysterectomy. Patients who undergo hysterectomy at a high-volume hospital by a low-volume surgeon are at substantially greater risk for perioperative morbidity and mortality.

Exome sequencing identifies novel somatic variants in African American esophageal squamous cell carcinoma

Esophageal cancer has a strikingly low survival rate mainly due to the lack of diagnostic markers for early detection and effective therapies. In the U.S., 75% of individuals diagnosed with esophageal squamous cell carcinoma (ESCC) are of African descent. African American ESCC (AA ESCC) is particularly aggressive, and its biological underpinnings remain poorly understood. We sought to identify the genomic abnormalities by conducting whole exome sequencing of 10 pairs of matched AA esophageal squamous cell tumor and control tissues. Genomic analysis revealed diverse somatic mutations, copy number alterations (SCNAs), and potential cancer driver genes. Exome variants created two subgroups carrying either a high or low tumor mutation burden. Somatic mutational analysis based on the Catalog of Somatic Mutations in Cancer (COSMIC) detected SBS16 as the prominent signature in the high mutation rate group suggesting increased DNA damage. SBS26 was also detected, suggesting possible defects in mismatch repair and microsatellite instability. We found SCNAs in multiple chromosome segments, encoding MYC on 8q24.21, PIK3CA and SOX2 on 3q26, CCND1, SHANK2, CTTN on 11q13.3, and KRAS on 12p12. Amplifications of EGFRvIII and EGFRvIVa mutants were observed in two patients, representing a novel finding in ESCC that has potential clinical relevance. This present exome sequencing, which to our knowledge, represents the first comprehensive exome analysis exclusively in AA ESCC, and highlights novel mutated loci that might explain the aggressive nature of AA ESCC and lead to the development of diagnostic and prognostic markers as well as therapeutic targets.

Stage Migration and Survival Trends in Laryngeal Cancer

BACKGROUND

During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy.

METHODS

From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year.

RESULTS

No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001).

CONCLUSION

Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.

County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA

INTRODUCTION

Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer.

METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level.

RESULTS

Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy.

CONCLUSION

Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.

Providing Appropriate Pancreatic Cancer Care for People Experiencing Homelessness: A Surgical Perspective

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.

Impact of race on care, readmissions, and survival for patients with glioblastoma: an analysis of the National Cancer Database

Background

The objective of this study was to explore racial/ethnic factors that may be associated with survival in patients with glioblastoma by querying the National Cancer Database (NCDB).

Methods

The NCDB was queried for patients diagnosed with glioblastoma between 2004 and 2014. Patient demographic variables included age at diagnosis, sex, race, ethnicity, Charlson-Deyo score, insurance status, and rural/urban/metropolitan location of zip code. Treatment variables included surgical treatment, extent of resection, chemotherapy, radiation therapy, type of radiation, and treatment facility type. Outcomes included 30-day readmission, 30- and 90-day mortality, and overall survival. Multivariable Cox regression analyses were performed to evaluate variables associated with race and overall survival.

Results

A total of 103 652 glioblastoma patients were identified. There was a difference in the proportion of patients for whom surgery was performed, as well as the proportion receiving radiation, when stratified by race (P < .001). Black non-Hispanics had the highest rates of unplanned readmission (7.6%) within 30 days (odds ratio [OR]: 1.39 compared to White non-Hispanics, P < .001). Asian non-Hispanics had the lowest 30- (3.2%) and 90-day mortality (9.8%) when compared to other races (OR: 0.52 compared to White non-Hispanics, P = .031). Compared to White non-Hispanics, we found Black non-Hispanics (hazard ratio [HR]: 0.88, P < .001), Asian non-Hispanics (HR: 0.72, P < .001), and Hispanics (HR: 0.69, P < .001) had longer overall survival.

Conclusions

Differences in treatment and outcomes exist between races. Further studies are needed to elucidate the etiology of these race-related disparities and to improve outcomes for all patients.

Assessment of Cancer Center Variation in Textbook Oncologic Outcomes Following Colectomy for Adenocarcinoma

BACKGROUND

Traditional metrics may inadequately represent rates of attaining optimal oncologic care. We evaluated a composite "textbook oncologic outcome" (TOO) to assess the incidence of achieving an "optimal" clinical result after colon adenocarcinoma (CA) resection.

