1
|
Syamal S, Tran AH, Huang CC, Badrinathan A, Bassiri A, Ho VP, Towe CW. Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database. Am Surg 2024; 90:1037-1044. [PMID: 38085592 DOI: 10.1177/00031348231220597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes. METHODS A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed. RESULTS In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality. DISCUSSION Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.
Collapse
Affiliation(s)
- Sujata Syamal
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Andrew H Tran
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Chi-Ching Huang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Trauma Recovery Center, Institute for H.O.P.E, The MetroHealth System, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
2
|
Manyak GA, Bassiri A, Alvarado CE, Sarnaik KS, Sinopoli J, Tapias L, Linden PA, Towe CW. Is Minimally Invasive Resection of Large Thymoma Appropriate? Am Surg 2024:31348241246180. [PMID: 38584508 DOI: 10.1177/00031348241246180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Current practice patterns suggest open rather than minimally invasive (MIS) approaches for thymomas >4 cm. We hypothesized there would be similar perioperative outcomes and overall survival between open and MIS approaches for large (>4 cm) thymoma resection. METHODS The National Cancer Database was queried for patients who underwent thymectomy from 2010 to 2020. Surgical approach was characterized as either open or MIS. The primary outcome was overall survival and secondary outcomes were margin status, and length of stay (LOS). Differences between approach cohorts were compared after a 1:1 propensity match. RESULTS Among 4121 thymectomies, 2474 (60%) were open and 1647 (40%) were MIS. Patients undergoing MIS were older, had fewer comorbidities, and had smaller tumors (median; 4.6 vs 6 cm, P < .001). In the unmatched cohort, MIS and open had similar 90-day mortality (1.1% vs 1.8%, P = .158) and rate of positive margin (25.1% vs 27.9%, P = .109). MIS thymectomy was associated with shorter LOS (2 (1-4) vs 4 (3-6) days, P < .001). Propensity matching reduced the bias between the groups. In this cohort, overall survival was similar between the groups by log-rank test (P = .462) and multivariate cox hazard analysis (HR .882, P = .472). Multivariable regression showed shorter LOS with MIS approach (Coef -1.139, P < .001), and similar odds of positive margin (OR 1.130, P = .150). DISCUSSION MIS has equivalent oncologic benefit to open resection for large thymomas, but is associated with shorter LOS. When clinically appropriate, MIS thymectomy may be considered a safe alternative to open resection for large thymomas.
Collapse
Affiliation(s)
- Grigory A Manyak
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kunaal S Sarnaik
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Jilian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Leonidas Tapias
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| |
Collapse
|
3
|
Towe CW, Grau-Sepulveda MV, Hartwig MG, Kang L, Jiang B, Sinopoli J, Tapias Vargas L, Kosinski A, Linden PA. The Society of Thoracic Surgeons Database Analysis: Comparing Sublobar Techniques in Stage IA Lung Cancer. Ann Thorac Surg 2024:S0003-4975(24)00191-7. [PMID: 38493921 DOI: 10.1016/j.athoracsur.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/05/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND This study compares sublobar resections-wedge resection and segmentectomy-in clinical stage IA lung cancers. It tests the hypothesis that overall survival after wedge resection is similar to segmentectomy. METHODS Adults undergoing wedge resection or segmentectomy for clinical stage IA lung cancer were identified from The Society of Thoracic Surgeons General Thoracic Surgery Database. Eligible patients were linked to the Centers for Medicare and Medicaid Services database using a matching algorithm. The primary outcome was long-term overall survival. Propensity scores overlap weighting (PSOW) adjustment of wedge resection using validated covariates was used for group difference mitigation. Kaplan-Meier and Cox regression models analyzed survival. All-cause first readmission, and morbidity and mortality were examined using PSOW regression models. RESULTS Of 9756 patients, 6141 met inclusion criteria, comprising 2154 segmentectomies and 3987 wedge resections. PSOW reduced differences between the groups. Unadjusted perioperative mortality was comparable, but wedge resection showed lower major morbidity rates. Weighted regression analysis indicated reduced mortality and major morbidity risks in wedge resection. Kaplan-Meier analysis revealed no mortality difference between groups, which was confirmed by PSOW Cox regression models. The cumulative risk of readmission was also comparable for both groups, with Cox Fine-Gray models showing no difference in rehospitalization risks. CONCLUSIONS In clinical stage IA lung cancer, relative to segmentectomy, wedge resection has comparable overall survival and lower perioperative morbidity, suggesting it is an equally effective option for the broader population of patients with clinical stage IA lung cancer, not only those at highest risk of complications.
Collapse
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | | | - Matthew G Hartwig
- Department of Surgery, Duke Health and Duke Clinical Research Institute, Durham, North Carolina
| | - Lillian Kang
- Division of Biostatistics, Duke Clinical Research Institute, Durham, North Carolina
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Andrzej Kosinski
- Division of Biostatistics, Duke Clinical Research Institute, Durham, North Carolina
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
4
|
Halloran SJ, Martin S, Jiang B, Bassiri A, Sinopoli J, Vargas LT, Linden PA, Towe CW. Risk Factors for Chronic Atrial Fibrillation Following Lung Lobectomy. J Surg Res 2024; 295:350-356. [PMID: 38064975 DOI: 10.1016/j.jss.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/04/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Postoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF. METHODS The TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months ("early") and 12-24 months postop ("chronic"). Propensity matching was performed to reduce bias between cohorts. RESULTS We identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003). CONCLUSIONS Postoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.
Collapse
Affiliation(s)
- Sean J Halloran
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Scott Martin
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| |
Collapse
|
5
|
Towe CW, Servais EL, Brown LM, Blasberg JD, Mitchell JD, Worrell SG, Seder CW, David EA. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2023 Update on Outcomes and Research. Ann Thorac Surg 2024; 117:489-496. [PMID: 38043852 DOI: 10.1016/j.athoracsur.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD) continues its trajectory of growth and enhancement, solidifying its stature as a premier global thoracic surgical database. The past year witnessed a notable expansion with the inclusion of 10 additional participating sites, now totaling 287, augmenting the database's repository to more than 800,000 procedures. A significant stride was made in refining the data audit process, thereby elevating the accuracy and completeness metrics, a testament to the relentless pursuit of data integrity. The GTSD further broadened its research apparatus, with 15 scholarly publications, a 50% uptick from the preceding year. These publications underscore the database's instrumental role in advancing thoracic surgical knowledge. In a concerted effort to alleviate data entry exigencies, the GTSD Task Force also instituted streamlined data submission protocols, a move lauded by participant sites. This report delineates the recent advancements, volume trajectories, and outcome metrics and encapsulates the prolific research output emanating from the GTSD, reflecting a year of substantial progress and academic fecundity.
Collapse
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Elliot L Servais
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts; Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - Lisa M Brown
- Section of General Thoracic Surgery, UC Davis Health, Sacramento, California
| | - Justin D Blasberg
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - John D Mitchell
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| | | | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Elizabeth A David
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| |
Collapse
|
6
|
Gasnick A, Sarode AL, Badrinathan A, Ho VP, Tisch DJ, Towe CW. Speed kills? Quantifying the association between police traffic stops, types of stops, and motor vehicle collisions. Injury 2024; 55:111241. [PMID: 38041924 DOI: 10.1016/j.injury.2023.111241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of traumatic death and injury. Police traffic stops (PTS) are a common approach to enforcing motor vehicle laws intended to prevent MVCs. However, it is unclear which types of PTS are most effective. This study examined the relationship of PTS subtypes among municipal police patrols on non-interstate roads and MVCs and MVC-related deaths. METHODS PTS subtype data were characterized from six North Carolina cities: Charlotte, Durham, Fayetteville, Greensboro, Raleigh, and Winston-Salem. The primary outcomes of this study were yearly non-interstate MVC and MVC-related death rates per 100 population. The data were analyzed as balanced time-series cross-sectional data. The statistical analysis accounted for time-dependent and city-dependent confounding. We used a two-way fixed effects model to analyze the relationship between PTS and MVC or MVC-related deaths. We also utilized the difference in difference (DID) analysis to analyze if the reduction of PTS following a 2012 policing administrative change in Fayetteville had an association with MVC or MVC-related deaths. RESULTS We found no significant overall association between non-interstate PTS and MVCs (Coeff: -0.00006; p = 0.43) or MVC-related deaths (Coeff: -0.00011; p = 0.15). Panel regression suggested no significant relationship between MVCs and MVC-related deaths and PTS related to driving while impaired (p = 0.36), safe movement violation (p = 0.43), or seatbelt violations (p = 0.17). However, speed limit violations (Coeff: -0.00025; p = 0.032) and stop-light/sign violations (Coeff: -0.00147; p = 0.017) related to PTS significantly reduced MVC-related deaths. The DID regression showed no significant impact on MVCs (p = 0.924) or MVC-related deaths (0.706) before and after the police reform period. CONCLUSIONS The evidence regarding the absence of an overall association and any association with most PTS subtypes suggest that PTS are not effective for MVC death prevention. Policymakers may proceed with exploring modifications to policing efforts without detriments to public safety as defined by MVC and MVC-related deaths. LEVEL OF EVIDENCE Retrospective epidemiological study, level IV.
