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Romatoski K, Davids JS, Sachs TE, Hagopian EJ. Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery: a report from the 2024 GI Surgery Summit. J Gastrointest Surg 2024; 28:1712-1716. [PMID: 39043323 DOI: 10.1016/j.gassur.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The 2024 GI Surgery Summit brought together Society for Surgery of the Alimentary Tract (SSAT), Society of Surgical Oncology (SSO), and Society of University Surgeons (SUS) members to assess the current state of gastrointestinal (GI) surgery. This report reviews the key discussions and recommendations after the dedicated plenary session that addressed challenges in providing high-quality, accessible GI surgery for all patients. METHODS The Summit took place from January 14 to 16. During the plenary session "Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery," leaders, rising leaders, and members of SSAT, SSO, and SUS met and discussed challenges in providing high-quality, accessible GI surgery. RESULTS Actionable recommendations to address the challenges in providing high-quality, accessible GI surgical care were made, including engaging communities and patients, building alliances across hospitals and surgeons, and establishing standards of GI surgical care. CONCLUSION Surgeons, hospital systems, and surgical societies can improve healthcare access and outcomes for all GI surgical patients.
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Affiliation(s)
- Kelsey Romatoski
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jennifer S Davids
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Ellen J Hagopian
- Department of Surgery, University of Toledo Medical Center, Toledo, OH, United States; Department of Medical Education and Surgery, University of Toledo College of Medicine & Life Sciences, Toledo, OH, United States.
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Kakish H, Drigotas C, Loftus AW, Boutros CS, Doh SJ, Ammori JB, Rothermel LD, Hoehn RS. Reasons for Surgical Attrition Among Nonmetastatic Upper Gastrointestinal Cancer Patients: A Single Institutional Experience. J Surg Oncol 2024. [PMID: 39257297 DOI: 10.1002/jso.27865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/20/2024] [Accepted: 08/21/2024] [Indexed: 09/12/2024]
Abstract
INTRODUCTION Upper gastrointestinal (UGI) cancers require multidisciplinary treatment, but surgery provides the only potentially curative option. We sought to understand reasons for attrition before surgery within our regional hospital network. METHODS We performed chart reviews of patients (age 18-80) with stage I-III UGI cancers (gastroesophageal junction, gastric, and hepatopancreatobiliary adenocarcinomas) in our multihospital cancer registry from 2015 to 2021. Our primary outcome was reasons for surgical attrition. Univariable analysis identified factors related to surgical attrition and the Kaplan-Meier method estimated overall survival based on surgery receipt. RESULTS Seven hundred and ninety-two patients were included in our analysis, of whom 107 (13.5%) did not undergo curative surgery. Reasons for not undergoing surgery included medical comorbidities (30.8%), patient preference/nonmedical barriers (24.3%, which included: not interested without further explanation, worried about complications, nonadherence to appointments, insurance issues, did not wish for blood transfusion, lack of social support, preferring home care, and worried about recurrence), psychosocial (5.6%), progression while on neoadjuvant therapy or waiting for transplant (15.0% and 7.5%), poor performance status (3.7%), side effects of neoadjuvant therapy (3.7%), and death unrelated to treatment or unknown cause (9.4%). Nonsurgical management was not associated with race, socioeconomic status, or distance traveled for care. Survival was greatly improved for patients who underwent surgery (158 vs. 63 weeks, p < 0.05). CONCLUSION Nearly one in seven patients (18-80 years old) with UGI cancers evaluated at our academic cancer center did not undergo surgical resection. Reasons for surgical attrition included potentially modifiable issues, and addressing these barriers could help overcome inequities in cancer treatment and survival.
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Affiliation(s)
- Hanna Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Claire Drigotas
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Alexander W Loftus
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christina S Boutros
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Susan J Doh
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Fonseca AL, Ahmad R, Amin K, Tripathi M, Abdalla A, Hearld L, Bhatia S, Heslin MJ. Understanding Barriers to Guideline-Concordant Treatment in Foregut Cancer: From Data to Solutions. Ann Surg Oncol 2024; 31:6007-6016. [PMID: 38954093 PMCID: PMC11300473 DOI: 10.1245/s10434-024-15627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/04/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND A large proportion of patients with foregut cancers do not receive guideline-concordant treatment (GCT). This study sought to understand underlying barriers to GCT through a root cause analysis approach. METHODS A single-institution retrospective review of 498 patients with foregut (gastric, pancreatic, and hepatobiliary) adenocarcinoma from 2018 to 2022 was performed. Guideline-concordant treatment was defined based on National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-GCT. RESULTS Overall, 34% did not receive GCT. Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. In decreasing order of frequency, the following contributed to non-GCT: receipt of incomplete therapy (N = 28, 16.5%), deconditioning on chemotherapy (N = 26, 15.3%), delays in care because of patient resource constraints followed by loss to follow-up (N = 19, 11.2%), physician factors (N = 19, 11.2%), no documentation of treatment plan after referral to oncologic expertise (N = 19, 11.2%), loss to follow-up before oncology referral (N = 17, 10%), nonreferral to medical oncologic expertise (N = 16, 9.4%), nonreferral to surgical oncology in patients with resectable disease (N = 15, 8.8%), and complications preventing completion of treatment (N = 11, 6.5%). Non-GCT often was a function of multiple intersecting patient, physician, and institutional factors. CONCLUSIONS A substantial percentage of patients with foregut cancer do not receive GCT. Solutions that may improve receipt of GCT include development of automated systems to improve patient follow-up; institutional prioritization of resources to enhance staffing; financial counseling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways.
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Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA.
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Rida Ahmad
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Krisha Amin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL, USA
| | - Ahmed Abdalla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Larry Hearld
- Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
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Fonseca AL, Ahmad R, Amin K, Tripathi M, Vobbilisetty V, Richman JS, Hearld L, Bhatia S, Heslin MJ. Time Kills: Impact of Socioeconomic Deprivation on Timely Access to Guideline-Concordant Treatment in Foregut Cancer. J Am Coll Surg 2024; 238:720-730. [PMID: 38205919 PMCID: PMC11089897 DOI: 10.1097/xcs.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Receipt of guideline-concordant treatment (GCT) is associated with improved prognosis in foregut cancers. Studies show that patients living in areas of high neighborhood deprivation have worse healthcare outcomes; however, its effect on GCT in foregut cancers has not been evaluated. We studied the impact of the area deprivation index (ADI) as a barrier to GCT. STUDY DESIGN A single-institution retrospective review of 498 foregut cancer patients (gastric, pancreatic, and hepatobiliary adenocarcinoma) from 2018 to 2022 was performed. GCT was defined based on National Comprehensive Cancer Network guidelines. ADI, a validated measure of neighborhood disadvantage was divided into terciles (low, medium, and high) with high ADI indicating the most disadvantage. RESULTS Of 498 patients, 328 (66%) received GCT: 66%, 72%, and 59% in pancreatic, gastric, and hepatobiliary cancers, respectively. Median (interquartile range) time from symptoms to workup was 6 (3 to 13) weeks, from diagnosis to oncology appointment was 4 (1 to 10) weeks, and from oncology appointment to treatment was 4 (2 to 10) weeks. Forty-six percent were diagnosed in the emergency department. On multivariable analyses, age 75 years or older (odds ratio [OR] 0.39 [95% CI 0.18 to 0.87]), Black race (OR 0.52 [95% CI 0.31 to 0.86]), high ADI (OR 0.25 (95% CI 0.14 to 0.48]), 6 weeks or more from symptoms to workup (OR 0.44 [95% CI 0.27 to 0.73]), 4 weeks or more from diagnosis to oncology appointment (OR 0.76 [95% CI 0.46 to 0.93]), and 4 weeks or more from oncology appointment to treatment (OR 0.63 [95% CI 0.36 to 0.98]) were independently associated with nonreceipt of GCT. CONCLUSIONS Residence in an area of high deprivation predicts nonreceipt of GCT. This is due to multiple individual- and system-level barriers. Identifying these barriers and developing effective interventions, including community outreach and collaboration, leveraging telehealth, and increasing oncologic expertise in underserved areas, may improve access to GCT.
