The order of surgery and chemotherapy matters: Multimodality therapy and stage-specific differences in survival in gastric cancer

BACKGROUND AND OBJECTIVES

Multimodality treatment improves survival for gastric cancer (GC). However, the effect of treatment sequence by stage remains unclear. We aim to compare outcomes between patients receiving neoadjuvant(neoadj) and adjuvant chemotherapy (adj).

METHODS

Nonmetastatic GC patients with clinical stage ≥ T2N0 who underwent both resection and neoadj or adj were identified using the National Cancer Database (2005-2014). Multivariable Cox regression analyses were performed on propensity score-matched (PSM) cohorts stratified by stage to compare overall survival (OS).

RESULTS

We identified 11 984 patients; 55% stage I (SI), 76% stage II (SII) and 57% stage III (SIII) received neoadj. Unadjusted analysis showed worse survival among SI neoadj patients (hazard ratio [HR] 1.195, confidence interval [CI] 1.04-1.38) and improved survival for SII (HR 0.93 CI 0.87-0.998) and SIII (HR 0.75, CI 0.68-0.84). After PSM, SI patients with neoadj had worse OS with increased risk of death compared to Adj (HR 1.186, CI 1.004-1.402). SII patients had no difference in OS (HR 0.98, CI 0.91-1.07) and SIII patients had improved OS (HR 0.78, CI 0.69-0.90).

CONCLUSIONS

In patients who received surgery and chemotherapy, the benefit of neoadj was limited to SIII with worse survival for SI. A clinical trial to examine the optimal sequence of chemotherapy is warranted.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together

BACKGROUND

Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts.

MATERIALS AND METHODS

Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified.

RESULTS

Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant.

CONCLUSIONS

Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Impact of Medicaid expansion on pancreatic cancer care: A difference-in-difference analysis

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Background: The Affordable Care Act (ACA) increased insurance coverage for low-income individuals, which should potentially lead to better access to care and improved oncological outcomes. This study seeks to evaluate the impact of Medicaid expansion (ME) on care for pancreatic ductal adenocarcinoma (PDAC). Methods: Patients who were uninsured or on Medicaid and diagnosed with PDAC between 2004 and 2017 were queried from the National Cancer Database (NCDB). Two different expansion cohorts were included: early expansion states and 2014 expansion states. For early expansion states, the time period of pre-expansion was 2004-2009 and post-expansion was 2010-2017. As for the 2014 expansion states, the pre-expansion period was from 2004-2013 and post-expansion period was from 2014-2017. Patients in non-expansion states formed the control group. A difference-in-difference (DID) analysis was used to assess the association of ME with stage of diagnosis, treatment and survival for each expansion cohort. Results: In both early and January 2014 expansion states, there was an increase in overall Medicaid coverage (Early: DID = 0.29, 2014: DID = 0.37; P < 0.001), in particular for non-Hispanic Black and Hispanic Black patients (Non-Hispanic Black: Early: DID = 0.11, 2014: DID = 0.11; P < 0.001, Hispanic-Black: 2014: DID = 0.20; P = 0.003). There were no differences in early stage diagnosis (Early: DID = 0.02, 2014: DID = -0.02; P > 0.05). There was an increase in the number of patients receiving surgery (Early: DID = 0.05; P = 0.001, 2014: DID = 0.03; P = 0.029) but no difference in time to surgery among patients receiving surgery upfront (Early: DID = 1.75, 2014: DID = 0.38; P > 0.05). There was no difference in 30-day readmission post-surgery (Early: DID = 0.003; 2014: DID = -0.00007; P > 0.05) or 90-day mortality (Early: DID = -0.007, 2014: DID = -0.035; P > 0.05). Moreover, there was no difference in receipt of chemotherapy (Early: DID = 0.01, 2014: DID = 0.005; P > 0.05) or time to chemotherapy for patients receiving neoadjuvant chemotherapy (Early: Early: DID = 9.62, 2014: DID = 0.01; P > 0.05). Finally, there was no difference in receipt of palliative care among stage IV patients in both cohorts (Early: DID = -0.004, 2014: DID = 0.004; P > 0.05). Conclusions: This study suggests that after ME, PDAC patients were more likely to be insured and had increased access to surgical care. Future, studies should evaluate the implications of improved surgical access on clinical outcomes such as mortality.

Abstract PS7-10: Hormone receptor positive breast cancers and Black race: Does gender matter?

Introduction: Male breast cancer (MBC) patients present with later disease stages and have higher mortality rates than female breast cancer (FBC) patients. Additionally, black breast cancer patients, regardless of gender, consistently have worse clinical outcomes than their white counterparts. To date, there are few studies exclusively comparing clinical outcomes between black MBC and black FBC patients. The objective of this study is to understand the differences in presentation, treatment and mortality between black MBC and black FBC patients with hormone receptor positive breast cancer using the National Cancer Database (NCDB).