Collapse
Affiliation(s)
- Allison Gasnick
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Anuja L Sarode
- Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center (UH-RISES), Cleveland, OH, United States
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5011, United States
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH, United States; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Daniel J Tisch
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5011, United States.
| |
Collapse
|
7
|
Kloos J, Bassiri A, Ho VP, Sinopoli J, Vargas LT, Linden PA, Towe CW. Frailty is associated with 90-day mortality in urgent thoracic surgery conditions. JTCVS Open 2024; 17:336-343. [PMID: 38420542 PMCID: PMC10897653 DOI: 10.1016/j.xjon.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 03/02/2024]
Abstract
Objective In patients undergoing elective thoracic surgery, frailty is associated with worse outcomes. However, the magnitude by which frailty influences outcomes of urgent thoracic surgery (UTS) is unknown. Methods We identified patients admitted with a UTS condition from January to September 2017 in the National Readmissions Database. UTS conditions were classified as esophageal perforation, hemo/pneumothorax, rib fracture, and obstructed hiatal hernia. Outcome of interest was mortality within 90 days of index admission. Frailty score was calculated using a deficit accumulation method. Cox proportional hazard modeling was used to calculate a hazard ratio for each combination of UTS disease type and frailty score, adjusted for sex, insurance payor, hospital size, and hospital and patient location, and was compared with the effect of frailty on elective lung lobectomy. Results We identified 107,487 patients with a UTS condition. Among UTS conditions overall, increasing frailty elements were associated with increased mortality (hazard ratio, 2270; 95% CI, 1463-3523; P < .001). Compared with patients without frailty undergoing elective lobectomy, increasing frailty demonstrated trending toward increased mortality in all diagnoses. The magnitude of the effect of frailty on 90-day mortality differed depending on the disease and level of frailty. Conclusions The effect of frailty on 90-day mortality after admission for urgent thoracic surgery conditions varies by disease type and level of frailty. Among UTS disease types, increasing frailty was associated with a higher 90-day risk of mortality. These findings suggest a valuable role for frailty evaluation in both clinical settings and administrative data for risk assessment.
Collapse
Affiliation(s)
- Jacqueline Kloos
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
8
|
Towe CW, Bachman KC, Ho VP, Pieracci F, Worrell SG, Moorman ML, Linden PA, Badrinathan A. Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample. Medicina (Kaunas) 2024; 60:153. [PMID: 38256413 PMCID: PMC10819862 DOI: 10.3390/medicina60010153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/01/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.
Collapse
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH 44109, USA
| | - Fredric Pieracci
- Department of Surgery Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| |
Collapse
|
9
|
Worrell SG, Alvarado CE, Thibault D, Towe CW, Mitchell JD, Vekstein A, Kosinski AS, Hartwig MG, Linden PA. Impact of Diabetes on Pathologic Response to Multimodality Therapy for Esophageal Cancer. Ann Thorac Surg 2024; 117:190-196. [PMID: 35970230 DOI: 10.1016/j.athoracsur.2022.07.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/03/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The incidence of esophageal cancer has increased faster than that of most cancers. Evidence from other malignant neoplasms suggests that diabetic patients have a worse response to multimodality therapy. We hypothesized that diabetic patients with esophageal cancer will have a decreased response to neoadjuvant chemotherapy and radiation therapy compared with nondiabetic patients. METHODS A retrospective study of The Society of Thoracic Surgeons General Thoracic Surgery Database identified all patients who had an esophagectomy after neoadjuvant therapy for esophageal cancer between 2012 and 2019. Patients were compared on the basis of the presence of diabetes. A pathologic complete response (pCR) was defined as ypT0 N0. The χ2 and Wilcoxon rank sum tests were used to compare patients' demographic and clinical characteristics between those with and those without diabetes. Multivariable logistic regression was used to evaluate the predictors of response to neoadjuvant therapy. RESULTS Of the 9171 patients who met inclusion criteria, 2011 (22%) patients were diabetic and 7160 (78%) patients were nondiabetic. Patients with diabetes were older, more likely to be male, and more likely to have all comorbidities. Univariate analysis revealed that diabetic patients were less likely to have pCR (16% vs 18%; P = .026). Although multivariable analysis showed a trend toward diabetic patients' having lower odds of achieving pCR, diabetes was not independently associated with pCR (odds ratio, 0.89; 95% CI, 0.78-1.01; P = .075). CONCLUSIONS Diabetic patients may be less likely than nondiabetic patients to achieve pCR after neoadjuvant treatment of esophageal cancer. This suggests the need for further exploration as diabetic patients with esophageal cancer can potentially benefit from different treatment paradigms compared with their nondiabetic counterparts.
Collapse
Affiliation(s)
- Stephanie G Worrell
- Division of Cardiothoracic Surgery, Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - John D Mitchell
- Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Andrew Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
10
|
Sarnaik KS, Bassiri A, Poston LM, Gasnick A, Sinopoli JN, Tapias Vargas L, Linden PA, Towe CW. Lymph Node Yield in Lung Cancer Resection is Associated With Demographic and Institutional Factors. J Surg Res 2024; 293:175-186. [PMID: 37776720 DOI: 10.1016/j.jss.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/09/2023] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Lymphadenectomy is routinely performed during surgical resection of nonsmall cell lung cancer (NSCLC). Lymph node yield and number of nodal stations sampled are important prognostic markers viewed as surrogates of surgical quality. The purpose of this study was to identify factors associated with these quality metrics after resection of NSCLC. MATERIALS AND METHODS We identified NSCLC patients undergoing resection at a single institution from 2010 to 2021. Cases were matched to detailed pathologist reports, which included lymph node yield and number of stations sampled. Demographic and clinical characteristics were analyzed individually using unadjusted linear regression to identify factors associated with lymph node yield and number of stations sampled. Multivariable linear regression analyses were performed to evaluate the same end points, using covariates determined through stepwise-backwards selection. RESULTS The study cohort included 836 patients. Multivariable regression demonstrated that male sex, history of cardiothoracic surgery, and individual pathologist were independently associated with lymph node yield. Among 18 pathologists, interpathologist coefficients with respect to lymph node yield varied from -5.61 to 11.25. Multivariable regression demonstrated White race and history of cardiothoracic surgery to be independently associated with number of nodal stations sampled, as well as individual surgeon and pathologist. CONCLUSIONS Lymph node yield and number of nodal stations sampled after NSCLC resection may vary based on patient demographic and clinical characteristics, as well as institutional factors. These factors should be accounted for when using these metrics as markers of surgical quality and prognosis of NSCLC.
Collapse
Affiliation(s)
- Kunaal S Sarnaik
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Lauren M Poston
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Allison Gasnick
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian N Sinopoli
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| |
Collapse
|
11
|
Bassiri A, Badrinathan A, Alvarado CE, Boutros C, Jiang B, Kwak M, Sinopoli J, Tapias Vargas L, Linden PA, Towe CW. Uncovering Health-Care Disparities Through Patient Decisions in Lung Cancer Surgery. J Surg Res 2024; 293:248-258. [PMID: 37804794 DOI: 10.1016/j.jss.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Declining cancer surgery represents a conflict between patients' rights to autonomy and providers' perspectives of best practice. We hypothesize that, among patients with nonmetastatic lung cancer, patient demographics would be associated with different rates of declination of lung cancer surgery. METHODS Patients with nonmetastatic lung cancer from 2004 to 2018 in the National Cancer Database were identified. Patients were categorized into two groups based on surgical treatment: surgical resection and declined surgery. Patient characteristics were compared using bivariate and multivariate models to identify factors associated with surgical declination. Additionally, we performed subgroup analyses of cT1N0M0 patients with no comorbidities. Survival analysis done using multivariate cox analysis and Kaplan-Meier survival analysis. RESULTS 478,757 patients were identified. In a multivariate model, declining surgery was associated with increased age (odds ratio 1.09, 1.09-1.10), non-Hispanic Black race (odds ratio 1.95, 1.73-2.21), nonprivate insurance, and lower Socioeconomic Status. In a subgroup of cT1N0M0 patients with no comorbidities, declining surgery was associated with increasing age, non-Hispanic Black race, nonprivate insurance, and socioeconomic status. Patient's that declined surgery demonstrated lower overall survival when compared to patients that underwent surgical resection (5 y overall survival: declined surgery 40% versus underwent resection 72%, P < 0.001). CONCLUSIONS Although early-stage lung cancer is potentially curable, many patients decline guideline-based surgery, and have worse overall survival. There are social and economic factors associated with patients declining lung cancer surgery. Providers have an ethical responsibility to understand the basis of patient's decision to decline recommended surgery and address endemic disparities related to race and access to care.