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Affiliation(s)
- Annabelle L. Fonseca
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, AL
| | - Rida Ahmad
- Department of Surgery, The University of South Alabama, Mobile, AL
| | - Krisha Amin
- Department of Surgery, The University of South Alabama, Mobile, AL
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL
| | | | - Joshua S. Richman
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, AL
| | - Larry Hearld
- Department of Health Services Administration, The University of Alabama at Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, AL
| | - Martin J. Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL
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Hoehn RS, Zenati M, Rieser CJ, Stitt L, Winters S, Paniccia A, Zureikat AH. Pancreatic Cancer Multidisciplinary Clinic is Associated with Improved Treatment and Elimination of Socioeconomic Disparities. Ann Surg Oncol 2024; 31:1906-1915. [PMID: 37989957 DOI: 10.1245/s10434-023-14609-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To identify the association between multidisciplinary clinic (MDC) management and disparities in treatment for patients with pancreatic cancer. BACKGROUND Socioeconomic status (SES) predicts treatment and survival for pancreatic cancer. Multidisciplinary clinics (MDCs) may improve surgical management for these patients. METHODS This is a retrospective cohort study (2010-2018) of all pancreatic cancer patients within a large, regional hospital system with a high-volume pancreatic cancer MDC. The primary outcome was receipt of treatment (surgery, chemotherapy, radiation, clinical trial participation, and palliative care); the secondary outcomes were overall survival and MDC management. Multiple logistic regressions were used for binary outcomes. Survival was analyzed using Kaplan-Meier survival analysis, Cox proportional hazards, and inverse probability of treatment weighting (IPTW). RESULTS Of the 4141 patients studied, 1420 (34.3%) were managed by the MDC. MDC management was more likely for patients who were younger age, married, and privately insured, while less likely for low SES patients (all p < 0.05). MDC patients were more likely to receive all treatments, including neoadjuvant chemotherapy (OR 3.33, 95% CI 2.82-3.93), surgery (OR 1.39, 95% CI 1.15-1.68), palliative care (OR 1.21, 95% CI 1.05-1.38), and clinical trial participation (OR 3.76, 95% CI 2.86-4.93). Low SES patients were less likely to undergo surgery outside of the MDC (OR 0.47, 95% CI 0.31-0.73) but there was no difference within the MDC (OR 1.10, 95% CI 0.68-1.77). Across multiple survival analyses, low SES predicted inferior survival outside of the MDC, but there was no association among MDC patients. CONCLUSION Multidisciplinary team-based care increases rates of treatment and eliminates socioeconomic disparities for pancreatic cancer patients.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Division of Surgical Oncology, University Hospitals, Cleveland, OH, USA.
| | - Mazen Zenati
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lauren Stitt
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sharon Winters
- Cancer Registries, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Kakish H, Zhao J, Ahmed FA, Elshami M, Hardacre JM, Ammori JB, Winter JM, Ocuin LM, Hoehn RS. Understanding surgical attrition for "resectable" pancreatic cancer. HPB (Oxford) 2024; 26:370-378. [PMID: 38042732 DOI: 10.1016/j.hpb.2023.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/21/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVES We used a novel combined analysis to evaluate various factors associated with failure to undergo surgery in non-metastatic pancreatic cancer. METHODS We identified rates of surgery and reasons for surgical attrition from clinical trials, which studied neoadjuvant therapy in resectable pancreatic cancer. Next, we queried the National Cancer Database (NCDB) for Stage I-III, T1-3 pancreatic adenocarcinoma patients. We investigated the rates and factors associated with the receipt of surgery. Finally, we evaluated variable importance predicting the receipt of surgery. RESULTS In clinical trials, 25-30 % of patients did not undergo surgery, mostly due to disease progression. In the NCDB, the overall surgical rate was only 49 %, but increased to 67 % in a curated cohort meant to mirror clinical trial patients. Patients treated at low-volume institutions (OR = 0.64, 95 % CI: 0.61-0.67) and who were uninsured (OR = 0.56, 95 % CI: 0.52-0.62) and Medicaid-insured (OR = 0.67, 95 % CI: 0.64-0.71) were less likely to receive potentially curative surgery. CONCLUSION We have identified a realistic target surgery rate of 70%-75 % in potentially-resectable pancreatic cancer. While attrition to pancreatic cancer surgery is mostly due to tumor biology, our study identified the most important non-medical barriers, such as facility volume and insurance, affecting pancreatic cancer surgery.
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Affiliation(s)
- Hanna Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Jack Zhao
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Fasih A Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA.
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Hoehn RS, Zureikat AH. ASO Author Reflections: Using Multidisciplinary Teams to Treat Cancer Disparities. Ann Surg Oncol 2024; 31:1941-1942. [PMID: 38082163 DOI: 10.1245/s10434-023-14769-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/25/2023] [Indexed: 02/08/2024]
Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University Hospitals, Cleveland, OH, USA.
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Swords DS, Newhook TE, Tzeng CWD, Massarweh NN, Chun YS, Lee S, Kaseb AO, Ghobrial M, Vauthey JN, Tran Cao HS. Treatment Disparities Partially Mediate Socioeconomic- and Race/Ethnicity-Based Survival Disparities in Stage I-II Hepatocellular Carcinoma. Ann Surg Oncol 2023; 30:7309-7318. [PMID: 37679537 DOI: 10.1245/s10434-023-14132-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/24/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) patients with early-stage hepatocellular carcinoma (HCC) receive procedural treatments less often and have shorter survival. Little is known about the extent to which these survival disparities result from treatment-related disparities versus other causal pathways. We aimed to estimate the proportion of SES-based survival disparities that are mediated by treatment- and facility-related factors among patients with stage I-II HCC. METHODS We analyzed patients aged 18-75 years diagnosed with stage I-II HCC in 2008-2016 using the National Cancer Database. Inverse odds weighting mediation analysis was used to calculate the proportion mediated by three mediators: procedure type, facility volume, and facility procedural interventions offered. Intersectional analyses were performed to determine whether treatment disparities played a larger role in survival disparities among Black and Hispanic patients. RESULTS Among 46,003 patients, 15.0% had low SES, 71.6% had middle SES, and 13.4% had high SES. Five-year overall survival was 46.9%, 39.9%, and 35.7% among high, middle, and low SES patients, respectively. Procedure type mediated 45.9% (95% confidence interval [CI] 31.1-60.7%) and 36.7% (95% CI 25.7-47.7%) of overall survival disparities for low and middle SES patients, respectively, which was more than was mediated by the two facility-level mediators. Procedure type mediated a larger proportion of survival disparities among low-middle SES Black (46.6-48.2%) and Hispanic patients (92.9-93.7%) than in White patients (29.5-29.7%). CONCLUSIONS SES-based disparities in use of procedural interventions mediate a large proportion of survival disparities, particularly among Black and Hispanic patients. Initiatives aimed at attenuating these treatment disparities should be pursued.
