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Herb JN, Snyder RA. Differences in DVT Rates in Patients Treated With and Without Preoperative Chemotherapy Prior to Distal Pancreatectomy: Is it the Therapy or Disease Burden? Ann Surg Oncol 2024; 31:2806-2808. [PMID: 38245653 DOI: 10.1245/s10434-024-14950-5] [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: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024]
Affiliation(s)
- Joshua N Herb
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Snyder RA, Katz MHG. NORPACT-1: implications for future trials. Lancet Gastroenterol Hepatol 2024; 9:408. [PMID: 38604195 DOI: 10.1016/s2468-1253(24)00054-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 02/23/2024] [Accepted: 02/23/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA.
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Maiga AW, Snyder RA, Kao LS, Raval MV, Patel MB, Blakely ML. Advancing Randomized Clinical Trials in Surgery: Role of Exception From Informed Consent, Central Institutional Review Board, and Bayesian Approaches. J Surg Res 2024:S0022-4804(24)00167-7. [PMID: 38670847 DOI: 10.1016/j.jss.2024.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/16/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Amelia W Maiga
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Rebecca A Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mayur B Patel
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Martin L Blakely
- Department of Surgery, Institute for Clinical Research and Learning Health Care, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, Texas
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Azimuddin A, Tzeng CWD, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Newhook TE, Kim MP, Ikoma N, Snyder RA, Lee JE, Perrier ND, Katz MH, Maxwell JE. Postoperative Global Period Cost Reduction Using 3 Successive Risk-Stratified Pancreatectomy Clinical Pathways. J Am Coll Surg 2024; 238:451-459. [PMID: 38180055 DOI: 10.1097/xcs.0000000000000944] [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] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND We hypothesized that iterative revisions of our original 2016 risk-stratified pancreatectomy clinical pathways would be associated with decreased 90-day perioperative costs. STUDY DESIGN From a single-institution retrospective cohort study of consecutive patients with 3 iterations: "version 1" (V1) (October 2016 to January 2019), V2 (February 2019 to October 2020), and V3 (November 2020 to February 2022), institutional data were aggregated using revenue codes and adjusted to constant 2022-dollar value. Grand total perioperative costs (primary endpoint) were the sum of pancreatectomy, inpatient care, readmission, and 90-day global outpatient care. Proprietary hospital-based costs were converted to ratios using the mean cost of all hospital operations as the denominator. RESULTS Of 814 patients, pathway V1 included 363, V2 229, and V3 222 patients. Accordion Grade 3+ complications decreased with each iteration (V1: 28.4%, V2: 22.7%, and V3: 15.3%). Median length of stay decreased (V1: 6 days, interquartile range [IQR] 5 to 8; V2: 5 [IQR 4 to 6]; and V3: 5 [IQR 4 to 6]) without an increase in readmissions. Ninety-day global perioperative costs decreased by 32% (V1 cost ratio 12.6, V2 10.9, and V3 8.6). Reduction of the index hospitalization cost was associated with the greatest savings (-31%: 9.4, 8.3, and 6.5). Outpatient care costs decreased consistently (1.58, 1.41, and 1.04). When combining readmission and all outpatient costs, total "postdischarge" costs decreased (3.17, 2.59, and 2.13). Component costs of the index hospitalization that were associated with the greatest savings were room or board costs (-55%: 1.74, 1.14, and 0.79) and pharmacy costs (-61%: 2.20, 1.61, and 0.87; all p < 0.001). CONCLUSIONS Three iterative risk-stratified pancreatectomy clinical pathway refinements were associated with a 32% global period cost savings, driven by reduced index hospitalization costs. This successful learning health system model could be externally validated at other institutions performing abdominal cancer surgery.