Collapse
Affiliation(s)
- Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christina Boutros
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Minyoung Kwak
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
12
|
Kwak M, Bassiri A, Jiang B, Sinopoli J, Tapias-Vargas L, Linden PA, Towe CW. National enrollment of lung cancer clinical trials is disproportionate based on race and health care access. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01199-6. [PMID: 38123063 DOI: 10.1016/j.jtcvs.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives. METHODS We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering. RESULTS A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll. CONCLUSIONS Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.
Collapse
Affiliation(s)
- Minyoung Kwak
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio.
| | - Aria Bassiri
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Boxiang Jiang
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Jillian Sinopoli
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Leonidas Tapias-Vargas
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Department of Thoracic and Esophageal Surgery, Cleveland Medical Center, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
13
|
Dingillo G, Bassiri A, Badrinathan A, Alvarado CE, Sinopoli J, Tapias L, Linden P, Towe CW. Lung Cancer in Young Patients is Associated With More Advanced Disease but Better Overall Survival. J Surg Res 2023; 292:307-316. [PMID: 37683455 DOI: 10.1016/j.jss.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/14/2023] [Accepted: 08/10/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION It is unclear whether nonsmall cell lung cancer (NSCLC) is associated with more aggressive disease and worse overall survival (OS) among younger patients. The aim of this study is to evaluate outcomes in young patients. We hypothesize that young age is associated with more advanced disease upon presentation, but better OS. METHODS We identified patients with NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized in 3 groups: age≤50, 51-84, and ≥85 y. The outcomes were OS, stage IV NSCLC and clinical nodal metastasis. OS was analyzed using multivariate cox and Kaplan-Meier analysis accounting for stage, comorbidities, and other factors. The association of age, presentation with stage IV NSCLC and node positivity was analyzed using multivariate logistic regression. RESULTS In total 1,651,744 patients were identified: 92,506 (5.57%) age ≤50, 1,477,723 (88.90%) age 51-84, and 91,964 (5.53%) age ≥85. Multivariate model showed stage IV NSCLC was associated with age ≤50 (OR 1.17 (1.15-1.20) P < 0.001) and ≥85 (odds ratio (OR) 1.03 (1.02-1.04) P < 0.001). Clinical lymph node positivity was associated with age ≤50 (OR 1.27 (1.23-1.30) P < 0.001). Relative to patients 51-84, the ≤50 group was associated with better survival in Stage I (hazard ratio (HR) 0.61 versus 1.00), stage II (HR 1.12 versus 1.50), stage III (HR 2.12 versus 2.53), and stage IV (HR 6.65 versus 7.53). CONCLUSIONS Patients ≤50-y-old present with more advanced NSCLC, but better OS compared to patients 51-84. These findings suggest the need for increased awareness regarding NSCLC among age groups seen as low risk.
Collapse
Affiliation(s)
- Gianna Dingillo
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| |
Collapse
|
14
|
Bassiri A, Badrinathan A, Alvarado CE, Kwak M, Sinopoli J, Tapias Vargas L, Linden PA, Towe CW. Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer. J Surg Res 2023; 292:297-306. [PMID: 37683454 DOI: 10.1016/j.jss.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/13/2023] [Accepted: 08/07/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer. METHODS We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival. RESULTS In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14). CONCLUSIONS Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.
Collapse
Affiliation(s)
- Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Minyoung Kwak
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
15
|
Dingillo G, Alvarado CE, Rice JD, Sinopoli J, Badrinathan A, Linden PA, Towe CW. Affordable Care Act Medicaid Expansion is Associated With Increased Utilization of Minimally Invasive Lung Resection for Early Stage Lung Cancer. Am Surg 2023; 89:5147-5155. [PMID: 36341749 DOI: 10.1177/00031348221138081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
OBJECTIVE Minimally invasive lung resection (MILR) is underutilized in the United States. Under the Affordable Care Act (ACA), 39 states adopted Medicaid expansion, while 12 did not. Although Medicaid expansion has been associated with improved access to cancer care, its effect on utilization of MILR is unclear. We hypothesize that MILR would increase in Medicaid expansion states. METHODS The National Cancer Database was queried for adult patients from 2010 to 2018 with cT1/2N0M0 non-small cell lung cancer who received surgical resection by wedge, segmentectomy, or lobectomy. Patients were grouped by whether they received care in a state without Medicaid expansion vs expansion in January 2014. The outcome of interest was MILR (defined as video-assisted or robotic-assisted thoracoscopy) relative to open. Multivariable difference in differences (DID) cross-sectional analysis was used to estimate the average treatment effect (ATE) of Medicaid expansion. RESULTS There were 41,439 patients who met inclusion criteria: 20,446 (49.3%) in expansion states and 20,993 (50.7%) in non-expansion states. Multivariable DID analysis showed that Medicaid expansion was associated with an increase in Medicaid insurance type with an ATE of 7.4% (95% CI 7.1-7.7%, P = .002). Medicaid expansion was also associated with increased MILR utilization in unadjusted analysis (10,278/20,446 (50.3%) vs 9,953/20,993 (47.4%), p < .001) and in multivariable DID analysis (ATE 0.6%, 95% CI 0.3-0.8%, P = .008). CONCLUSIONS Although Medicaid expansion was associated with increased utilization of MILR for early stage lung cancer, the treatment effect was modest. This suggests that barriers in access to MILR are larger than simply access to care.
Collapse
Affiliation(s)
- Gianna Dingillo
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jonathan D Rice
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
16
|
Alvarado CE, Worrell SG, Sarode AL, Jiang B, Halloran SJ, Argote-Greene LM, Linden PA, Towe CW. Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database. Am Surg 2023; 89:5340-5348. [PMID: 36573595 DOI: 10.1177/00031348221148347] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. METHODS The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. RESULTS Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). CONCLUSIONS In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.
Collapse
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sean J Halloran
- Department of Surgery, University of Toledo School College of Medicine and Life Sciences, Toledo, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
17
|
Bassiri A, Badrinathan A, Kishawi S, Sinopoli J, Linden PA, Ho VP, Towe CW. Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis. Medicina (Kaunas) 2023; 59:2046. [PMID: 38004095 PMCID: PMC10673139 DOI: 10.3390/medicina59112046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.
Collapse
Affiliation(s)
- Aria Bassiri
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Avanti Badrinathan
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Sami Kishawi
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Jillian Sinopoli
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Philip A. Linden
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH 44109, USA;
| | - Christopher W. Towe
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| |
Collapse
|
18
|
Poston LM, Bassiri A, Jiang B, Boutros C, Sinopoli J, Tapias Vargas L, Linden PA, Towe CW. Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis. J Surg Res 2023; 291:380-387. [PMID: 37516045 DOI: 10.1016/j.jss.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/01/2023] [Accepted: 06/25/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC. MATERIALS AND METHODS In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery. RESULTS Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001). CONCLUSIONS This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.
Collapse
Affiliation(s)
- Lauren M Poston
- Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christina Boutros
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
19
|
Kishawi SK, Badrinathan A, Towe CW, Ho VP. Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis. J Surg Res 2023; 291:213-220. [PMID: 37453222 DOI: 10.1016/j.jss.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/02/2023] [Accepted: 05/13/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture. MATERIALS AND METHODS The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS. RESULTS Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals. CONCLUSIONS Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.
Collapse
Affiliation(s)
- Sami K Kishawi
- Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
20
|
Alvarado CE, Worrell SG, Sarode AL, Bassiri A, Jiang B, Linden PA, Towe CW. Disparities and access to thoracic surgeons among esophagectomy patients in the United States. Dis Esophagus 2023; 36:doad025. [PMID: 37163475 DOI: 10.1093/dote/doad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/27/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.
Collapse
Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
21
|
Stabellini N, Cao L, Towe CW, Amin AL, Montero AJ. Estimating the overall survival benefit of adjuvant chemo-endocrine therapy in women over age 50 with pT1-2N0 early stage breast cancer and 21-gene recurrence score ≥26: A National Cancer Database analysis. Cancer Med 2023; 12:19607-19616. [PMID: 37766666 PMCID: PMC10587951 DOI: 10.1002/cam4.6584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 09/02/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Validation studies of the 21-gene recurrence score (RS) previously demonstrated that adjuvant chemotherapy plus endocrine therapy (CET) was associated with a significant survival benefit in women with node negative breast cancer (BC) and RS >31. However, the TAILORx trial, did not quantify the benefit of adjuvant CET in older women with node negative hormone receptor positive (HR+) BC with RS ≥26. We hypothesized that CET would be associated with improved overall survival (OS) compared to endocrine therapy (ET) in women >50 with HR+/HER2-node negative BC and RS ≥26. METHODS The National Cancer Database (NCDB) was queried to identify women >50 with RS ≥26 ER+/HER2-BC pT1-2N0M0. Chi-square and logistic regression analysis determined the difference between ET and CET. OS was analyzed using a multivariable Cox model. RESULTS We included 16,745 women-4740 (28.3%) received ET and 12,005 (71.7%) received CET. Women who received CET had: moderately (OR = 1.853, p < 0.001) or poorly/undifferentiated tumors (OR = 3.875, p < 0.001), pT2 (OR = 1.356, p < 0.001), or lymph-vascular invasion (OR = 1.206, p = 0.001). After accounting for demographic and oncologic factors, 5-year OS rates were significantly superior in women receiving CET vs. ET alone (95.4% vs. 92.0%, Hazard Ratio = 0.680, p < 0.001). CONCLUSIONS We observed that CET was associated with a clinically and statistically significant higher OS compared to ET alone in women >50 years of age with RS ≥26 pT1 and pT2 N0M0 HR+/HER2-breast cancer, and which suggests that cytotoxic chemotherapy has an impact on reducing mortality that is independent of induction of premature ovarian failure.