METHODS

The National Cancer Database (NCDB) was queried to identify patients undergoing colectomy for non-metastatic CA between 2010 and 2015. TOO was defined as a margin negative resection with an AJCC compliant lymph node evaluation, no prolonged length of stay (LOS) or 30-day readmission/mortality, as well as receipt of stage appropriate adjuvant chemotherapy.

RESULTS

Among 170,120 patients who underwent colectomy at 1315 hospitals, 93,204 (54.8%) achieved TOO with large variations observed among facilities. While certain factors were achieved nearly universally (R0 margin, 95.6%; no 30-day mortality, 97.2%), avoidance of prolonged LOS (77.3%) and appropriate adjuvant chemotherapy (83.0%) were achieved less consistently. On multivariable analysis, Black race/ethnicity (OR 0.82, 95% CI 0.80-0.85), Medicaid insurance (OR 0.64, 0.61-0.68), and low-volume facility (< 50/year) (OR 0.83, 0.77-0.89) were associated with decreased likelihood of TOO. Achievement of TOO was associated with improved long-term survival (HR 0.45; 95% CI 0.44-0.46).

CONCLUSIONS

Roughly one-half of patients undergoing resection of CA achieved an optimal clinical outcome. TOO may be a more useful quality metric to assess patient-centric composite outcomes following surgical procedures.

Commission on Cancer Facility Type is Associated with Overall Survival in Patients with Gastric Adenocarcinoma in the United States

BACKGROUND

In the United States, "high-volume" centers for gastric cancer treat significantly fewer cases per year compared with centers in Asia. Factors associated with oncologic outcomes, aside from volume, are poorly understood.

METHODS

Patients with gastric adenocarcinoma between 2004 and 2015 were analyzed in the NCDB cohort. Commission on Cancer facility types were classified as either Academic/Research Programs (ARP) or Non-Academic Programs (NAP). Factors associated with treatment at facility type were assessed by logistic regression. Overall survival was compared between facility types by Cox proportional hazard models.

RESULTS

Thirty-nine percent of patients were treated at ARPs. In multivariable analysis, patients treated at ARPs were younger, healthier (Charlson-Deyo score), and had lower AJCC stage. Treatment at an ARP was associated with superior median OS compared with treatment at a NAP (17.3 months vs. 11.1 months, respectively, P < 0.001,) and in each stage of disease. Treatment of stages II and III patients at ARPs increased over time. Among patients with stages II and III disease, adherence to therapy guidelines was higher and postoperative mortality was lower at ARPs.

CONCLUSION

Although patients at ARPs tend to have favorable characteristics, superior overall survival may also be due to better adherence to therapy guidelines and capacity to rescue after surgical complications.

Up-Conversion Luminescent Nanoparticles for Molecular Imaging, Cancer Diagnosis and Treatment

In the past few years, we have witnessed great development and application potential of various up-conversion luminescent nanoparticles (UCNPs) in the nanomedicine field. Based on the unique luminescent mechanism of UCNPs and the distinguishable features of cancer biomarkers and the microenvironment, an increasing number of smart UCNPs nanoprobes have been designed and widely applied to molecular imaging, cancer diagnosis, and treatment. Considerable technological success has been achieved, but the main obstacles to oncology nanomedicine is becoming an incomplete understanding of nano-bio interactions, the challenges regarding chemistry manufacturing and controls required for clinical translation and so on. This review highlights the progress of the design principles, synthesis and surface functionalization preparation, underlying applications and challenges of UCNPs-based probes for cancer bioimaging, diagnosis and treatment that capitalize on our growing understanding of tumor biology and smart nano-devices for accelerating the commercialization of UCNPs.

Traveling for Pancreatic Cancer Care Is Worth the Trip

BACKGROUND

Centralized care for patients with pancreatic cancer is associated with longer survival. We hypothesized that increased travel distance from home is associated with increased survival for pancreatic cancer patients.

METHODS

The National Cancer Database user file for all pancreatic cancer patients was investigated from 2004 through 2015. Distance from the patients' zip code to the treating facility was determined. Survival was investigated using the Kaplan-Meier method. Cox hazard ratios (CoxHRs) were determined based on stage of disease, distance traveled for care, and clinical factors.