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Affiliation(s)
- Ahad Azimuddin
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
- Texas A&M School of Medicine, Houston, TX (Azimuddin)
| | - Ching-Wei D Tzeng
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Laura R Prakash
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Morgan L Bruno
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Elsa M Arvide
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Whitney L Dewhurst
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Timothy E Newhook
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Michael P Kim
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Naruhiko Ikoma
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Rebecca A Snyder
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jeffrey E Lee
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Nancy D Perrier
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Matthew Hg Katz
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jessica E Maxwell
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
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Boyev A, Arvide EM, Newhook TE, Prakash LR, Bruno ML, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Prophylactic Antibiotic Duration and Infectious Complications in Pancreatoduodenectomy Patients With Biliary Stents: Opportunity for De-escalation. Ann Surg 2024; 279:657-664. [PMID: 37389897 DOI: 10.1097/sla.0000000000005982] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The aim of this study was to compare infectious complications in pancreatoduodenectomy (PD) patients with biliary stents treated with short, medium, or long durations of prophylactic antibiotics. BACKGROUND Pre-existing biliary stents have historically been associated with higher infection risk after PD. Patients are administered prophylactic antibiotics, but the optimal duration remains unknown. METHODS This single-institution retrospective cohort study included consecutive PD patients from October 2016 to April 2022. Antibiotics were continued past the operative dose per surgeon discretion. Infection rates were compared by short (≤24 h), medium (>24 but ≤96 h), and long (>96 h) duration antibiotics. Multivariable regression analysis was performed to evaluate associations with a primary composite outcome of wound infection, organ-space infection, sepsis, or cholangitis. RESULTS Among 542 PD patients, 310 patients (57%) had biliary stents. The composite outcome occurred in 28% (34/122) short, 25% (27/108) medium, and 29% (23/80) long-duration ( P =0.824) antibiotic patients. There were no differences in other infection rates or mortality. On multivariable analysis, antibiotic duration was not associated with infection rate. Only postoperative pancreatic fistula (odds ratio 33.1, P <0.001) and male sex (odds ratio 1.9, P =0.028) were associated with the composite outcome. CONCLUSIONS Among 310 PD patients with biliary stents, long-duration prophylactic antibiotics were associated with similar composite infection rates to short and medium durations but were used almost twice as often in high-risk patients. These findings may represent an opportunity to de-escalate antibiotic coverage and promote risk-stratified antibiotic stewardship in stented patients by aligning antibiotic duration with risk-stratified pancreatectomy clinical pathways.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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Cass SH, Tzeng CWD, Prakash LR, Maxwell J, Snyder RA, Kim MP, Huey RW, Smaglo BG, Pant S, Koay EJ, Wolff RA, Lee JE, Katz MHG, Ikoma N. Trends Over Time in Recurrence Patterns and Survival Outcomes after Neoadjuvant Therapy and Surgery for Pancreatic Cancer. Ann Surg 2024:00000658-990000000-00817. [PMID: 38506042 DOI: 10.1097/sla.0000000000006269] [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: 03/21/2024]
Abstract
OBJECTIVE We aimed to determine if advances in neoadjuvant therapy affected recurrence patterns and survival outcomes after pancreatectomy for pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Data are limited on how modern multimodality therapy affects PDAC recurrence and post-recurrence survival. METHODS Patients who received neoadjuvant therapy followed by curative-intent pancreatectomy for PDAC during 1998-2018 were identified. Treatments, recurrence sites and timing, and survival were compared between patients who completed neoadjuvant therapy and pancreatectomy in 1998-2004, 2005-2011, and 2012-2018. RESULTS The study included 727 patients (203, 251, and 273 in the 1998-2004, 2005-2011, and 2012-2018 cohorts, respectively). Use of neoadjuvant induction chemotherapy increased over time, and regimens changed over time, with >80% of patients treated in 2012-2018 receiving FOLFIRINOX or gemcitabine with nab-paclitaxel. Overall, recurrence sites and incidence (67.5%, 66.1%, and 65.9%) remained stable, and 85% of recurrences occurred within 2 years of surgery. However, compared to earlier cohorts, the 2012-2018 cohort had lower conditional risk of recurrence in postoperative year 1 and higher risk in postoperative year 2. Overall survival increased over time (median, 30.6, 33.6, and 48.7 mo, P < 0.005), driven by improved post-recurrence overall survival (median, 7.8, 12.5, and 12.6 mo; 3-year rate, 7%, 10%, and 20%; P < 0.005). CONCLUSIONS We observed changes in neoadjuvant therapy regimens over time and an associated shift in the conditional risk of recurrence from postoperative year 1 to postoperative year 2, although recurrence remained common. Overall survival and post-recurrence survival remarkably improved over time, reflecting improved multimodality regimens for recurrent disease.