Collapse
Affiliation(s)
- Nickolas Stabellini
- Case Western Reserve University School of MedicineClevelandOhioUSA
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloBrazil
| | - Lifen Cao
- Division of Hematology and Oncology, Department of MedicineUniversity Hospitals/Seidman Cancer Center, Case Western Reserve University School of MedicineOhioClevelandUSA
| | - Christopher W. Towe
- Division of Thoracic and Esophageal Surgery, Department of SurgeryUniversity Hospitals Research in Surgical Outcomes and Effectiveness (UH‐RISES), University Hospitals/Seidman Cancer Center, Case Western Reserve University School of MedicineOhioClevelandUSA
| | - Amanda L. Amin
- Division of Surgical Oncology, Department of SurgeryUniversity Hospitals Research in Surgical Outcomes and Effectiveness (UH‐RISES), University Hospitals/Seidman Cancer Center, Case Western Reserve University School of MedicineOhioClevelandUSA
| | - Alberto J. Montero
- Division of Hematology and Oncology, Department of MedicineUniversity Hospitals/Seidman Cancer Center, Case Western Reserve University School of MedicineOhioClevelandUSA
| |
Collapse
|
22
|
Stabellini N, Cao L, Towe CW, Miller ME, Sousa-Santos AH, Amin AL, Montero AJ. Validation of the PREDICT Prognostication Tool in US Patients With Breast Cancer. J Natl Compr Canc Netw 2023; 21:1011-1019.e6. [PMID: 37856198 DOI: 10.6004/jnccn.2023.7048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/20/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND PREDICT is an online prognostication tool derived from breast cancer registry information on approximately 6,000 women treated in the United Kingdom that estimates the postsurgical treatment benefit of surgery alone, chemotherapy, trastuzumab, endocrine therapy, and/or adjuvant bisphosphonates in early-stage breast cancer. Our aim was to validate the PREDICT algorithm in predicting 5- and 10-year overall survival (OS) probabilities using real-world outcomes among US patients with breast cancer. METHODS A retrospective study was performed including women diagnosed with unilateral breast cancer in 2004 through 2012. Women with primary unilateral invasive breast cancer were included. Patients with bilateral or metastatic breast cancer, no breast surgery, or missing critical clinical information were excluded. Prognostic scores from PREDICT were calculated and external validity was approached by assessing statistical discrimination through area under time-dependent receiver-operator curves (AUC) and comparing the predicted survival to the observed OS in relevant subgroups. RESULTS We included 708,652 women, with a median age of 58 years. Most patients were White (85.4%), non-Hispanic (88.4%), and diagnosed with estrogen receptor-positive breast cancer (79.6%). Approximately 50% of patients received adjuvant chemotherapy, 67% received adjuvant endocrine therapy, 60% underwent a partial mastectomy, and 59% had 1 to 5 axillary sentinel nodes removed. Median follow-up time was 97.7 months. The population's 5- and 10-year OS were 89.7% and 78.7%, respectively. Estimated 5- and 10-year median survival with PREDICT were 88.3% and 73.8%, and an AUC of 0.77 and 0.76, respectively. PREDICT performed most poorly in patients with high Charlson-Deyo comorbidity scores (2-3), where PREDICT overestimated OS. Sensitivity analysis by year of diagnosis and HER2 status showed similar results. CONCLUSIONS In this prognostic study utilizing the National Cancer Database, the PREDICT tool accurately predicted 5- and 10-year OS in a contemporary and diverse population of US patients with nonmetastatic breast cancer.
Collapse
Affiliation(s)
- Nickolas Stabellini
- 1Case Western Reserve University School of Medicine, Cleveland, Ohio
- 2Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
- 3Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Lifen Cao
- 3Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- 4Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- 5University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Megan E Miller
- 5University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
- 6Division of Surgical Oncology, Department of Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Artur H Sousa-Santos
- 2Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Amanda L Amin
- 5University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
- 6Division of Surgical Oncology, Department of Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alberto J Montero
- 1Case Western Reserve University School of Medicine, Cleveland, Ohio
- 3Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
23
|
Sarnaik KS, Linden PA, Gasnick A, Bassiri A, Manyak GA, Jarrett CM, Sinopoli JN, Tapias Vargas L, Towe CW. Computational risk model for predicting 2-year malignancy of pulmonary nodules using demographic and radiographic characteristics. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00851-6. [PMID: 37717851 DOI: 10.1016/j.jtcvs.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES To determine whether discriminatory performance of a computational risk model in classifying pulmonary lesion malignancy using demographic, radiographic, and clinical characteristics is superior to the opinion of experienced providers. We hypothesized that computational risk models would outperform providers. METHODS Outcome of malignancy was obtained from selected patients enrolled in the NAVIGATE trial (NCT02410837). Five predictive risk models were developed using an 80:20 train-test split: univariable logistic regression model based solely on provider opinion, multivariable logistic regression model, random forest classifier, extreme gradient boosting model, and artificial neural network. Area under the receiver operating characteristic curve achieved during testing of the predictive models was compared to that of prebiopsy provider opinion baseline using the DeLong test with 10,000 bootstrapped iterations. RESULTS The cohort included 984 patients, 735 (74.7%) of which were diagnosed with malignancy. Factors associated with malignancy from multivariable logistic regression included age, history of cancer, largest lesion size, lung zone, and positron-emission tomography positivity. Testing area under the receiver operating characteristic curve were 0.830 for provider opinion baseline, 0.770 for provider opinion univariable logistic regression, 0.659 for multivariable logistic regression model, 0.743 for random forest classifier, 0.740 for extreme gradient boosting, and 0.679 for artificial neural network. Provider opinion baseline was determined to be the best predictive classification system. CONCLUSIONS Computational models predicting malignancy of pulmonary lesions using clinical, demographic, and radiographic characteristics are inferior to provider opinion. This study questions the ability of these models to provide additional insight into patient care. Expert clinician evaluation of pulmonary lesion malignancy is paramount.
Collapse
Affiliation(s)
- Kunaal S Sarnaik
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Allison Gasnick
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aria Bassiri
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Grigory A Manyak
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Craig M Jarrett
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian N Sinopoli
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| |
Collapse
|
24
|
Kanagasegar N, Alvarado CE, Lyons JL, Rivero MJ, Vekstein C, Levine I, Towe CW, Worrell SG, Marks JM. Risk factors for adverse outcomes following paraesophageal hernia repair among obese patients. Surg Endosc 2023; 37:6791-6797. [PMID: 37253871 DOI: 10.1007/s00464-023-10115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR. METHODS A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO. RESULTS In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO. CONCLUSIONS Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR.
Collapse
Affiliation(s)
- Nithya Kanagasegar
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Joshua L Lyons
- Division of General and Minimally Invasive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Marco-Jose Rivero
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Carolyn Vekstein
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Iris Levine
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, 85724, USA
| | - Jeffrey M Marks
- Division of General and Minimally Invasive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
| |
Collapse
|
25
|
Dowlati A, Towe CW, Linden PA. Who Are You "KITTING"? The Use of Kits to Collect Lymph Nodes During Lung Cancer Surgery. J Thorac Oncol 2023; 18:838-840. [PMID: 37348990 DOI: 10.1016/j.jtho.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Afshin Dowlati
- Division of Medical Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio.
| | - Christopher W Towe
- Division of Thoracic Surgery, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic Surgery, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
26
|
Cao L, Shenk R, Stabellini N, Amin AL, Montero AJ, Towe CW. Adjuvant Therapy in Breast Cancer Patients With Microscopic Residual Disease. J Surg Res 2023; 285:114-120. [PMID: 36657304 DOI: 10.1016/j.jss.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Surgical resection is the gold standard for early-stage breast cancer. Positive surgical margins are associated with poor outcome. Endocrine therapy (ET) is recommended as primary systemic treatment for hormone receptor positive (HR+) breast cancer after surgery. We hypothesized that chemoenocrine therapy (CET) would not be associated with improved survival relative to ET for patients with positive margins. MATERIALS AND METHODS The National Cancer Database was queried for pathologic stage I HR + HER2-breast cancer patients treated with partial mastectomy and adjuvant whole-breast irradiation between 2004 and 2017. The adjuvant treatment approaches to positive surgical margins were investigated and compared. Overall survival was compared between systemic treatment groups using multivariable cox proportional hazards regression. RESULTS Among 228,453 patients, a positive surgical margin (microscopic residual disease, R1) was identified in 3561 (1.6%) patients. Compared with complete resections, positive margin was associated with inferior overall survival (hazard ratio [HR] = 1.276, P = 0.003). Among the R1 patients, 78.7% received ET only, 11.7% received CET, 1.2% received chemotherapy only, and 8.5% received no systemic therapy. After controlling for patient, facility, and tumor characteristics, ET provided greatest survival benefit (relative to no therapy, HR = 0.378, P < 0.001) followed by CET (HR = 0.446, P = 0.020). Compared with ET alone, CET is not associated with additional overall survival benefit (HR = 1.179, P = 0.595). CONCLUSIONS CET appeared not to be associated with an improved overall survival in early stage HR + HER2-breast cancer with microscopic residual disease relative to ET. Positive surgical margins therefore are probably not a relevant clinical factor for adjuvant chemotherapy decision-making.