RESULTS

340 780 patients were identified. In the average age of 68 ± 12 years, 51% were male and 83% were Caucasian. For all stages of cancer, longer survival was associated with traveling farther (P < .001). The survival advantage was longer for Caucasians than African Americans (3.7 months vs. 2.6 months, P < .001) Travel was associated with a 13% decrease in risk of death (P < .001). Even controlling for the pathologic stage, traveling farther was associated with decreased risk of death (CoxHR = .91, P < .001).

DISCUSSION

Traveling for care is associated with improved survival for pancreatic cancer patients. While a selection bias may exist, the fact that all stages of patients investigated benefited suggests that this is a real phenomenon.

Access denied: The relationship between patient insurance status and access to high-volume hospitals

BACKGROUND

Underinsured patients face significant barriers in accessing high-quality care. Evidence of whether access to high-volume surgical care is mediated by disparities in health insurance coverage remains wanting.

METHODS

The authors used the National Cancer Data Base to identify all adult patients who had a confirmed diagnosis of breast, prostate, lung, or colorectal cancer during 2004 through 2016. The odds of receiving surgical care at a high-volume hospital were estimated according to the type of insurance using multivariable logistic regression analyses for each malignancy. Then, the interactions between study period and insurance status were assessed.

RESULTS

In total, 1,279,738 patients were included in the study. Of these, patients with breast cancer who were insured by Medicare (odds ratio [OR], 0.75; P < .001), Medicaid (OR, 0.55; P < .001), or uninsured (OR, 0.50; P < .001); patients with prostate cancer who were insured by Medicare (OR, 0.87; P = .003), Medicaid (OR, 0.58; P = .001), or uninsured (OR, 0.36; P < .001); and patients with lung cancer who were insured by Medicare (OR, 0.84; P = .020), Medicaid (OR, 0.74; P = .001), or uninsured (OR, 0.48; P < .001) were less likely to receive surgical care at high-volume hospitals compared with patients who had private insurance. For patients with colorectal cancer, the effect of insurance differed by study period, and improved since 2011. For those on Medicaid, the odds of receiving care at a high-volume hospital were 0.51 during 2004 through 2007 and 0.99 during 2014 through 2016 (P for interaction = .001); for uninsured patients, the odds were 0.45 during 2004 through 2007 and 1.19 during 2014 through 2016 (P for interaction < .001) compared with patients who had private insurance.

CONCLUSIONS

Uninsured, Medicare-insured, and Medicaid-insured patients are less likely to receive surgical care at high-volume hospitals. For uninsured and Medicaid-insured patients with colorectal cancer, the odds of receiving care at high-volume hospitals have improved since implementation of the Patient Protection and Affordable Care Act of 2010.

Clinical presentations and outcomes in pulmonary embolism patients with cancer

To study whether a diagnosis of cancer affects the clinical presentation and outcomes of patients with pulmonary embolism (PE). A retrospective analysis was performed of all consecutive patients diagnosed with PE on a computed tomography scan from 2014 to 2016 at an urban tertiary-referral medical center. Baseline characteristics, treatment decisions, and mortality data were compared between study subjects with and without a known diagnosis of active cancer. There were 581 subjects, of which 187 (33.0%) had a diagnosis of cancer. On average, cancer subjects tended to be older (64.8 vs. 58.5 years, p < 0.01), had lower body mass index (BMI) (29.0 vs. 31.5 kg/m², p = 0.01), and were less likely to be active smokers (9.2% vs. 21.1%, p < 0.01), as compared to non-cancer subjects. Cancer subjects were also less likely to present with chest pain (18.2% vs. 37.4%, p < 0.01), syncope (2.7% vs. 6.6%, p = 0.05), bilateral PEs (50% vs. 60%, p = 0.025), and evidence of right heart strain (48% vs. 58%, p = 0.024). There was no difference in-hospital length of stay (8.9 vs. 9.4 days, p = 0.61) or rate of intensive care unit (ICU) admission (31.9% vs. 33.3%, p = 0.75) between the two groups. Presence of cancer increased the risk of all-cause one-year mortality (adjusted HR 9.7, 95% CI 4.8-19.7, p < 0.01); however, it did not independently affect in-hospital mortality (adjusted HR 2.9, 95% CI 0.86-9.87, p = 0.086). Patients with malignancy generally presented with less severe PE. In addition, malignancy did not independently increase the risk of in-hospital mortality among PE patients.