Methods: The NCDB was queried for all black MBC and FBC patients, ages 18-90, with hormone receptor positive breast cancer diagnosed between 2010-2016. Hormone receptor positivity was defined as estrogen receptor positive, progesterone positive and HER 2-negative cancer. Sociodemographic and clinical variables were compared between MBC and FBC patients on univariate analysis. For stages I-III patients, a propensity score (PS) was generated by a logistic regression model including the following covariates: age at diagnosis, tumor size, nodes removed, node positivity, resection margin status, hormonal treatment, chemotherapy treatment, and radiation treatment. MBC patients were matched to FBC patients using PS 2:1 nearest-neighbor matching. A log rank test was used to determine differences in survival between the matched cohort.

Results: There were 994 black MBC and 65,931 black FBC patients that met study criteria. MBC patients were older at diagnosis than women (age, MBC 63 ± 12.5, FBC 60.6± 13.3). Compared to FBC patients, more MBC patients had lower oncotype scores (RS 0-10, MBC 39.7%, FBC 24%, p&lt;0.001). Additionally, MBC patients were more likely to present with metastatic disease (stage 4, MBC 4.4%, FBC 2.6%, p&lt;0.001), had fewer smaller tumors (tumor size &lt;2cm, MBC 32.1, FBC 49.1%, p&lt;0.001) and a higher percentage of poorly differentiated tumors (grade 3, MBC 28.5%, FBC 21.4%, p&lt;0.001). Notably, MBC patients had lower rates of hormone therapy (MBC 66.4%, FBC 80.7%, p&lt;0.001) and neoadjuvant chemotherapy (MBC 5.8%, FBC 7.5%, p=0.05) utilization than their female counterparts. On propensity score matched analysis black MBC patients had a higher overall mortality compared to FBC patients (p=0.026).

Conclusion: Hormone receptor positive black MBC patients in the NCDB present with more advanced stages of disease, are less likely to receive endocrine therapy and have worse overall mortality compared to their black FBC counterparts. These results indicate that significant gender-based disparities exist in presentation, treatment and mortality among black breast cancer patients. Future studies should evaluate how biologic sex and tumor biology intersect to affect these intra-racial differences in clinical outcomes.

Citation Format: Mariam Eskander, Yaming Li, Bridget Oppong, Oindrila Bhattacharyya, Allan Tsung, Samilia Obeng-Gyasi. Hormone receptor positive breast cancers and Black race: Does gender matter? [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-10.

The implications of neighborhood socioeconomic status on surgical management and mortality in malignant phyllodes patients in the Surveillance, Epidemiology, and End Results program

BACKGROUND

Neighborhood socioeconomic status has been implicated in breast cancer incidence and mortality. However, there are no studies on the impact of neighborhood socioeconomic status on clinical outcomes or surgical management among patients with phyllodes tumors. The objective of this study is to understand the relationship between neighborhood socioeconomic status, surgical management and disease specific mortality in malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program.

METHODS

Surveillance, Epidemiology, and End Results program was queried for malignant phyllodes tumor patients diagnosed between 2000 and 2016. Using the National Cancer Institute census tract-level index for neighborhood socioeconomic status the data were stratified into low neighborhood socioeconomic status, middle neighborhood socioeconomic status, and high neighborhood socioeconomic status. Bivariate intergroup analysis was conducted. Disease specific mortality was evaluated using a Cox proportional hazards model.

RESULTS

Of the 651 patients with malignant phyllodes tumor in the sample, the disease specific mortality was 7.6% and 7.9% at 5 and 10 years, respectively. On bivariate analysis, there were no differences between the neighborhood socioeconomic status groups and surgery type (P = .794). On multivariable analysis, older age (≥71 years; hazard ratio 9.9; 95% confidence interval, 2.84-34.57; P < .001) and larger tumor size (≥40 mm; hazard ratio 2.20; 95% confidence interval, 1.09-4.44; P = .027) were associated with a higher disease specific mortality compared with younger age (≤ 40 years) and smaller tumor size (<40 mm). There was no association between neighborhood socioeconomic status and disease specific mortality (low neighborhood socioeconomic status-ref, middle neighborhood socioeconomic status hazard ratio 0.87 (95% confidence interval, 0.71-1.78; P = .71), high hazard ratio 0.91 (95% confidence interval, 0.44-1.90, P = .81).

CONCLUSION

Among malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program, disease specific mortality and surgical management are mostly driven by tumor characteristics and not social determinants of health.

Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level

Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.