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Affiliation(s)
- Douglas S Swords
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Timothy E Newhook
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark Ghobrial
- Department of Surgery-Transplant, Houston Methodist, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Kakish HH, Loftus AW, Ahmed FA, Elshami M, Ocuin LM, Rothermel LD, Hoehn RS. Patient and provider factors predict non-surgical management for complex upper gastrointestinal cancers. Surgery 2023; 174:618-625. [PMID: 37391325 DOI: 10.1016/j.surg.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/05/2023] [Accepted: 05/24/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Surgery is the only potentially curative treatment for non-metastatic upper gastrointestinal cancers. We analyzed patient and provider characteristics associated with non-surgical management. METHODS We queried the National Cancer Database for patients with upper gastrointestinal cancers from 2004 to 2018 who underwent surgery, refused surgery, or for whom surgery was contraindicated. Multivariate logistic regression identified factors associated with surgery being refused or contraindicated, and Kaplan-Meier curves assessed survival. RESULTS We identified 249,813 patients based on our selection criteria-86.3% had surgery, 2.4% refused, and for 11.3%, surgery was contraindicated. Median overall survival was 48.2 months for patients who underwent surgery versus 16.3 and 9.4 months for the refusal and contraindicated groups. Medical and non-medical factors predicted both surgery refusals and contraindications, such as increasing age (odds ratio = 1.07 and 1.03, respectively, P < .001), Black race (odds ratio = 1.72 and 1.45, P < .001), comorbidities (Charlson-Deyo score 2+, odds ratio = 1.18 and 1.66, P < .001), low socioeconomic status (odds ratio = 1.70 and 1.40, P < .001), no health insurance (odds ratio = 3.26 and 2.34, P < .001), community cancer programs (odds ratio = 1.43 and 1.40, P < .001), low volume facilities (odds ratio = 1.82 and 1.52, P < .001), and stage 3 disease (odds ratio = 1.51 and 6.50, P < .001). On subset analysis (excluding patients age >70, Charlson-Deyo score 2+, and stage 3 cancer), non-medical predictors of both outcomes were similar. CONCLUSION Refusal of and medical contraindications for surgery profoundly impact overall survival. The same factors (ie, race, socioeconomic status, hospital volume, and hospital type) predict these outcomes. These findings suggest variation and potential bias that may exist between physicians and patients discussing cancer surgery.
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Affiliation(s)
- Hanna H Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH. https://twitter.com/HannaKakish
| | - Alexander W Loftus
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Fasih Ali Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH.
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Shin WS, Xie F, Chen B, Yu P, Yu J, To KF, Kang W. Updated Epidemiology of Gastric Cancer in Asia: Decreased Incidence but Still a Big Challenge. Cancers (Basel) 2023; 15:cancers15092639. [PMID: 37174105 PMCID: PMC10177574 DOI: 10.3390/cancers15092639] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Despite the decline in incidence and mortality rates, gastric cancer (GC) is the fifth leading cause of cancer deaths worldwide. The incidence and mortality of GC are exceptionally high in Asia due to high H. pylori infection, dietary habits, smoking behaviors, and heavy alcohol consumption. In Asia, males are more susceptible to developing GC than females. Variations in H. pylori strains and prevalence rates may contribute to the differences in incidence and mortality rates across Asian countries. Large-scale H. pylori eradication was one of the effective ways to reduce GC incidences. Treatment methods and clinical trials have evolved, but the 5-year survival rate of advanced GC is still low. Efforts should be put towards large-scale screening and early diagnosis, precision medicine, and deep mechanism studies on the interplay of GC cells and microenvironments for dealing with peritoneal metastasis and prolonging patients' survival.
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Affiliation(s)
- Wing Sum Shin
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Fuda Xie
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong 999077, China
- CUHK-Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen 518000, China
| | - Bonan Chen
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong 999077, China
- CUHK-Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen 518000, China
| | - Peiyao Yu
- Department of Pathology, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Jun Yu
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong 999077, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Ka Fai To
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Wei Kang
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong 999077, China
- CUHK-Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen 518000, China
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Kakish HH, Ahmed FA, Pei E, Dong W, Elshami M, Ocuin LM, Rothermel LD, Ammori JB, Hoehn RS. Understanding Factors Leading to Surgical Attrition for "Resectable" Gastric Cancer. Ann Surg Oncol 2023:10.1245/s10434-023-13469-5. [PMID: 37046129 DOI: 10.1245/s10434-023-13469-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVES We used a novel combined analysis to evaluate various factors associated with failure to surgical resection in non-metastatic gastric cancer. METHODS We identified factors associated with the receipt of surgery in publicly available clinical trial data for gastric cancer and in the National Cancer Database (NCDB) for patients with stages I-III gastric adenocarcinoma. Next, we evaluated variable importance in predicting the receipt of surgery in the NCDB. RESULTS In published clinical trial data, 10% of patients in surgery-first arms did not undergo surgery, mostly due to disease progression and 15% of patients in neoadjuvant therapy arms failed to reach surgery. Effects related to neoadjuvant administration explained the increased attrition (5%). In the NCDB, 61.7% of patients underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (younger, healthier, and privately insured patients treated at high-volume and academic centers) the rate of surgery was 79.2%. Decreased likelihood of surgery was associated with advanced age (OR 0.97, p < 0.01), Charlson-Deyo score of 2+ (OR 0.90, p < 0.01), T4 tumors (OR 0.39, p < 0.01), N+ disease (OR 0.84, p < 0.01), low socioeconomic status (OR 0.86, p = 0.01), uninsured or on Medicaid (OR 0.58 and 0.69, respectively, p < 0.01), low facility volume (OR 0.64, p < 0.01), and non-academic cancer programs (OR 0.79, p < 0.01). CONCLUSION Review of clinical trials shows attrition due to unavoidable tumor and treatment factors (~ 15%). The NCDB indicates non-medical patient and provider characteristics (i.e., age, insurance status, facility volume) associated with attrition. This combined analysis highlights specific opportunities for improving potentially curative surgery rates.
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Affiliation(s)
- Hanna H Kakish
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Fasih Ali Ahmed
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Evonne Pei
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Weichuan Dong
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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12
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Rice-Townsend SE, Nicassio L, Glazer D, Avansino J, Durham MM, Frischer J, Calkins C, Rentea RM, Ralls M, Fuller M, Wood RJ, Rollins M, Lee J, Lewis KE, Reeder RW, Smith CA. Fecal continence outcomes and potential disparities for patients with anorectal malformations treated at referral institutions for pediatric colorectal surgery. Pediatr Surg Int 2023; 39:157. [PMID: 36952009 DOI: 10.1007/s00383-023-05447-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Fecal incontinence is a problem for many patients born with an anorectal malformation (ARM) that can impact quality of life. It is unknown if racial, ethnic, and socioeconomic disparities relate to fecal continence in these children. We sought to examine outcomes and potential disparities in care. METHODS We performed a multicenter retrospective study of children > 3y with ARM evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The primary outcome was fecal continence. We evaluated for associations between fecal continence and race, sex, age, and insurance status. RESULTS 509 patients with ARM from 11 institutions were included. Overall, 24% reported complete fecal continence, and fecal continence was associated with older age (p < .001). For school-aged children, 27% reported complete continence, while 53% reported none. On univariate analysis, patients with combined private and public insurance showed lower rates of continence when compared to those with private insurance (23 vs. 12%; p = 0.02). Age was associated with continence on univariate and multivariable analyses. CONCLUSION Rates of complete fecal continence in this population are low. Differences based on payor status may exist. There were no observed disparities related to sex and race. Further investigation is warranted to improve care for this patient population. LEVEL OF EVIDENCE III. TYPE OF STUDY Multi-institutional retrospective comparative study.