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Affiliation(s)
- Samuel H Cass
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jessica Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ryan W Huey
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Brandon G Smaglo
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Shubham Pant
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Robert A Wolff
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jeffery E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Lyu HG, Snyder RA, Roland CL. ASO Author Reflections: Is a Patient's Home Address Associated with Survival Outcomes After Surgery for Extremity and Truncal Soft Tissue Sarcoma? Ann Surg Oncol 2024:10.1245/s10434-024-15170-7. [PMID: 38504045 DOI: 10.1245/s10434-024-15170-7] [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: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Heather G Lyu
- The University of Texas MD Anderson Cancer Center, Houston, USA
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8
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Collins RA, Herman T, Snyder RA, Haines KL, Stey A, Arora TK, Geevarghese SK, Phillips JD, Vicente D, Griggs CL, McElroy IE, Wall AE, Hughes TM, Sen S, Valinejad J, Alban A, Swan JS, Mercaldo N, Jalali MS, Chhatwal J, Gazelle GS, Rangel E, Yang CFJ, Donelan K, Gold JA, West CP, Cunningham C. Unspoken Truths: Mental Health Among Academic Surgeons. Ann Surg 2024; 279:429-436. [PMID: 37991182 DOI: 10.1097/sla.0000000000006159] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.
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Affiliation(s)
- Reagan A Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Tianna Herman
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Anne Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tania K Arora
- Department of Surgery, Augusta University at the Medical College of Georgia, Augusta, GA
| | | | | | - Diego Vicente
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cornelia L Griggs
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Srijan Sen
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Jaber Valinejad
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andres Alban
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - J Shannon Swan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Mohammad S Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Erika Rangel
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Karen Donelan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jessica A Gold
- Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Colin P West
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carrie Cunningham
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
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Hinshaw TP, Fu Y, Irish WD, Parikh AA, Snyder RA. Racial Differences in Stage IV Colorectal Cancer Molecular Profiling and Mutation Rates. J Surg Res 2024; 295:763-769. [PMID: 38150868 DOI: 10.1016/j.jss.2023.11.011] [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: 04/24/2023] [Revised: 09/26/2023] [Accepted: 11/09/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Despite advances in colorectal cancer (CRC) treatment, racial disparities persist. The primary aims of the study were to: evaluate differences in molecular testing rates over time by race; and measure the incidence of tumor mutations by race in patients with metastatic CRC. METHODS A retrospective cohort study was performed of all adult patients with stage IV CRC (2008-2018) identified within the cancer registry of a large regional health system. Demographic/clinical characteristics were collected through primary data abstraction of the electronic health record. Molecular profiling results were obtained directly from Caris Molecular Intelligence and electronic health record. RESULTS Three hundred eighty-three patients were included: 40.5% (n = 155) were Black and 59.5% (n = 228) were White. Significant increases were observed in microsatellite instability (MSI), KRAS, and BRAF testing rates during the study period (P < 0.0001). The odds of testing over time increased more significantly in Black compared to White patients for MSI testing (White: odds ratio [OR] 1.26 [95% confidence interval [CI] 1.12-1.41], Black: OR 1.69 [95% CI 1.41-2.02], P = 0.005) and BRAF testing (White: OR 1.42 [95% CI 1.26-1.62], Black: OR 1.89 [95% CI 1.51-2.36], P = 0.027). An increase in KRAS testing over time was observed for both cohorts and was independent of race (P = 0.58). Mutation rates did not differ by race: KRAS (Black 55.8% versus White 45.6%, P = 0.13) and BRAF (Black 4.8% versus White 10.0%, P = 0.33). CONCLUSIONS Within a large regional health system, molecular testing rates in patients with metastatic CRC increased significantly following National Comprehensive Cancer Network guideline changes for both Black and White patients. Black and White patients who underwent molecular testing had similar rates of MSI, KRAS, and BRAF mutations.