Collapse
Affiliation(s)
- Lifen Cao
- Division of Hematology and Oncology, Department of Medicine, University Hospitals/Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Shenk
- Division of Surgical Oncology, Department of Surgery, University Hospitals/Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES) Center
| | - Nickolas Stabellini
- Case Western Reserve University School of Medicine, Cleveland, Ohio; Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Amanda L Amin
- Division of Surgical Oncology, Department of Surgery, University Hospitals/Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES) Center
| | - Alberto J Montero
- Division of Hematology and Oncology, Department of Medicine, University Hospitals/Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Christopher W Towe
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES) Center; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| |
Collapse
|
27
|
Badrinathan A, Sarode AL, Alvarado CE, Sinopoli J, Rice JD, Linden PA, Moorman ML, Towe CW. Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis. Trauma Surg Acute Care Open 2023; 8:e000994. [PMID: 37082302 PMCID: PMC10111909 DOI: 10.1136/tsaco-2022-000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/07/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundSurgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.MethodsThe Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.ResultsAmong 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.ConclusionThe majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.TypeTherapeutic/care management.Level of evidenceIV
Collapse
Affiliation(s)
- Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christine E Alvarado
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jonathan D Rice
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Matthew L Moorman
- Division of Trauma and Acute Care Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
28
|
Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
Collapse
Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
29
|
Cao L, Linden PA, Biswas T, Worrell SG, Sinopoli JN, Miller ME, Shenk R, Montero AJ, Towe CW. Modeling the COVID Pandemic: Do Delays in Surgery Justify Using Stereotactic Radiation to Treat Low-Risk Early Stage Non-Small Cell Lung Cancer? J Surg Res 2023; 283:532-539. [PMID: 36436290 PMCID: PMC9686123 DOI: 10.1016/j.jss.2022.10.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/02/2022] [Accepted: 10/08/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION It was suggested that stereotactic radiation (SBRT) is an "alternative if no surgical capacity is available" for non-small cell lung cancer (NSCLC) care during the COVID-19 pandemic. The purpose of this study was to compare the oncologic outcomes of delayed surgical resection and early SBRT among operable patients with early stage lung cancer. METHODS The National Cancer Database was queried for patients with cT1aN0M0 NSCLC who underwent surgery or SBRT (2010-2016) with no comorbidity. Patients with any comorbidities or age >80 were excluded. The outcome of interest was overall survival. Delays in surgical care were modeled using different times from diagnosis to surgery. A 1:1 propensity match was performed and survival was analyzed using multivariable Cox regression. RESULTS Of 6720 healthy cT1aN0M0 NSCLC patients, 6008 (89.4%) received surgery and 712 (10.6%) received SBRT. Among surgery patients, time to surgery >30 d was associated with inferior survival (HR > 1.4, P ≤ 0.013) compared with patients receiving surgery ≤14 d. Relative to SBRT, surgery demonstrated superior survival at all time points evaluated: 0-30 d, 31-60 d, 61-90 d, and >90 d (all P < 0.001). Among a propensity-matched cohort of 256 pairs of patients, delayed surgery (>90 d) remained association with better overall survival relative to early SBRT (5-year survival 76.9% versus 32.3%, HR = 0.266, P < 0.001). CONCLUSIONS Although longer time to surgery is associated with inferior survival among surgery patients, delayed surgery is superior to early SBRT. Surgical resection should remain the standard of care to treat operable early stage lung cancer despite delays imposed by the COVID-19 pandemic.
Collapse
Affiliation(s)
- Lifen Cao
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Philip A. Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Tithi Biswas
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G. Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Jillian N. Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio
| | - Megan E. Miller
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Shenk
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alberto J. Montero
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W. Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, Ohio,Corresponding author. Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011. Tel.: +1 216 844 0405
| |
Collapse
|
30
|
Ho VP, Bensken WP, Flippin JA, Santry HP, Claridge JA, Towe CW, Koroukian SM. Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions. J Surg Res 2023; 283:224-232. [PMID: 36423470 PMCID: PMC9923717 DOI: 10.1016/j.jss.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients. METHODS We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference. RESULTS We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes. CONCLUSIONS More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.
Collapse
Affiliation(s)
- Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Hospital, Columbus, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
31
|
Worrell SG, Gupta S, Alvarado CE, Sarode A, Luo X, Towe CW, Linden PA. Morbidity After Esophagectomy Is Higher for Benign Than Malignant Disease. Ann Thorac Surg 2023; 115:363-369. [PMID: 36126720 DOI: 10.1016/j.athoracsur.2022.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications. METHODS A retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts. RESULTS Of 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62). CONCLUSIONS Esophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.
Collapse
Affiliation(s)
- Stephanie G Worrell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Shreya Gupta
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Anuja Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Xun Luo
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
32
|
Poston LM, Gupta S, Alvarado CE, Sinopoli J, Vargas LT, Linden PA, Towe CW. Contemporary outcomes of esophageal and gastroesophageal junction neuroendocrine tumors. Dis Esophagus 2023:6995427. [PMID: 36688874 DOI: 10.1093/dote/doad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/28/2022] [Accepted: 12/31/2022] [Indexed: 01/24/2023]
Abstract
Adenocarcinoma and squamous cell esophageal cancers have been extensively studied in the literature. Esophageal neuroendocrine (NET)/carcinoid tumors are less commonly studied and have only been described in small series. The purpose of this study was to describe the demographics and natural history of esophageal NETs, as well as optimal treatments. We hypothesized that surgical resection would be the best treatment of esophageal NETs. The National Cancer Database was used to identify adult patients with esophageal or gastroesophageal junction (GEJ) cancer from 2004 to 2018. Patients were characterized as carcinoid/NET, adenocarcinoma, or squamous cell cancer. Clinical and demographic characteristics were compared between the histology groups. The primary outcome was overall survival, which was assessed by multivariable Cox analysis. Multivariable Cox analysis was also used to analyze factors associated with survival among NET patients who underwent surgery. Among 206,321 patients with esophageal cancer, 1,563 were NETs (<0.01%). Relative to the other two histologies, NETs were associated with younger age, female sex, and advanced clinical stage at diagnosis. Multivariate analysis suggested that NETs were less likely to be treated with surgical resection (OR 0.51, P < 0.001). Nonetheless, surgical resection was associated with improved survival (HR 0.64, P = 0.003). Among patients with NETs who received surgery, neoadjuvant therapy was associated with improved overall survival (HR 0.38, P = 0.013). NET of the esophagus presents with more advanced disease than other common histologies. Among patients with nonmetastatic cancer, surgical resection appears to be the best treatment. Neoadjuvant systemic therapy may offer survival benefit, but future studies are necessary.
Collapse
Affiliation(s)
- Lauren M Poston
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Shreya Gupta
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Leonidas T Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
33
|
Alvarado CE, Rice JD, Linden PA, Sarode AL, Halloran SJ, Sinopoli J, Towe CW. Contemporary outcomes of surgical resection for chest wall chondrosarcoma. JTCVS Open 2023; 13:435-443. [PMID: 37063154 PMCID: PMC10091297 DOI: 10.1016/j.xjon.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 11/26/2022] [Accepted: 12/12/2022] [Indexed: 01/18/2023]
Abstract
Objective Chondrosarcoma is the most common primary malignant chest wall tumor and is historically associated with poor prognosis. Recommendations regarding surgical excision are on the basis of small, single-institution studies. We used a large national database to assess outcomes of surgery for chest wall chondrosarcoma (CWC) hypothesizing that surgical excision remains standard of care. Methods The National Cancer Databases for bone and soft tissue were merged to identify patients with chondrosarcoma from 2004 to 2018. Clinical and demographic characteristics of CWC were compared with chondrosarcoma from other sites. The primary outcome was overall survival described using Kaplan-Meier estimate. Univariable and multivariable Cox analysis was used to determine risk factors for poor survival among CWC patients who underwent surgery. Multivariable analysis of predictors of margin status was performed because of worse prognosis associated with positive margins. Results Among 11,925 patients with chondrosarcoma, 1934 (16.2%) had a CWC. Relative to other sites, CWC was associated with older age, male sex, White race, surgical resection, and care at a nonacademic institution. CWC was associated with 1-, 3-, 5-, and 10-year survival of 91.5%, 82.0%, 75.5%, and 62.7%, respectively. In univariable analysis, survival was associated with surgery (hazard ratio, 0.02; P < .001) and adversely affected by positive margins (hazard ratio, 2.66; P < .001). Multivariable analysis showed larger tumor size was independently associated with increased risk for positive margins (odds ratio, 1.04; 95% CI, 1.011-1.075). Conclusions CWC represents a different cohort of patients relative to chondrosarcoma from other sites. Surgical excision remains the optimal treatment, and positive margins are associated with poor prognosis.