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Affiliation(s)
- Samuel E Rice-Townsend
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA.
| | - Lauren Nicassio
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Deb Glazer
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Jeffrey Avansino
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Megan M Durham
- Children's Healthcare of Atlanta, Emory University Pediatric Institute, Atlanta, GA, USA
| | | | - Casey Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | | | - Justin Lee
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | | | - Caitlin A Smith
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
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13
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Postdischarge Racial and Ethnic Disparities in Pediatric Appendicitis: A Mediation Analysis. J Surg Res 2023; 282:174-182. [PMID: 36308900 DOI: 10.1016/j.jss.2022.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge. MATERIALS AND METHODS We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes. RESULTS A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively. CONCLUSIONS Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.
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14
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Rieser C, Phelos H, Zureikat A, Pingpank J, Ongchin M, Lee A, Brown J, Choudry MH, Hoehn RS. Socioeconomic Barriers to CRS HIPEC for Appendiceal Cancer within a Regional Academic Hospital System. Ann Surg Oncol 2022; 29:6593-6602. [PMID: 35639293 PMCID: PMC9547669 DOI: 10.1245/s10434-022-11949-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Appendiceal cancer with peritoneal metastases (ACPM) is a complex disease requiring multidisciplinary care. Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) can significantly improve survival but requires evaluation by a surgical oncologist and significant treatment endurance. The impacts of socioeconomic status (SES) and other social determinants of health on rates of surgical evaluation and treatment have not been examined. METHODS We conducted a retrospective cohort study examining all patients with ACPM from 2010 to 2018 in a regional healthcare system. Patient characteristics, oncologic details, treatment strategies, and survival were examined. The primary outcomes of interest were referral to Surgical Oncology, receipt of CRS HIPEC, and survival. RESULTS Of 194 patients identified, 94% had synchronous ACPM. The majority of patients (95%) were referred to surgical oncology. Advanced age was the only predictor of nonreferral (p < 0.001). A total of 147 patients (76%) ultimately underwent CRS HIPEC. After adjusting for medical and tumor characteristics, CRS HIPEC was less likely for patients who were unmarried [odds ratio (OR) 0.253, p = 0.004] or of low SES (OR 0.372, p = 0.03). On subanalysis of patients undergoing CRS HIPEC, median overall survival was worse for patients of low SES [51 months versus not reached (NR), p = 0.05], and this disparity persisted on multivariate analysis [hazard ratio (HR) = 2.278, p = 0.001]. CONCLUSIONS This analysis is the first to evaluate barriers to CRS HIPEC for ACPM. While most patients were evaluated by a multidisciplinary team, nonmedical factors may play a role in the treatment received and ultimate outcomes. Addressing these disparities is crucial for ensuring equitable outcomes and improving patient care.
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Affiliation(s)
- Caroline Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heather Phelos
- Division of Trauma and Acute Care Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James Pingpank
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melanie Ongchin
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew Lee
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Brown
- Division of Trauma and Acute Care Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Haroon Choudry
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard S Hoehn
- Division of Surgical Oncology, University Hospitals, Cleveland, OH, USA.
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15
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Herb J, Dunham L, Stitzenberg K. A Comparison of Area-Level Socioeconomic Status Indices in Colorectal Cancer Care. J Surg Res 2022; 280:304-311. [PMID: 36030606 DOI: 10.1016/j.jss.2022.07.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION There are multiple measures of area socioeconomic status (SES) and there is little evidence on the comparative performance of these measures. We hypothesized adding area SES measures improves model ability to predict guideline concordant care and overall survival compared to models with standard clinical and demographic data alone. MATERIALS AND METHODS We included patients with colorectal cancer from 2006 to 2015 from the North Carolina Cancer Registry merged with insurance claims data. The primary area SES study variables were the Social Deprivation Index, Distressed Communities Index, Area Deprivation Index, and Social Vulnerability Index. We used multivariable logistic modeling and Cox proportional hazards modeling to assess the adjusted association of each indicator, with guideline concordant care and overall survival, respectively. Model performance of the SES measures was compared to a base model using likelihood ratio testing and area under the curve (AUC) assessments to compare SES indicator models with each other. RESULTS We found that the Area Deprivation Index, Social Vulnerability Index and Social Deprivation Index, but not Distressed Communities Index, were significantly associated with receiving guideline concordant care and significantly improved model fit over the base model on likelihood ratio testing. All models had similar AUCs. With respect to overall survival, we found that all indices were independently and significantly associated with survival and had significantly improved model fit over the base model on likelihood ratio testing. AUC analysis again showed all area SES measures had comparable performance for overall survival at 5 y. CONCLUSIONS This analysis demonstrates the importance of including these measures in risk adjustment models. However, of the commonly available measures, no one measure stood out as superior to others.
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Affiliation(s)
- Joshua Herb
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Lisette Dunham
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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Xu J, Du S, Dong X. Associations of Education Level With Survival Outcomes and Treatment Receipt in Patients With Gastric Adenocarcinoma. Front Public Health 2022; 10:868416. [PMID: 35757623 PMCID: PMC9218109 DOI: 10.3389/fpubh.2022.868416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background It remains largely unclear how education level, an important socioeconomic factor, affects prognoses for patients with gastric adenocarcinoma (GAC). We aimed to demonstrate the associations between education level and clinical outcomes in patients with GAC. Methods We included a total of 30,409 patients diagnosed with GAC from the Surveillance, Epidemiology, and End Results 18 registry database. Education level, household income, unemployment rate, poverty rate, insurance status, and marital status were selected as sociodemographic variables for the comprehensive analysis. Cox and logistic regression models, Kaplan–Meier curves, and subgroup analyses were the primary statistical methods employed. Results A low level of education was correlated with less income, higher unemployment rates, and higher poverty rates (all p < 0.001). The multivariate Cox analysis indicated that a high education level was significantly associated with superior overall survival rates and cancer-specific survival rates in patients with GAC (both p < 0.001). We also corroborated favorable survival outcomes by high education level within almost every clinical and demographic subgroup. Furthermore, chemotherapy combined with surgery could markedly prolong the survival for all patients, including patients of stage IV cancer (both p < 0.001). By using multivariable logistic models, patients in counties with high education levels had a higher probability of chemotherapy receipt (p < 0.001). Contrarily, those in the counties with low levels of education were less likely to receive chemotherapy or undergo surgery (p < 0.001). Conclusions Education level was identified and confirmed as an independent predictor of treatment and survival for GAC patients. Efforts are needed to provide effective interventions for those whose educational status is adverse.