Factors Associated with Treatment and Survival of Early Stage Pancreatic Cancer in the Era of Modern Chemotherapy: An Analysis of the National Cancer Database

Background: Underutilization of operative management of early stage pancreatic cancer is associated with sociodemographic variables, including age, race, facility type, insurance, and education. It is currently unclear how these variables are associated with survival in patients who undergo surgery.

Methods: Patients with clinical stage I pancreatic adenocarcinoma were identified within the National Cancer Database (2010–2016). Utilization of surgery and nonoperative management was determined. Nonclinical factors associated with nonoperative management were identified by multivariable analysis. The association between nonclinical factors and survival was assessed in patients who received operative management.

Results: A total of 17,833 patients with clinical stage I pancreatic cancer were identified, and 41.2% underwent operative intervention. Approximately 46% of nonoperatively managed patients lacked a contraindication. Operatively managed patients had longer overall survival (OS) than those who were nonoperatively managed or untreated (25.1 months vs. 11.1 months vs. 5.1 months, p < 0.0001). Factors associated with nonoperative management included age, black/Hispanic race, nonacademic facilities, nonprivate health insurance, lower education level, and lower income. In operatively managed patients, nonclinical factors associated with lower OS included Medicaid (hazard ratio [HR] 1.27) and treatment at nonacademic facilities (HR 1.20–1.22). Patients on Medicaid received less adjuvant therapy and had higher 30- and 90-day mortality rates. Patients treated at nonacademic facilities received less neoadjuvant therapy, had worse pathologic outcomes, and had higher 30- and 90-day mortality rates.

Conclusions: Surgical management is underutilized in clinical stage I pancreatic cancer. Primary insurance payor and facility type appear to be associated with OS in patients who undergo operative management.

Optimal Cystectomy Outcome: A Composite Measurement Evaluating Quality of Care and Mortality Benefit

OBJECTIVES

To evaluate the incidence and impact of an "optimal cystectomy outcome" (OCO), a simplified performance metric that encompasses multiple patient-centered outcomes.

METHODS

We identified patients in the National Cancer Center Database undergoing radical cystectomy for stage cT2-cT3 urothelial carcinoma (2006-2014). OCO was defined as negative resection margin, adequate lymphadenectomy (>10 nodes), no prolonged length-of-stay (<75th percentile), no 30-day-readmission, and no 30-day-mortality. We used multivariable logistic regression and Cox proportional-hazards models to identify factors associated with OCO and overall survival (OS).

RESULTS

Among 12,997 patients who fit the inclusion criteria, individual OCO components were attained at a relatively high rate; however, only 37.6% of patients met all 5 OCO criteria. Patients who underwent surgery at a high-volume (OR 2.45) academic facility (OR 1.60) using a minimally-invasive approach (OR 1.32) were more likely to receive an OCO. Patients were less likely to receive an OCO if they were older (OR 0.98), African American (OR 0.71), had Medicaid insurance (OR 0.66), or more comorbidities (OR 0.48) (all P <0.05). Patients who received an OCO were found to have a significantly lower risk of overall mortality (HR 0.69, P <0.05).

CONCLUSION

Various patient- and hospital-specific factors affect a system's ability to achieve OCO in patients undergoing radical cystectomy. OCO is directly associated with improved OS and has the potential to function as a composite performance metric for the quality of care in bladder cancer.

Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies

INTRODUCTION

Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care.

METHODS

Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined.

RESULTS

In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22-0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34-0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38-0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76-2.71).

CONCLUSION

Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.

Inequity in selective referral to high-volume hospitals for genitourinary malignancies

INTRODUCTION

Compared to low-volume hospitals, high-volume hospitals are associated with lower rates of perioperative morbidity and mortality. However, access to high-volume hospitals is unequal. We investigated racial and socioeconomic disparities among patients undergoing surgery for genitourinary malignancies at high-volume hospitals.

MATERIAL AND METHODS

We queried the National Cancer Database from 2004-2015 to identify patients who underwent radical prostatectomy, radical cystectomy, and nephrectomy for nonmetastatic prostate cancer, muscle-invasive urothelial bladder cancer, and kidney cancer, respectively. Hospitals were ranked based on their annual volume for the given procedure. The endpoint of our study was receipt of treatment at a high-volume hospital. Multivariable logistic regression models were used to identify predictors of treatment at a high-volume hospital.