Collapse
Affiliation(s)
- Christine E. Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan D. Rice
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip A. Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anuja L. Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sean J. Halloran
- The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W. Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
- Address for reprints: Christopher W. Towe, MD, 11100 Euclid Ave, Cleveland, OH 44106-501.
| |
Collapse
|
34
|
Stabellini N, Cao L, Towe CW, Luo X, Amin AL, Montero AJ. Adjuvant chemotherapy is associated with an overall survival benefit regardless of age in ER+/HER2- breast cancer pts with 1-3 positive nodes and oncotype DX recurrence score 20 to 25: an NCDB analysis. Front Oncol 2023; 13:1115208. [PMID: 37168373 PMCID: PMC10165881 DOI: 10.3389/fonc.2023.1115208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/11/2023] [Indexed: 05/13/2023] Open
Abstract
Background The RxPONDER trial found that among breast cancer patients with estrogen receptor positive (ER+) breast cancer, 1-3 positive axillary nodes, and a recurrence score of ≤25, only pre-menopausal women benefitted from adjuvant chemoendocrine therapy; postmenopausal women with similar characteristic did not benefit from adjuvant chemotherapy. We aimed to replicate the RxPonder trial using a larger patient cohort with real world data to determine whether a RS threshold existed where adjuvant chemotherapy was beneficial regardless of age. Methods The National Cancer Database (NCDB) was queried for women with ER+, human epidermal growth factor receptor 2 (HER2) negative breast cancer, 1-3 positive axillary nodes, and RS ≤25 who received endocrine (ET) only or chemo-endocrine therapy (CET). Cox regression interaction was explored between CET and age as a surrogate for menopausal status. Results The final analytic cohort included 28,427 eligible women: 7,487 (26.3%) received adjuvant CET and 20,940 (73.7%) ET. In the entire cohort, RS had a normal distribution, with a median score of 14. After correcting for demographic and clinical variables, a threshold effect was observed with RS >20 being associated with a significantly inferior overall survival (OS) (P value range: < 0.001-0.019). In women with RS of 20-25, CET was associated with a significant improvement in OS compared to ET alone, regardless of age (age <=50: HR = 0.334, P=0.002; age>50: HR=0.521, P=0.019). Conclusion Among women with ER+/HER2- breast cancer with 1-3 positive nodes, and a RS of 20-25-in contrast to the RxPONDER trial-we observed that CET was associated with an OS benefit in women regardless of age.
Collapse
Affiliation(s)
- Nickolas Stabellini
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, OH, United States
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Lifen Cao
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Christopher W. Towe
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, OH, United States
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Xun Luo
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, OH, United States
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amanda L. Amin
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, OH, United States
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, United States
- Division of Surgical Oncology, Department of Surgery, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Alberto J. Montero
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, OH, United States
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
- *Correspondence: Alberto J. Montero,
| |
Collapse
|
35
|
Servais EL, Blasberg JD, Brown LM, Towe CW, Seder CW, Onaitis MW, Block MI, David EA. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2022 Update on Outcomes and Research. Ann Thorac Surg 2023; 115:43-49. [PMID: 36404445 DOI: 10.1016/j.athoracsur.2022.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 12/31/2022]
Abstract
The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most robust thoracic surgical database in the world. Participating sites receive risk-adjusted performance reports for benchmarking and quality improvement initiatives. The GTSD also provides several mechanisms for high-quality clinical research using data from 274 participant sites and 781,000 procedures since its inception in 2002. Participant sites are audited at random annually for completeness and accuracy. Over the last year and a half, the GTSD Task Force continued to refine the data collection process, implementing an updated data collection form in July 2021, ensuring high data fidelity while minimizing data entry burden. In addition, the STS Workforce on National Databases has supported a robust GTSD-based research program, which led to eight scholarly publications in 2021. This report provides an update on volume trends, outcomes, and database initiatives as well as a summary of research productivity resulting from the GTSD over the preceding year.
Collapse
Affiliation(s)
- Elliot L Servais
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, and Tufts University School of Medicine, Boston, Massachusetts.
| | - Justin D Blasberg
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Lisa M Brown
- Section of General Thoracic Surgery, UC Davis Health, Sacramento, California
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mark W Onaitis
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Diego, California
| | - Mark I Block
- Division of Thoracic Surgery, Memorial Healthcare System, Hollywood, Florida
| | - Elizabeth A David
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| |
Collapse
|
36
|
Lai CK, Towe CW, Patel NJ, Brown LR, Claridge JA, Ho VP. Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters. Surg Infect (Larchmt) 2022; 23:866-872. [PMID: 36394462 PMCID: PMC9784599 DOI: 10.1089/sur.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.
Collapse
Affiliation(s)
- Clara K.N. Lai
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W. Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nimitt J. Patel
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
37
|
Halloran S, Dingillo G, Badrinathan A, Alvarado CE, Worrell SG, Sinopoli JN, Argote-Greene LM, Linden PA, Towe CW. YouTube Videos Contain Poor and Biased Thoracic Surgery Educational Content. Surgery in Practice and Science 2022. [DOI: 10.1016/j.sipas.2022.100133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
|
38
|
Villarin S, Flippin JA, Bensken WP, Curfman E, Towe CW, Claridge JA, Ho VP. What if You Need More Than One? More Acute Care Surgery Procedures Are Associated with Mortality. Surg Infect (Larchmt) 2022; 23:525-531. [PMID: 35917385 PMCID: PMC9398479 DOI: 10.1089/sur.2021.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: It is unknown whether having multiple acute care surgery (ACS) procedures performed in one admission confers additional risk. We hypothesized that having multiple procedures (for example, hernia repair plus bowel resection) would be associated with higher mortality. Patients and Methods: We identified all 2017 National Inpatient Sample admissions with ACS procedures including: colon, small bowel/appendix (SB), hernia, adhesiolysis, peptic ulcer procedures, gallbladder, debridement, other laparotomy, other laparoscopy. The total number of procedures for each admission and common dyad (two-procedure) and triad (three-procedure) combinations were identified. Logistic regression estimated the odds of in-hospital mortality for increasing procedure count and specific dyad and triad combinations, using patients with one procedure as the reference. Results: A total of 216,317 ACS patients (median age, 57, interquartile range [IQR], 43-70; 50.6% female) were included; 2.8% died. Patients with multiple procedures were more likely to die than patients with one procedure (7.4% vs. 1.9%). An increasing number of procedures was associated with higher odds of death (two procedures: odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9-3.2] to six or more procedures, OR, 9.5; 95% CI, 4.9-18.5); having more than three procedures was associated with at least fivefold higher odds of death. Specific dyads/triads were associated with particularly high risk of mortality, including ulcer/laparotomy (OR, 15.5; 95% CI, 13.7-17.5) and laparotomy/SB (OR, 8.31; 95% CI, 5.15-13.40). Conclusions: Multiple ACS procedures in one hospitalization confer increased odds of in-hospital mortality. This knowledge enables the ACS providers to better counsel patients by giving more specific expectations regarding mortality based on the number of procedures required or anticipated during an admission.
Collapse
Affiliation(s)
- Sigfredo Villarin
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Eric Curfman
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
39
|
Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, Worrell SG, Ho VP, Argote-Greene LM, Towe CW. Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis. Ann Thorac Surg 2022; 115:1378-1384. [PMID: 35921860 DOI: 10.1016/j.athoracsur.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.
Collapse
Affiliation(s)
- Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Anuja Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Phillip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
40
|
Towe CW. Radiomics to the Rescue. Ann Surg Oncol 2022; 29:7953-7954. [PMID: 35842536 DOI: 10.1245/s10434-022-12236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA.
| |
Collapse
|
41
|
Chang C, Linden PA, Jiang B, Sarode A, Bachman K, Towe CW, Argote-Greene L, Worrell SG. Monitoring for Recurrence After Esophagectomy. Ann Thorac Surg 2022; 114:211-217. [PMID: 34793765 DOI: 10.1016/j.athoracsur.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 09/20/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival. METHODS A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy. RESULTS During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047). CONCLUSIONS SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.