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Affiliation(s)
- Jiaxuan Xu
- Department of Hematology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Education, Nanjing University, Nanjing, China
| | - Shuhui Du
- Department of Hematology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Education, Nanjing University, Nanjing, China
| | - Xiaoqing Dong
- Department of Hematology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Education, Nanjing University, Nanjing, China
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17
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Fabregas JC, Riley KE, Brant JM, George TJ, Orav EJ, Lam MB. Association of social determinants of health with late diagnosis and survival of patients with pancreatic cancer. J Gastrointest Oncol 2022; 13:1204-1214. [PMID: 35837201 DOI: 10.21037/jgo-21-788] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/30/2022] [Indexed: 12/22/2022] Open
Abstract
Background Pancreatic cancer disparities have been described. However, it is unknown if they contribute to a late diagnosis and survival of patients with metastatic disease. Identifying their role is important as it will open the door for interventions. We hypothesize that social determinants of health (SDH) such as income, education, race, and insurance status impact (I) stage of diagnosis of PC (Stage IV vs. other stages), and (II) overall survival (OS) in Stage IV patients. Methods Using the National Cancer Database, we evaluated a primary outcome of diagnosis of Stage IV PC and a secondary outcome of OS. Primary predictors included race, income, education, and insurance. Covariates included age, sex and Charlson-Deyo comorbidity score. Univariate, multivariable logistic regression models evaluated risk of a late diagnosis. Univariate, multivariable Cox proportional hazards model examined OS. 95% confidence intervals were used. Results 230,877 patients were included, median age of 68 years (SD 12.1). In univariate analysis, a better education, higher income, and insurance decreased the odds of Stage IV PC, while Black race increased it. In multivariable analysis, education [>93% high-school completion (HSC) vs. <82.4%, OR 0.96 (0.93-0.99)] and insurance [private vs. no, OR 0.72 (0.67-0.74)] significantly decreased the risk of a late diagnosis, whereas Black race increased the odds [vs. White, OR 1.09 (1.07-1.12)]. In univariate Cox analysis, having a higher income, insurance and better education improved OS, while Black race worsened it. In multivariable Cox, higher income [>$63,333 (vs. <$40,277), HR 0.87 (0.85-0.89)] and insurance [private vs. no, HR 0.77 (0.74-0.79)] improved OS. Conclusions SDH impacted the continuum of care for patients with advanced pancreatic cancer, including stage at diagnosis and overall survival.
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Affiliation(s)
- Jesus C Fabregas
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Kristen E Riley
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | | | - Thomas J George
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - E John Orav
- Harvard Medical School, Department of Medicine, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Miranda B Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Department of Radiation Oncology, Boston, MA, USA.,Harvard T. H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA, USA
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18
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Boscoe FP, Liu B, Lafantasie J, Niu L, Lee F. Estimating uncertainty in a socioeconomic index derived from the American community survey. SSM Popul Health 2022; 18:101078. [PMID: 35647260 PMCID: PMC9130578 DOI: 10.1016/j.ssmph.2022.101078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/22/2021] [Accepted: 03/22/2022] [Indexed: 11/19/2022] Open
Abstract
Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.
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19
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Del Valle JP, Fillmore NR, Molina G, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3194-3202. [PMID: 35006509 DOI: 10.1245/s10434-021-11250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - George Molina
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Fairweather
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiping Wang
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanley W Ashley
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Whang
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Fonseca AL, Khan H, Mehari KR, Cherla D, Heslin MJ, Johnston FM. Disparities in Access to Oncologic Care in Pancreatic Cancer: A Systematic Review. Ann Surg Oncol 2022; 29:3232-3250. [PMID: 35067789 DOI: 10.1245/s10434-021-11258-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Pancreatic cancer care is complex, and multiple disparities in receipt of therapies have been documented. The authors aimed to conduct a systematic review of the literature to critically assess and summarize disparities in access to oncologic therapies for pancreatic cancer. METHODS A search of PubMed, Scopus, Web of Science, and Cochrane databases were performed for studies reporting disparities in access to oncologic care for pancreatic cancer. Primary research articles published in the United States from 2000 to 2020 were included. Data were independently extracted, and risk of bias was assessed using the modified Newcastle-Ottawa scale. RESULTS The inclusion criteria were met by 47 studies. All the studies used retrospective data, with 70 % involving national database studies, 41 assessing the impact of race/ethnicity, 22 assessing the impact of socioeconomic status, 18 assessing the impact of insurance status, 23 assessing the impact of gender, 26 assessing the impact of age, and 3 assessing the impact of location on the delivery of cancer-directed therapies. Race, socioeconomic status, insurance status, gender, and age- based disparities in receipt of surgical resection, treatment at high-volume facilities and multimodal therapy for resectable pancreatic cancer, receipt of systemic chemotherapy for metastatic cancer, and receipt of expected standard-of-care treatment are reported. CONCLUSION Significant sociodemographic disparities in access to equitable oncologic care exist along the continuum of pancreatic cancer care. Multiple patient, provider, and systemic factors contribute to these disparities. The ongoing study of these disparities is important to elucidate processes that may be targeted to improve access to equitable oncologic care for patients with pancreatic cancer.
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Affiliation(s)
| | - Hamza Khan
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista R Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Deepa Cherla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tron L, Fauvernier M, Bouvier AM, Robaszkiewicz M, Bouvier V, Cariou M, Jooste V, Dejardin O, Remontet L, Alves A, Molinié F, Launoy G. Socioeconomic Environment and Survival in Patients with Digestive Cancers: A French Population-Based Study. Cancers (Basel) 2021; 13:cancers13205156. [PMID: 34680305 PMCID: PMC8533795 DOI: 10.3390/cancers13205156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 12/16/2022] Open
Abstract
Social inequalities are an important prognostic factor in cancer survival, but little is known regarding digestive cancers specifically. We aimed to provide in-depth analysis of the contextual social disparities in net survival of patients with digestive cancer in France, using population-based data and relevant modeling. Digestive cancers (n = 54,507) diagnosed between 2006-2009, collected through the French network of cancer registries, were included (end of follow-up 30 June 2013). Social environment was assessed by the European Deprivation Index. Multidimensional penalized splines were used to model excess mortality hazard. We found that net survival was significantly worse for individuals living in a more deprived environment as compared to those living in a less deprived one for esophageal, liver, pancreatic, colon and rectal cancers, and for stomach and bile duct cancers among females. Excess mortality hazard was up to 57% higher among females living in the most deprived areas (vs. least deprived) at 1 year of follow-up for bile duct cancer, and up to 21% higher among males living in the most deprived areas (vs. least deprived) regarding colon cancer. To conclude, we provide a better understanding of how the (contextual) social gradient in survival is constructed, offering new perspectives for tackling social inequalities in digestive cancer survival.
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Affiliation(s)
- Laure Tron
- ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France; (V.B.); (O.D.); (A.A.); (G.L.)
- Correspondence:
| | - Mathieu Fauvernier
- Service de Biostatistique–Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, 69000 Lyon, France; (M.F.); (L.R.)
- Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, University of Lyon 1, CNRS, UMR 5558, 69100 Villeurbanne, France
| | - Anne-Marie Bouvier
- Digestive Cancer Registry of Burgundy, Dijon University Hospital, INSERM UMR 1231, University of Burgundy, 21079 Dijon, France; (A.-M.B.); (V.J.)
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
| | - Michel Robaszkiewicz
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
- Digestive Tumors Registry of Finistère, EA SPURBO 7479, CHRU Morvan, 29200 Brest, France
| | - Véronique Bouvier
- ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France; (V.B.); (O.D.); (A.A.); (G.L.)
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
- Digestive Cancer Registry of Calvados, Caen University Hospital, ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France
| | - Mélanie Cariou
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
- Digestive Tumors Registry of Finistère, EA SPURBO 7479, CHRU Morvan, 29200 Brest, France
| | - Valérie Jooste
- Digestive Cancer Registry of Burgundy, Dijon University Hospital, INSERM UMR 1231, University of Burgundy, 21079 Dijon, France; (A.-M.B.); (V.J.)