Early surgical bypass versus endoscopic stent placement in pancreatic cancer

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Background: Biliary obstruction frequently occurs in locally advanced or metastatic pancreatic cancer and is often managed by surgical biliary bypass or endoscopic stenting. We compared readmissions/reinterventions among pancreatic cancer patients undergoing bypass vs. stenting. Methods: Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database and Florida State Ambulatory Surgery Database 2007-2011 using revisit variables. Patients with early surgical or endoscopic approach analyzed. Subsequent admissions and surgical, endoscopic or percutaneous interventions identified. Propensity score matching by approach. Univariate analysis of patient characteristics and outcomes before and after matching. Multivariate analysis of readmission and reintervention performed by logistic regression. Results: 1,823 and 342 underwent endoscopic treatment vs. early surgical bypass, respectively. After propensity score matching, 684 patients analyzed (table). 64.0% (219) of endoscopic and 70.5% (241) of surgical patients readmitted (p=0.07) and 15.2% (57) and 9.1% (31) underwent reintervention (p=0.01). Endoscopic patients had lower index median length of stay (6 vs 11 days, p<0.01) and admission costs ($11,549 vs $23,215, p<0.01). In multivariate analysis, surgical biliary bypass was predictive of readmission (OR 1.50; 95% CI 1.03-2.18), but initial procedure was not predictive of reintervention (p=0.20). Conclusions: Surgical biliary bypass is less commonly performed than endoscopic stenting. Among propensity score-matched patients, readmission rates are similar, though endoscopic patients require more subsequent interventions. Candidates for both techniques may experience fewer invasive procedures if offered initial surgical biliary bypass. [Table: see text]

Complications of pregnancy and foetal outcomes in pregnant diabetic patients managed in a tertiary hospital in Saudi Arabia

OBJECTIVE

To compare the pregnancy complications and fetal outcomes in pregnancies complicated by diabetes mellitus.

DESIGN

A retrospective cohort study. Setting- Abha Maternity Hospital, Abha, Saudi Arabia.

MATERIALS AND METHODS

One hundred and eighty five diabetic pregnant patients who delivered at the Abha Maternity Hospital during the 3-year-period from April 2000-March 2003 formed the subjects of this study. There were 27(14.6%) (type 1) - insulin dependent diabetics, group 1, 19 (10.2%)(type 2), non insulin dependent diabetic patients who constituted group 2 and 139(75.2%) gestational diabetic patients who made up group 3. Data extracted from the case files included maternal age, gravidity, parity, number of abortions, gestational age at booking, time of diagnosis of diabetes mellitus, complications during pregnancy, birth weight, placental weight.

RESULTS

There were no statistically significant differences in the three groups regarding the mean gravidity, parity, birth weight and placental weight (p > 0.05). However, statistically significant differences were found with respect to the mean maternal age, gestation at booking, fasting blood sugar, and gestation at delivery (p < 0.05). Out of 139 gestational diabetics, 23(16.5%) were diagnosed by the 141 week of pregnancy while 24(17.2%) were diagnosed between the 15- 27 weeks of gestation. The control of blood sugar was adjudged to be poor in 32% of gestational diabetics, 50% of type 2 diabetics and 69% of type l diabetics, with statistically significant difference between the groups, (p < 0.05). Although there was statistically significant difference between the groups regarding one of the pregnancy complications (polyhydramnios) (p < 0.05), none were found in other complications (p > 0.05). The overall caesarean section rate was 48%. The overall perinatal mortality was 5.7%, all the deaths occurred in babies born to patients with gestational diabetes.

CONCLUSION

Gestational diabetes accounted for all the fetal losses in this study, while polyhydramnios was the most common antenatal complication which was significantly higher in type 1 diabetics.

Elective hysterectomy: a clinicopathological review from Abha catchment area of Saudi Arabia

OBJECTIVE

To review the major indications, types and clinicopathological features of elective hysterectomy managed in our locality.

MATERIAL AND METHODS

A retrospective study of 317 consecutive patients who had elective hysterectomy performed for various indications during the study period from January 1994-December 2001,(96 months) was conducted. The patients were divided into 3 groups: Group 1, total abdominal hysterectomy(TAH) 165 (52%); Group 2: subtotal abdominal hysterectomy(STAH) 59(18.6%) and Group 3: vaginal hysterectomy (VH),93 (28.4%). Data extracted from the case files included age, parity, presenting symptoms and indication for hysterectomy. Others included relevant investigation results, type of hysterectomy, and histopathological diagnosis of the specimens

SETTING

Abha Maternity Hospital, Abha, Saudi Arabia.

RESULTS

No statistically significant trend was found in the annual number of hysterectomies performed during the study period (p > 0.05). There was statistically significant difference in the mean age in the 3 groups of patients (p < 0.05), but none in the parity (p > 0.05). Menorrhagia and abnormal vaginal bleeding was the indication for hysterectomy in 123(38.8%) patients, followed by uterine prolapse in 91(28.7%), abdominopelvic mass, 48 (15.1%) and pelvic mass in 46 (14.8%). Histopathology of hysterectomy specimens and appendages were reported as abnormal in 179 (56.4%), with uterine fibroids the most common pathology in 82 specimens (25.8%) followed by adenomyosis in 72 specimens(22.7%).

CONCLUSION

Uterine fibroids and adenomyosis were the most common benign conditions in hysterectomy specimens in our community with peak incidence at 41-50 years, while endometrial and ovarian cancers peaked at the same age group. At the same time, vaginal hysterectomy was performed exclusively for utero-vaginal prolapse.

Watson-Jones tenodesis for chronic ankle joint instability

Twenty-three patients (22 soldiers and 1 civilian) were admitted to the Cambridge Military Hospital between May 1990 and May 1992 with chronic inversion instability of an ankle and underwent Watson-Jones Tenodesis. A retrospective study was carried out to evaluate their results.