Collapse
Affiliation(s)
- Carolyn Chang
- Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Anuja Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
| |
Collapse
|
42
|
Cao L, Towe CW, Luo X, Stabellini N, Amin AL, Montero AJ. Adjuvant chemotherapy is associated with an overall survival benefit regardless of age in patients with ER+/HER2-breast cancer with 1-3 positive nodes and Oncotype DX recurrence score 20 to 25: A National Cancer Database analysis. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
540 Background: Based on the results of the RxPonder trial, post-menopausal women over age 50 with estrogen receptor (ER)+ breast cancer, 1-3+ nodes, and a 21-gene Oncotype DX recurrence score (RS) score of <25, did not benefit from receiving adjuvant chemotherapy. By contrast, adjuvant chemotherapy was beneficial in premenopausal women. We aimed to replicate the RxPonder trial using a larger sample sizes with real world data to determine whether a threshold with RS exists where adjuvant chemoendocrine therapy (CET) is beneficial regardless of age. Methods: The National Cancer Database (NCDB) was queried for women with ER+, human epidermal growth factor receptor 2 (HER2) negative breast cancer, 1-3 positive axillary nodes, and RS <25 who received endocrine therapy (ET) only or CET. Interaction was explored between CET and age as a surrogate for menopausal status in the Cox regression models. Results: The final analytic cohort included 28,427 eligible women: 7,487 (26.3%) received adjuvant CET and 20,940 (73.7%) ET. In the entire cohort, RS had a normal distribution, with a median score of 14. After correcting for demographic and clinical variables, a threshold effect was observed with RS >20 being associated with a significantly inferior overall survival (OS) (P value range: < 0.001-0.019). In women with RS of 20-25, CET was associated with a significant improvement in OS compared to ET alone, regardless of age (age < = 50: HR = 0.334, P = 0.002; age > 50: HR = 0.521, P = 0.019). Conclusions: Among women with ER+/HER2- breast cancer with 1–3 positive nodes, and RS of 20-25, in contrast to the RxPonder trial we observed that CET was associated with an OS benefit in women regardless of age.
Collapse
Affiliation(s)
- Lifen Cao
- University Hospitals at Cleveland Medical Center, Cleveland, OH
| | | | - Xun Luo
- University Hospitals at Cleveland Medical Center, Cleveland, OH
| | | | - Amanda L. Amin
- University Hospitals at Cleveland Medical Center, Cleveland, OH
| | | |
Collapse
|
43
|
Cao L, Towe CW, Stabellini N, Amin AL, Montero AJ. Estimating survival benefit of adjuvant chemotherapy in postmenopausal women with pT1-2N0 early-stage breast cancer and Oncotype DX recurrence score > 26: A National Cancer Database (NCDB) analysis. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
543 Background: Early validation studies using the Oncotype DX recurrence score (RS) in NSABP B20 demonstrated that women with node negative breast cancer and RS >31 had significant survival benefit from the addition of adjuvant chemotherapy to endocrine therapy (CET). Consequently, in the prospective TAILORx trial, node negative women with RS >26 received CET. These studies did not clearly delineate the magnitude of benefit of adjuvant chemotherapy for post-menopausal node negative women. A recently published well-designed adjuvant trial (RxPONDER) demonstrated that adjuvant chemotherapy was not beneficial in post-menopausal pts with ER+/HER2- breast cancer, 1-3 positive nodes, and RS <25. We hypothesized that CET would be associated with a modest but statistically significant overall survival (OS) in women with hormone receptor positive ER+/HER2- node negative breast cancer with RS >26 compared to endocrine therapy (ET) alone, given that CET is more beneficial in women <50 years of age. Methods: The National Cancer Database (NCDB) was queried to analyze women age > 50 with ER+/HER2- pT1-2N0M0 breast cancer with RS >26, to assess real world utilization. We separated women into two groups based on adjuvant treatment: ET alone or CET. Chi-square and logistic regression analysis determined difference between different systemic treatment groups. OS was analyzed using a multivariable Cox model. Results: A total of 16,745 eligible women who underwent surgery and received ET were identified in the NCDB—4,740 (28.3%) received ET alone and 12,005 (71.7%) received CET. We observed that CET use increased over time. Women were more likely to receive CET if their tumors were moderately differentiated (OR = 1.853, p < 0.001), poorly/undifferentiated tumors (OR = 3.875, p < 0.001), or associated with lymph-vascular invasion (OR = 1.206, p = 0.001). After accounting for demographic and oncologic factors, 5-year OS rates in this cohort were significantly superior in women receiving CET compared to ET alone (95.4% vs 92.0%, Hazard Ratio = 0.680, p < 0.001). Conclusions: Utilizing the NCDB to represent real world outcomes, we observed that women > 50 years with pT1-2N0M0 ER+/HER2- breast cancer, and RS > 26 had a significantly superior 5-year OS when receiving adjuvant chemotherapy provides a measurable OS benefit for post-menopausal women in this setting and should be discussed with patients.
Collapse
Affiliation(s)
- Lifen Cao
- University Hospitals at Cleveland Medical Center, Cleveland, OH
| | | | | | - Amanda L. Amin
- University Hospitals at Cleveland Medical Center, Cleveland, OH
| | | |
Collapse
|
44
|
Kishawi SK, Tseng ES, Adomshick VJ, Towe CW, Ho VP. Race and trauma mortality: The effect of hospital-level Black-White patient race distribution. J Trauma Acute Care Surg 2022; 92:958-966. [PMID: 35125445 PMCID: PMC9133009 DOI: 10.1097/ta.0000000000003538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals. METHODS We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality. RESULTS We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]). CONCLUSION After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
Collapse
Affiliation(s)
- Sami K. Kishawi
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Esther S. Tseng
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Victoria J. Adomshick
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Christopher W. Towe
- University Hospitals Cleveland Medical Center, Department of Surgery, 11100 Euclid Avenue, Lakeside 7 Floor, Cleveland, OH 44106
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Vanessa P. Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500 MetroHealth Drive, Cleveland, OH 44109
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106
| |
Collapse
|
45
|
Thomas HS, Siki MA, Lansing SS, Zogg CK, Patrick B, Towe CW, Stein SL. Spotlighting Research During COVID-19: Introduction of an International Online Multi-Round Research Competition for Trainees. Am Surg 2022; 88:2644-2648. [PMID: 35574734 PMCID: PMC9118000 DOI: 10.1177/00031348221101474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Problem The coronavirus pandemic led to the cancellation of many academic events.
While some transitioned to virtual formats, others disappeared, offering
fewer opportunities for trainees to share research. Facing this challenge,
the Association of Women Surgeons developed a novel
approach. Designed to promote greater global inclusion, increase audience
engagement and opportunities for networking and feedback from practicing
surgeons, they restructured their annual trainee research symposium as a
virtual, multi-round competition. Approach Submission to the research competition was open to trainees at any level. The
competition comprised four rounds: (1) visual abstracts (all welcomed), (2)
three-minute “Quickshot” presentation (32 advance), (3) eight-minute oral
presentations (16 advance), and (4) final question-and-answer style defense
(final 4 compete). Progression through the first three rounds was determined
by public voting. Winners were determined by live voting during the final
session. Outcomes A total of 73 visual abstracts were accepted for presentation. Fifty-six
percent (n = 41) of first authors were medical students, 36% residents (n =
26), and 7% fellows (n = 6). Five were from international first authors
(7%). Abstracts represented research topics including basic science (n = 6,
8%)), clinical outcomes (n = 38, 52%), and education (n = 29, 40%). Social
media impressions exceeded a total of 30,000 views. Next Steps This virtual, multi-round research competition served as a blueprint for a
novel approach to research dissemination. The format enabled expanded US
national and international engagement with trainees in all stages of their
career. Future research symposia should consider the impact of popularity
bias, timing, and voting strategies during the event planning period to
optimize success.