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
| | - Olivier Dejardin
- ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France; (V.B.); (O.D.); (A.A.); (G.L.)
- Research Department, Caen University Hospital, ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France
| | - Laurent Remontet
- Service de Biostatistique–Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, 69000 Lyon, France; (M.F.); (L.R.)
- Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, University of Lyon 1, CNRS, UMR 5558, 69100 Villeurbanne, France
| | - Arnaud Alves
- ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France; (V.B.); (O.D.); (A.A.); (G.L.)
- Research Department, Caen University Hospital, ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France
- Department of Digestive Surgery, University Hospital of Caen, 14000 Caen, France
| | | | - Florence Molinié
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
- Loire-Atlantique/Vendée Cancer Registry, 44000 Nantes, France
- CERPOP, Université de Toulouse, Inserm, UPS, 31000 Toulouse, France
| | - Guy Launoy
- ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France; (V.B.); (O.D.); (A.A.); (G.L.)
- French Network of Cancer Registries, 31000 Toulouse, France; (M.R.); (M.C.); (F.M.)
- Research Department, Caen University Hospital, ‘ANTICIPE’ U1086 INSERM-UCN, Normandie University UNICAEN, Centre François Baclesse, 14000 Caen, France
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22
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Swords DS, You YN. ASO Author Reflections: Understanding Factors That Mediate the Association Between Socioeconomic Status and Survival After Surgery for Locoregional Colon Cancer. Ann Surg Oncol 2021; 29:717-718. [PMID: 34467508 DOI: 10.1245/s10434-021-10744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Douglas S Swords
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Y Nancy You
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
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23
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Swords DS, Bednarski BK, Messick CA, Tillman MM, Chang GJ, You YN. Quality and Location of the Surgical Episode Mediate a Large Proportion of Socioeconomic-Based Survival Disparities in Patients with Resected Stage I-III Colon Cancer. Ann Surg Oncol 2021; 29:706-716. [PMID: 34406541 DOI: 10.1245/s10434-021-10643-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Lower socioeconomic status (SES) is associated with shorter overall survival (OS) in patients with locoregional colon cancer. We aimed to estimate: (1) the proportion of SES-based OS disparities mediated by disparities in the quality and location of surgical treatment in patients with resected stage I-III colon cancer and (2) the relative importance of components of surgical quality. PATIENTS AND METHODS We examined patients ages 18-80 years with resected stage I-III colon adenocarcinoma using the 2010-2016 National Cancer Database. SES was defined at the zip code level. Inverse odds weighting mediation analysis was used to estimate the proportion mediated (PM) for nine treatment quality-related and facility-related factors and composite PMs in models including all nine mediators. Models compared high SES patients with each lower SES stratum. RESULTS Among 171,009 patients, 5-year OS increased from 70.4% in low SES patients to 78.1% in high SES. When high SES patients were compared with low, lower-middle, and upper-middle SES patients, PM ranges among lower SES strata were: minimally invasive surgery 16.0-16.6%, lymph nodes examined 7.7-9.6%, positive margins 3.8-6.5%, length of stay 16.7-28.1%, readmissions insignificant to 3.7%, treatment at > 1 CoC facility 2.7-3.1%, facility type insignificant to 7.3%, facility volume 2.9-8.2%, and adjusted facility 90-day mortality rates 33.2-42.8%. Composite PMs were 76.9% (95% CI 61.3%, 92.4%) for low SES, 68.7% (95% CI 56.4%, 81.1%) for lower-middle SES, and 60.9% (95% CI 43.1%, 78.6%) for upper-middle SES. CONCLUSIONS These data suggest that improving the quality of the surgical episode for disadvantaged patients undergoing resection for locoregional colon cancer could decrease SES-based survival disparities by over half.
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Affiliation(s)
- Douglas S Swords
- Department of Surgical Oncology, University of Texas MD Anderson Cancer, Houston, TX, USA.
| | - Brian K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer, Houston, TX, USA.,Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Craig A Messick
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Matthew M Tillman
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - George J Chang
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Y Nancy You
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
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24
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Granular neighborhood-level socioeconomic data: An opportunity for a different kind of precision oncology? Am J Surg 2021; 222:8-9. [DOI: 10.1016/j.amjsurg.2021.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 11/18/2022]
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25
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Dhahri A, Kaplan J, Naqvi SMH, Brownstein NC, Ntiri SO, Imanirad I, Felder SI, Dineen SP, Sanchez J, Dessureault S, Carballido E, Powers BD. The impact of socioeconomic status on survival in stage III colon cancer patients: A retrospective cohort study using the SEER census-tract dataset. Cancer Med 2021; 10:5643-5652. [PMID: 34197047 PMCID: PMC8366079 DOI: 10.1002/cam4.4099] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/20/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background The impact of socioeconomic status (SES) has been described for screening and accessing treatment for colon cancer. However, little is known about the “downstream” effect in patients who receive guideline‐concordant treatment. This study assessed the impact of SES on cancer‐specific survival (CSS) and overall survival (OS) for stage III colon cancer patients. Methods The SEER Census Tract‐Level SES Dataset from 2004 to 2015 was used to identify stage III colon adenocarcinoma patients who received curative‐intent surgery and adjuvant chemotherapy. The predictor variable was census tract SES. SES was analyzed as quintiles. The outcome variables were OR and CSS. Statistical analysis included chi square tests for association, Kaplan–Meier, Cox, Fine and Gray regression for survival analysis. Results In total, 27,222 patients met inclusion criteria. Lower SES was associated with younger age, Black or Hispanic race/ethnicity, Medicaid/uninsured, higher T stage, and lower grade tumors. CSS at the 25th percentile was 54 months for the lowest SES quintile and 80 for the highest. Median OS was 113 months for the lowest SES quintile and not reached for highest. The 5‐year CSS rate was 72.4% for the lowest SES quintile compared to 78.9% in the highest (p < 0.001). The 5‐year OS rate was 66.5% for the lowest SES quintile and 74.6% in the highest (p < 0.001). Conclusion This is the first study to evaluate CSS and OS in an incidence‐based cohort of stage III colon cancer patients using a granular, standardized measure of SES. Despite receipt of guideline‐based treatment, SES was associated with disparities in CSS and OS.
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Affiliation(s)
- Amina Dhahri
- Department of Internal Medicine, University of Maryland Capital Region Health, Largo, MD, USA
| | - Jori Kaplan
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Syeda M H Naqvi
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Naomi C Brownstein
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shana O Ntiri
- The University of Maryland Greenbaum Comprehensive Cancer Center, University of Maryland Greenbaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Iman Imanirad
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Seth I Felder
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Sean P Dineen
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Julian Sanchez
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Estrella Carballido
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA.,Health Outcomes and Behavior Program, Moffitt Cancer Center, Tampa, FL, USA
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26
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Johnston FM, Yeo HL, Clark C, Stewart JH. Bias Issues in Colorectal Cancer Management: A Review. Ann Surg Oncol 2021; 29:2166-2173. [PMID: 34142287 DOI: 10.1245/s10434-021-10232-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/02/2021] [Indexed: 12/11/2022]
Abstract
Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients.