RESULTS

Our final cohort consisted of 397,242 prostate cancer patients, 39,480 bladder cancer patients, and 292,095 kidney cancer patients. For prostate and bladder cancer, Black race was associated with lower odds of treatment at a high-volume hospital (Odds Ratio [OR] 0.83, 95% confidence interval [CI] 0.79-0.87 and 0.71, 95%CI 0.58-0.87; reference: White). Higher education level and private insurance status were associated with greater odds of treatment across all 3 procedures (strongest effect for prostate cancer; higher education level: OR 1.63 [1.58-1.68]; private insurance 1.86 [1.77-1.97]). Moreover, an interaction was found between race and study period for all cancers examined (P < 0.001). Subgroup analyses revealed that Black patients were more likely to undergo radical prostatectomy at high-volume hospitals in 2013-2015 (OR 0.98, 95%CI 0.94-1.02) compared to 2004-2006 (OR 0.83, 95%CI 0.79-0.87).

CONCLUSION

Across all procedures, patients with lower education status and lack of insurance were less likely to be treated at high-volume hospitals. For prostate cancer and bladder cancer, Black race was a negative predictor of treatment at high-volume hospitals. Further studies are needed to understand the root causes for this inequity.

Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital

Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.

Regionalization of esophagectomy: where are we now?

The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.

Epidemiology of gastrostomy insertion for children and adolescents with intellectual disability

The largest group of recipients of pediatric gastrostomy have neurological impairment with intellectual disability (ID). This study investigated trends in first gastrostomy insertion according to markers of disadvantage and ID etiology. Linked administrative and health data collected over a 32-year study period (1983-2014) for children with ID born between 1983 and 2009 in Western Australia were examined. The annual incidence rate change over calendar year was calculated for all children and according to socioeconomic status, geographical remoteness, and Aboriginality. The most likely causes of ID were identified using available diagnosis codes in the linked data set. Of 11,729 children with ID, 325 (2.8%) received a first gastrostomy within the study period. The incidence rate was highest in the 0-2 age group and there was an increasing incidence trend with calendar time for each age group under 6 years of age. This rate change was greatest in children from the lowest socioeconomic status quintile, who lived in regional/remote areas or who were Aboriginal. The two largest identified groups of ID were genetically caused syndromes (15.1%) and neonatal encephalopathy (14.8%).Conclusion: Gastrostomy is increasingly used in multiple neurological conditions associated with ID, with no apparent accessibility barriers in terms of socioeconomic status, remoteness, or Aboriginality. What is Known: • The use of gastrostomy insertion in pediatrics is increasing and the most common recipients during childhood have neurological impairment, most of whom also have intellectual disability (ID). What is New: • Nearly 3% of children with ID had gastrostomy insertion performed, with the highest incidence in children under 3 years of age. • Gastrostomy use across different social groups was equitable in the Australian setting.

Closing the Disparity in Pancreatic Cancer Outcomes: A Closer Look at Nonmodifiable Factors and Their Potential Use in Treatment

OBJECTIVES

African Americans (AAs) have disproportionately higher incidence and lower survival rates from pancreatic cancer compared with whites. Historically, this disparity has been attributed to modifiable risk factors. Recent studies suggest that nonmodifiable aspects may also play an important role. We review these new contributions as potential targets for closing the disparity.

METHODS

A PubMed search was conducted to review studies of nonmodifiable elements contributing to pancreatic cancer disparities in AAs.

RESULTS

Several nonmodifiable risks are associated with the racial disparity in pancreatic cancer. SSTR5 P335L, Kaiso, and KDM4/JMJD2A demonstrate differential racial expression, increasing their potential as therapeutic targets. Many social determinants of health and their associations with diabetes, obesity, and the microbiome are partially modifiable risk factors that significantly contribute to outcomes in minorities. Barriers to progress include the low minority inclusion in research studies.

CONCLUSIONS

Genomics, epigenetics, the microbiome, and social determinants of health are components that contribute to the pancreatic cancer disparity in AAs. These factors can be researched, targeted, and modified to improve mortality rates. Closing the disparity in pancreatic cancer will require an integrated approach of personalized medicine, increased minority recruitment to studies, and advanced health care/education access.