Collapse
Affiliation(s)
- Hannah S Thomas
- University of Edinburgh School of Medicine, Edinburgh, UK.,Association of Women Surgeons, Chicago, IL, USA
| | - Mary A Siki
- Association of Women Surgeons, Chicago, IL, USA.,12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Shan S Lansing
- Association of Women Surgeons, Chicago, IL, USA.,12305The Ohio State College of Medicine, Columbus, OH, USA
| | - Cheryl K Zogg
- Association of Women Surgeons, Chicago, IL, USA.,12228Yale School of Medicine, New Haven, CT, USA
| | - Bridget Patrick
- Department of Surgery, 114516University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, USA
| | - Christopher W Towe
- Department of Surgery, 114516University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, USA
| | - Sharon L Stein
- Association of Women Surgeons, Chicago, IL, USA.,Department of Surgery, 114516University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
46
|
Ho VP, Bensken WP, Warner DF, Claridge JA, Santry HP, Robenstine JC, Towe CW, Koroukian SM. Association of Complex Multimorbidity and Long-term Survival After Emergency General Surgery in Older Patients With Medicare. JAMA Surg 2022; 157:499-506. [PMID: 35476053 PMCID: PMC9047756 DOI: 10.1001/jamasurg.2022.0811] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Although nearly 1 million older patients are admitted for emergency general surgery (EGS) conditions yearly, long-term survival after these acute diseases is not well characterized. Many older patients with EGS conditions have preexisting complex multimorbidity defined as the co-occurrence of at least 2 of 3 key domains: chronic conditions, functional limitations, and geriatric syndromes. The hypothesis was that specific multimorbidity domain combinations are associated with differential long-term mortality after patient admission with EGS conditions. Objective To examine multimorbidity domain combinations associated with increased long-term mortality after patient admission with EGS conditions. Design, Setting, and Participants This cohort study included community-dwelling participants aged 65 years and older from the Medicare Current Beneficiary Survey with linked Medicare data (January 1992 through December 2013) and admissions for diagnoses consistent with EGS conditions. Surveys on health and function from the year before EGS conditions were used to extract the 3 domains: chronic conditions, functional limitations, and geriatric syndromes. The number of domains present were summed to calculate a categorical rank: no multimorbidity (0 or 1), multimorbidity 2 (2 of the 3 domains present), and multimorbidity 3 (all 3 domains present). Whether operative treatment was provided during the admission was also identified. Data were cleaned and analyzed between January 16, 2020, and April 29, 2021. Exposures Mutually exclusive multimorbidity domain combinations (functional limitations and geriatric syndromes; functional limitations and chronic conditions; chronic conditions and geriatric syndromes; or functional limitations, geriatric syndromes, and chronic conditions). Main Outcomes and Measures Time to death (up to 3 years from EGS conditions admission) in patients with multimorbidity combinations was analyzed using a Cox proportional hazards model and compared with those without multimorbidity; hazard ratios (HRs) and 95% CIs are presented. Models were adjusted for age, sex, and operative treatment. Results Of 1960 patients (median [IQR] age, 79 [73-85] years; 1166 [59.5%] women), 383 (19.5%) had no multimorbidity, 829 (42.3%) had 2 multimorbidity domains, and 748 (38.2%) had all 3 domains present. A total of 376 (19.2%) were known to have died in the follow-up period, with a median (IQR) follow-up of 377 (138-621) days. Patients with chronic conditions and geriatric syndromes had a mortality risk similar to those without multimorbidity. However, all domain combinations with functional limitations were associated with significantly increased risk of death: functional limitations and chronic conditions (HR, 1.83; 95% CI, 1.03-3.23); functional limitations and geriatric syndromes (HR, 2.91; 95% CI, 1.37-6.18); and functional limitations, geriatric syndromes, and chronic conditions (HR, 2.08; 95% CI, 1.49-2.89). Conclusions and Relevance Findings of this study suggest that a patient's baseline complex multimorbidity level efficiently identifies risk stratification groups for long-term survival. Functional limitations are rarely considered in risk stratification paradigms for older patients with EGS conditions compared with chronic conditions and geriatric syndromes. However, functional limitations may be the most important risk factor for long-term survival.
Collapse
Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - David F Warner
- Department of Sociology, University of Alabama at Birmingham, Birmingham.,Center for Family & Demographic Research, Bowling Green State University, Bowling Green, Ohio
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Health, Kettering, Ohio.,NBBJ Design, Columbus, Ohio
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burn, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
47
|
Cao L, Towe CW, Shenk R, Stabellini N, Amin AL, Montero AJ. A comparison of local therapy alone with local plus systemic therapy for stage I pT1aN0M0 HER2+ breast cancer: A National Cancer Database analysis. Cancer 2022; 128:2433-2440. [PMID: 35363881 DOI: 10.1002/cncr.34200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Small invasive breast cancers (BCs) with tumor sizes ≤5 mm (T1a) are associated with an excellent prognosis without systemic therapy. Although HER2 overexpression (HER2+) is associated with a higher risk of recurrence and poorer clinical outcomes, in the absence of HER2 directed therapy, it remains unclear whether adjuvant systemic therapy is necessary in node-negative patients diagnosed with HER2+ invasive BCs ≤5 mm (pT1aN0M0). METHODS The National Cancer Database was searched to identify patients diagnosed with HER2+ pT1aN0M0 BCs from 2004 to 2017. The cohort was stratified by treatment status: local therapy alone or local plus adjuvant systemic therapy. A 1:1 propensity match was performed. Overall survival (OS) was analyzed using stratified multivariable Cox proportional hazards regression analyses. RESULTS Of the 8948 patients found, 4026 (45.0%) underwent surgery alone, and 4922 (55.0%) received surgery plus systemic therapy. Patients with either moderately differentiated (odds ratio [OR], 2.053; P < .001) or poorly/undifferentiated tumors (OR, 3.780; P < .001) or with the presence of lymphovascular invasion (OR, 3.351; P < .001) were more likely to have received systemic therapy. Propensity matching generated 1162 pairs of patients who were hormone receptor positive (HR+) and 748 pairs who were hormone receptor negative (HR-). Propensity matching effectively reduced selection bias between study groups. In the matched cohort, the addition of systemic therapy was not associated with superior OS (hazard ratio for HR+, 1.613; P = .107, and hazard ratio for HR- 1.319; P = .369) compared with patients who received local therapy alone. CONCLUSIONS In pT1aN0M0 HER2+ BC, the addition of adjuvant systemic therapy after surgical excision was not associated with improved OS compared with local therapy alone.
Collapse
Affiliation(s)
- Lifen Cao
- Department of Medicine, Division of Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Shenk
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,University Hospitals Research in Surgical Outcomes and Effectiveness, Cleveland, Ohio
| | | | - Amanda L Amin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,University Hospitals Research in Surgical Outcomes and Effectiveness, Cleveland, Ohio
| | - Alberto J Montero
- Department of Medicine, Division of Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
48
|
Ho VP, Bensken WP, Santry HP, Towe CW, Warner DF, Connors AF, Koroukian SM. Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions. Surgery 2022; 172:446-452. [DOI: 10.1016/j.surg.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
|
49
|
Cao L, Stabellini N, Towe CW, Miller ME, Shenk R, Amin AL, Montero AJ. BPI22-014: Independent Validation of the PREDICT Prognostication Tool in U.S. Breast Cancer Patients Using the National Cancer Database (NCDB). J Natl Compr Canc Netw 2022. [DOI: 10.6004/jnccn.2021.7137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Lifen Cao
- 1 University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nickolas Stabellini
- 1 University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
- 2 Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Christopher W Towe
- 1 University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Megan E Miller
- 3 University Hospitals Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Robert Shenk
- 3 University Hospitals Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amanda L Amin
- 3 University Hospitals Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Alberto J Montero
- 1 University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
50
|
Linden PA, Block MI, Perry Y, Gaissert HA, Worrell SJ, Grau-Sepulveda MV, Kosinski AS, Jawitz OK, Hartwig MG, Towe CW. Risk of Each of the Five Lung Lobectomies: A Society of Thoracic Surgery Database Analysis. Ann Thorac Surg 2022; 114:1871-1877. [PMID: 35339439 DOI: 10.1016/j.athoracsur.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The perioperative risk of pulmonary lobectomy as a solitary procedure has been extensively studied, yet the differences in outcomes between each lobe, which have unique anatomy and a different amount of lung parenchyma, are entirely unknown. The purpose of this study is to define the risk of each of the five lobectomies. METHODS The Society of Thoracic Surgery Database was queried for patients undergoing lobectomy between 2008 and 2018. Patient and disease characteristics, operative variables, major morbidity and 30-day mortality were examined. A multivariable logistic regression model (using the same variables in the current STS lobectomy risk model) was developed to assess for the contribution to lobectomy site to adverse outcomes. RESULTS 65,006 patients were analyzed. Adjusted perioperative mortality rate is lowest for RML (0.63%) intermediate for RUL, LUL and LLL (1.08-1.24%), and highest for RLL (1.63%). The adjusted major morbidity rate is lowest for RML (5.36%) intermediate for LLL and LUL (7.82-8.33%), and highest for RUL and RLL (8.94-9.32%). Adjusted intraoperative transfusion rate is lowest for RML (1.37%) intermediate for RLL and LLL (1.81-1.94%) and highest for RUL and LUL (2.47-2.72%). CONCLUSIONS There are clear differences in postoperative outcomes by lobectomy location. Mortality, major morbidity, and transfusion rate are lowest for RML, but vary across other lobectomies. These differences should be appreciated when evaluating risk of operation, deciding upon best therapy, counseling patients, and comparing outcomes.
Collapse
Affiliation(s)
- Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Mark I Block
- Division of Thoracic Surgery, Memorial Healthcare System, Hollywood, FL
| | - Yaron Perry
- Division of Thoracic Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
| | - Henning A Gaissert
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stephanie J Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Maria V Grau-Sepulveda
- Duke Clinical Research Institute, Durham, NC Classifications: Database, Lung Cancer Surgery, Statistics - risk analysis/modeling, Surgery - complications
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC Classifications: Database, Lung Cancer Surgery, Statistics - risk analysis/modeling, Surgery - complications
| | - Oliver K Jawitz
- Duke Clinical Research Institute, Durham, NC Classifications: Database, Lung Cancer Surgery, Statistics - risk analysis/modeling, Surgery - complications
| | - Matthew G Hartwig
- Duke Clinical Research Institute, Durham, NC Classifications: Database, Lung Cancer Surgery, Statistics - risk analysis/modeling, Surgery - complications
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| |
Collapse
|