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Affiliation(s)
- Fabian M Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA.
| | - Heather L Yeo
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Callisia Clark
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John H Stewart
- Department of Surgery, The University of Illinois at Chicago, Chicago, IL, USA.,University of Illinois Cancer Center, Chicago, IL, USA
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27
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Hoehn RS, Rieser CJ, Phelos H, Sabik LM, Nassour I, Khan S, Kaltenmeier C, Paniccia A, Zureikat AH, Tohme ST. Medicaid expansion and the management of pancreatic cancer. J Surg Oncol 2021; 124:324-333. [PMID: 33939838 DOI: 10.1002/jso.26515] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/02/2021] [Accepted: 04/16/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. METHODS Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. RESULTS In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival. CONCLUSION Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Heather Phelos
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sidrah Khan
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christof Kaltenmeier
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samer T Tohme
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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28
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Rieser CJ, Hoehn RS, Zenati M, Hall LB, Kang E, Zureikat AH, Lee A, Ongchin M, Holtzman MP, Pingpank JF, Bartlett DL, Choudry MHA. Impact of Socioeconomic Status on Presentation and Outcomes in Colorectal Peritoneal Metastases Following Cytoreduction and Chemoperfusion: Persistent Inequalities in Outcomes at a High-Volume Center. Ann Surg Oncol 2021; 28:3522-3531. [PMID: 33687614 PMCID: PMC8184539 DOI: 10.1245/s10434-021-09627-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) can offer significant survival advantage for select patients with colorectal peritoneal metastases (CRPM). Low socioeconomic status (SES) is implicated in disparities in access to care. We analyze the impact of SES on postoperative outcomes and survival at a high-volume tertiary CRS HIPEC center. PATIENTS AND METHODS We conducted a retrospective cohort study examining patients who underwent CRS HIPEC for CRPM from 2000 to 2018. Patients were grouped according to SES. Baseline characteristics, perioperative outcomes, and survival were examined between groups. RESULTS A total of 226 patients were analyzed, 107 (47%) low-SES and 119 (53%) high-SES patients. High-SES patients were younger (52 vs. 58 years, p = 0.01) and more likely to be White (95.0% vs. 91.6%, p = 0.06) and privately insured (83% vs. 57%, p < 0.001). They traveled significantly further for treatment and had lower burden of comorbidities and frailty (p = 0.01). Low-SES patients more often presented with synchronous peritoneal metastases (48% vs. 35%, p = 0.05). Following CRS HIPEC, low-SES patients had longer length of stay and higher burden of postoperative complications, 90-day readmission, and 30-day mortality. Median overall survival following CRS HIPEC was worse for low-SES patients (17.8 vs. 32.4 months, p = 0.02). This disparity persisted on multivariate survival analysis (low SES: HR = 1.46, p = 0.03). CONCLUSIONS Despite improving therapies for CRPM, low-SES patients remain at a significant disadvantage. Even patients who overcome barriers to care experience worse short- and long-term outcomes. Improving access and addressing these disparities is crucial to ensure equitable outcomes and improve patient care.
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Affiliation(s)
- Caroline J Rieser
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA.
| | - Richard S Hoehn
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Mazen Zenati
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Lauren B Hall
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Eliza Kang
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Andrew Lee
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Melanie Ongchin
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - Matthew P Holtzman
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - James F Pingpank
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - M Haroon A Choudry
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, UPMC Cancer Pavilion, Pittsburgh, PA, USA
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29
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Bliton JN, Parides M, Muscarella P, Papalezova KT, In H. Understanding Racial Disparities in Gastrointestinal Cancer Outcomes: Lack of Surgery Contributes to Lower Survival in African American Patients. Cancer Epidemiol Biomarkers Prev 2021; 30:529-538. [PMID: 33303644 PMCID: PMC8049948 DOI: 10.1158/1055-9965.epi-20-0950] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/11/2020] [Accepted: 12/01/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Race/ethnicity-related differences in rates of cancer surgery and cancer mortality have been observed for gastrointestinal (GI) cancers. This study aims to estimate the extent to which differences in receipt of surgery explain racial/ethnic disparities in cancer survival. METHODS The National Cancer Database was used to obtain data for patients diagnosed with stage I-III mid-esophageal, distal esophagus/gastric cardia (DEGC), noncardia gastric, pancreatic, and colorectal cancer in years 2004-2015. Mediation analysis was used to identify variables influencing the relationship between race/ethnicity and mortality, including surgery. RESULTS A total of 600,063 patients were included in the study: 3.5% mid-esophageal, 12.4% DEGC, 4.9% noncardia gastric, 17.0% pancreatic, 40.1% colon, and 22.0% rectal cancers. The operative rates for Black patients were low relative to White patients, with absolute differences of 21.0%, 19.9%, 2.3%, 8.3%, 1.6%, and 7.7%. Adjustment for age, stage, and comorbidities revealed even lower odds of receiving surgery for Black patients compared with White patients. The observed HRs for Black patients compared with White patients ranged from 1.01 to 1.42. Mediation analysis showed that receipt of surgery and socioeconomic factors had greatest influence on the survival disparity. CONCLUSIONS The results of this study indicate that Black patients appear to be undertreated compared with White patients for GI cancers. The disproportionately low operative rates contribute to the known survival disparity between Black and White patients. IMPACT Interventions to reduce barriers to surgery for Black patients should be promoted to reduce disparities in GI cancer outcomes.See related commentary by Hébert, p. 438.
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Affiliation(s)
- John N Bliton
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Michael Parides
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Peter Muscarella
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Katia T Papalezova
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Haejin In
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.
- Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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30
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Boscoe FP, Liu B, Lee F. A comparison of two neighborhood-level socioeconomic indexes in the United States. Spat Spatiotemporal Epidemiol 2021; 37:100412. [PMID: 33980407 DOI: 10.1016/j.sste.2021.100412] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/04/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
socioeconomic indexes that capture information about wealth, education, employment, and housing are in wide use in public health. Here we compare the widely used Area Deprivation Index (ADI) to the Yost index. Though they are derived largely from the same data, there are substantial differences between the two. Examination of the geographic areas where the two indexes are most dissimilar suggest that the Yost index has greater face validity and that the ADI is highly sensitive to locations with incomplete census data and with census data containing outliers.
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Affiliation(s)
- Francis P Boscoe
- Pumphandle, LLC, Portland, ME, USA; New York State Department of Health, Albany, NY, USA.