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Affiliation(s)
- Tyler P Hinshaw
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Yuanyuan Fu
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - William D Irish
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina; Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina; Division of Surgical Oncology, The University of Texas Health San Antonio Mays Cancer Center, San Antonio, Texas
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina; Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, North Carolina; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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10
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Traweek RS, Lyu HG, Witt RG, Snyder RA, Nassif EF, Krijgh DD, Smith JM, Tilney GS, Feng C, Chiang YJ, Torres KE, Roubaud MJ, Scally CP, Hunt KK, Keung EZ, Mericli AF, Roland CL. High Community-Level Social Vulnerability is Associated with Worse Recurrence-Free Survival (RFS) After Resection of Extremity and Truncal Soft Tissue Sarcoma. Ann Surg Oncol 2024:10.1245/s10434-024-15074-6. [PMID: 38396039 DOI: 10.1245/s10434-024-15074-6] [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] [Received: 07/07/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Although social vulnerability has been associated with worse postoperative and oncologic outcomes in other cancer types, these effects have not been characterized in patients with soft tissue sarcoma. This study evaluated the association of social vulnerability and oncologic outcomes. METHODS The authors conducted a single-institution cohort study of adult patients with primary and locally recurrent extremity or truncal soft tissue sarcoma undergoing resection between January 2016 and December 2021. The social vulnerability index (SVI) was measured on a low (SVI 1-39%, least vulnerable) to high (60-100%, most vulnerable) SVI scale. The association of SVI with overall survival (OS) and recurrence-free survival (RFS) was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS The study identified 577 patients. The median SVI was 44 (interquartile range [IQR], 19-67), with 195 patients categorized as high SVI and 265 patients as low SVI. The median age, tumor size, histologic subtype, grade, comorbidities, stage, follow-up time, and perioperative chemotherapy and radiation utilization were similar between the high and low SVI cohorts. The patients with high SVI had worse OS (p = 0.07) and RFS (p = 0.016) than the patients with low SVI. High SVI was independently associated with shorter RFS in the multivariate analysis (hazard ratio, 1.64; 95% confidence interval, 1.06-2.54) but not with OS (HR, 1.47; 95% CI 0.84-2.56). CONCLUSION High community-level social vulnerability appears to be independently associated with worse RFS for patients undergoing resection of extremity and truncal soft tissue sarcoma. The effect of patient and community-level social risk factors should be considered in the treatment of patients with extremity sarcoma.
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Affiliation(s)
- Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather G Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Division of Surgical Oncology, The University of Virginia, Charlottesville, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elise F Nassif
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David D Krijgh
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeffrey M Smith
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gordon S Tilney
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chun Feng
- Pharmacy Informatics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keila E Torres
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Margaret J Roubaud
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher P Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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11
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Alimi Y, Bevilacqua LA, Snyder RA, Walsh DS, Jackson PG, Betsy JE, Altieri MS. The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training. Ann Surg 2024; 279:167-171. [PMID: 37565351 DOI: 10.1097/sla.0000000000006074] [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] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training. BACKGROUND There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees. METHODS A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions. RESULTS A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001). CONCLUSIONS Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.