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Furrina Lee
- New York State Department of Health, Albany, NY, USA
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31
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Hoehn RS, Rieser CJ, Zureikat AH. ASO Author Reflections: Improving Our Understanding of Socioeconomic Disparities in Cancer Treatment and Outcomes. Ann Surg Oncol 2021; 28:2447-2448. [PMID: 33523365 DOI: 10.1245/s10434-021-09642-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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32
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Hoehn RS, Rieser CJ, Winters S, Stitt L, Hogg ME, Bartlett DL, Lee KK, Paniccia A, Ohr JP, Gorantla VC, Krishnamurthy A, Rhee JC, Bahary N, Olson AC, Burton S, Ellsworth SG, Slivka A, McGrath K, Khalid A, Fasanella K, Chennat J, Brand RE, Das R, Sarkaria R, Singhi AD, Zeh HJ, Zureikat AH. A Pancreatic Cancer Multidisciplinary Clinic Eliminates Socioeconomic Disparities in Treatment and Improves Survival. Ann Surg Oncol 2021; 28:2438-2446. [PMID: 33523364 DOI: 10.1245/s10434-021-09594-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/31/2020] [Indexed: 11/18/2022]
Abstract
AIMS National studies have demonstrated disparities in the treatment and survival of pancreatic cancer patients based on socioeconomic status (SES). This study aimed to identify specific differences in perioperative management and outcomes based on patient SES and to study the role of a multidisciplinary clinic (MDC) in mitigating any variations. METHODS The study analyzed patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma in a large hospital system. The patients were categorized into groups of high and low SES and whether they were managed by the authors' pancreatic cancer MDC or not. The study compared differences in disease characteristics, receipt of multimodality therapy, perioperative outcomes, and recurrence-free and overall survival. RESULTS Of the 162 low-SES patients and 119 high-SES patients, 54% were managed in the MDC. Outside the MDC, low-SES patients were less likely to receive neoadjuvant chemotherapy and had less minimally invasive surgery, a longer OR time, less enhanced recovery participation, and more major complications (p < 0.05). No SES disparities were observed among the MDC patients. Despite similar tumor characteristics, the low-SES patients had inferior median overall survival (21 vs 32 months; p = 0.005), but the MDC appeared to eliminate this disparity. Low SES correlated with inferior survival for the non-MDC patients (17 vs 32 months; p < 0.001), but not for the MDC patients (24 vs 25 months; p = 0.33). These findings persisted in the multivariable analysis. CONCLUSION A pancreatic cancer MDC standardizes treatment decisions, eliminates disparities in surgical outcomes, and improves survival for low-SES patients.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sharon Winters
- Cancer Registries, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lauren Stitt
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore Hospital, Chicago, IL, USA
| | - David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James P Ohr
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikram C Gorantla
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anuradha Krishnamurthy
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John C Rhee
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathan Bahary
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam C Olson
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steve Burton
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susannah G Ellsworth
- Division of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin McGrath
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Asif Khalid
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth Fasanella
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Chennat
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Randal E Brand
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rohit Das
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ritu Sarkaria
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Afshar N, English DR, Milne RL. Factors Explaining Socio-Economic Inequalities in Cancer Survival: A Systematic Review. Cancer Control 2021; 28:10732748211011956. [PMID: 33929888 PMCID: PMC8204531 DOI: 10.1177/10732748211011956] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/06/2021] [Accepted: 03/31/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND There is strong and well-documented evidence that socio-economic inequality in cancer survival exists within and between countries, but the underlying causes of these differences are not well understood. METHODS We systematically searched the Ovid Medline, EMBASE, and CINAHL databases up to 31 May 2020. Observational studies exploring pathways by which socio-economic position (SEP) might causally influence cancer survival were included. RESULTS We found 74 eligible articles published between 2005 and 2020. Cancer stage, other tumor characteristics, health-related lifestyle behaviors, co-morbidities and treatment were reported as key contributing factors, although the potential mediating effect of these factors varied across cancer sites. For common cancers such as breast and prostate cancer, stage of disease was generally cited as the primary explanatory factor, while co-morbid conditions and treatment were also reported to contribute to lower survival for more disadvantaged cases. In contrast, for colorectal cancer, most studies found that stage did not explain the observed differences in survival by SEP. For lung cancer, inequalities in survival appear to be partly explained by receipt of treatment and co-morbidities. CONCLUSIONS Most studies compared regression models with and without adjusting for potential mediators; this method has several limitations in the presence of multiple mediators that could result in biased estimates of mediating effects and invalid conclusions. It is therefore essential that future studies apply modern methods of causal mediation analysis to accurately estimate the contribution of potential explanatory factors for these inequalities, which may translate into effective interventions to improve survival for disadvantaged cancer patients.
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Affiliation(s)
- Nina Afshar
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Cancer Health Services Research Unit, Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Dallas R. English
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Swords DS, Scaife CL. ASO Author Reflections: Using Causal Mediation Analysis to Understand the Proportion of Survival Disparities Mediated by Potentially Modifiable Treatment Factors. Ann Surg Oncol 2020; 28:3169-3170. [PMID: 33169299 DOI: 10.1245/s10434-020-09322-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Douglas S Swords
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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35
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Swords DS, Scaife CL. Decompositions of the Contribution of Treatment Disparities to Survival Disparities in Stage I-II Pancreatic Adenocarcinoma. Ann Surg Oncol 2020; 28:3157-3168. [PMID: 33145705 DOI: 10.1245/s10434-020-09267-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Higher socioeconomic status (SES) and non-Hispanic White (NHW) race/ethnicity are associated with higher treatment rates and longer overall survival (OS) among US patients with stage I-II pancreatic ductal adenocarcinoma. The proportion of OS disparities mediated through treatment disparities (PM) and the proportion predicted to be eliminated (PE) if treatment disparities were eliminated are unknown. METHODS We analyzed 2007-2015 data from the Surveillance, Epidemiology, and End Results (SEER) census tract-level database and the National Cancer Database (NCDB) using causal mediation analysis methods to understand the extent to which treatment disparities mediate OS disparities. In the first set of decompositions, race/ethnicity was controlled for as a covariate proximal to SES, and lower SES strata were compared with the highest SES stratum. In the second set, an intersectional perspective was taken and each SES-race/ethnicity combination was compared with highest SES-NHW patients, who had the highest treatment rates and longest OS. RESULTS The SEER and NCDB cohorts contained 16,921 patients and 44,638 patients, respectively. When race/ethnicity was controlled for, PMs ranged from 43 to 48% and PEs ranged from 46 to 50% for various lower SES strata. When separately comparing each SES-race/ethnicity combination with the highest SES-NHW patients, results were similar for lower SES-NHW patients but differed markedly for non-Hispanic Black and Hispanic patients, for whom PMs ranged from 60 to 80% and PEs ranged from 55 to 75% for most lower SES strata. CONCLUSIONS These results suggest that efforts to reduce treatment disparities are worthwhile, particularly for NHB and Hispanic patients, and simultaneously point to the importance of non-treatment-related causal pathways.
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Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, Salt Lake City, UT, USA.
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Davis LE, Coburn NG, Hallet J, Earle CC, Liu Y, Myrehaug S, Mahar AL. Material deprivation and access to cancer care in a universal health care system. Cancer 2020; 126:4545-4552. [DOI: 10.1002/cncr.33107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Laura E. Davis
- Department of Epidemiology, Biostatistics, and Occupational Health McGill University Montreal Quebec Canada
| | - Natalie G. Coburn
- Division of Surgical Oncology Odette Cancer CentreSunnybrook Health Sciences Centre Toronto Ontario Canada
- ICES Toronto Ontario Canada
| | - Julie Hallet
- Division of Surgical Oncology Odette Cancer CentreSunnybrook Health Sciences Centre Toronto Ontario Canada
- ICES Toronto Ontario Canada
| | - Craig C. Earle
- ICES Toronto Ontario Canada
- Division of Medical Oncology Odette Cancer CentreSunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Sten Myrehaug
- Division of Radiation Oncology Odette Cancer CentreSunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Alyson L. Mahar
- ICES Toronto Ontario Canada
- Department of Community Health Sciences University of Manitoba Winnipeg Manitoba Canada
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37
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Swords DS, Scaife CL. ASO Author Reflections: Socioeconomic Disparities in Use of Surgery for Gastrointestinal Cancers Are Large and Impactful in Poor-Prognosis Cancers. Ann Surg Oncol 2019; 27:342-343. [PMID: 31686347 DOI: 10.1245/s10434-019-08063-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, Salt Lake City, UT, USA.
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