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Affiliation(s)
- Yewande Alimi
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Lisa A Bevilacqua
- Department of General Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | | | - Patrick G Jackson
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - J E Betsy
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Maria S Altieri
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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12
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Hirata Y, Gottumukkala V, Ajith J, Schmeisser JA, Ninan EP, Maxwell JE, Snyder RA, Kim MP, Tran Cao HS, Tzeng CWD, Badgwell BD, Katz MHG, Ikoma N. Laparoscopic transverse abdominis plane block: how I do it and a cost efficiency analysis. Langenbecks Arch Surg 2023; 409:16. [PMID: 38147123 DOI: 10.1007/s00423-023-03210-x] [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: 09/29/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE To determine the efficacy and efficiency of laparoscopic transverse abdominis plane block (Lap-TAP) in patients undergoing pancreatoduodenectomy and gastrectomy compared to those of ultrasound-guided TAP (US-TAP). METHODS We retrospectively analyzed the records of patients who underwent open or minimally invasive (MIS) pancreatoduodenectomy and major gastrectomy with the use of Lap-TAP or US-TAP at our institution between November 1, 2018, and September 30, 2021. We compared the estimated time and cost associated with Lap-TAP and US-TAP. We also compared postoperative opioid use and pain scores between patients who underwent open laparotomy with these TAPs. RESULTS A total of 194 patients were included. Overall, 114 patients (59%) underwent pancreatectomy, and 80 patients (41%) underwent gastrectomy. Additionally, 138 patients (71%) underwent an open procedure, and 56 patients (29%) underwent MIS. A total of 102 patients (53%) underwent US-TAP, and 92 (47%) underwent Lap-TAP. The median time to skin incision was significantly shorter in the Lap-TAP group (US-TAP, 59 min vs. Lap-TAP, 45 min; P < 0.001), resulting in an estimated reduction in operation cost by $602. Pain scores and postoperative opioid use were similar between Lap-TAP and US-TAP among open surgery patients, indicating equivalent pain control between Lap-TAP and US-TAP. CONCLUSION Lap-TAP was equally effective in pain control as US-TAP after pancreatectomy and gastrectomy, and Lap-TAP can reduce operation time and cost. Lap-TAP is considered the preferred approach for MIS pancreatectomy and gastrectomy, which occasionally needs conversion to laparotomy.
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Affiliation(s)
- Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeeva Ajith
- Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason A Schmeisser
- Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth P Ninan
- Division of Procedures and Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Boyev A, Azimuddin A, Newhook TE, Maxwell JE, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Evaluation and Recalibration of Risk-Stratified Pancreatoduodenectomy Drain Fluid Amylase Removal Criteria. J Gastrointest Surg 2023; 27:2806-2814. [PMID: 37935998 DOI: 10.1007/s11605-023-05863-x] [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: 05/31/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Risk-stratified drain fluid amylase cutoff values for postoperative day 1 (POD1) (DFA1) and POD3 (DFA3) can guide early drain removal after pancreatoduodenectomy (PD). The aim of this study was to evaluate and recalibrate cutoff values instituted in Feb 2019 using a prospective sequential cohort. METHODS We performed a single-institution prospective cohort study of consecutive patients who underwent pancreatoduodenectomy following implementation of institution-specific DFA cutoffs in February 2019 through April 2022. DFA values, drain removal, and clinically relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values. RESULTS In total, 267 patients, 173 (65%) low-risk and 94 (35%) high-risk, underwent 228 (85%) open and 39 (15%) robotic pancreatoduodenectomies. Seven (4%) low-risk patients and 21 (22%) high-risk patients developed CR-POPF. Drains were removed in 147 (55%) patients before/on POD3, with 1 (0.7%) CR-POPF. In low-risk patients, CR-POPF was excluded with 100% sensitivity if DFA1 < 286 (area under curve, AUC = 0.893, p = 0.001) or DFA3 < 97 (AUC = 0.856, p = 0.002). DFA1 < 137 (AUC = 0.786, p < 0.001) or DFA3 < 56 (AUC = 0.819, p < 0.001) were 100% sensitive in high-risk patients. Previously established DFA1 cutoffs of 100 (low-risk) and < 26 (high-risk) were 100% sensitive, while DFA3 cutoffs of 300 (low-risk) and 200 (high-risk) had 57% and 91% sensitivity. CONCLUSIONS Within a learning health system, we recalibrated post-PD drain removal thresholds to DFA1 ≤ 300 and DFA3 ≤ 100 for low-risk and DFA1 ≤ 100 and DFA3 ≤ 50 for high-risk patients. This methodology is generalizable to other centers for developing institution-specific criteria to optimize safe early drain removal.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Ahad Azimuddin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA.
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14
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Boyev A, Prakash LR, Chiang YJ, Newhook TE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Tzeng CWD, Katz MHG, Maxwell JE. Elevated CA 19-9 is associated with worse survival in patients with resected ampullary adenocarcinoma. Surg Oncol 2023; 51:101994. [PMID: 37742542 DOI: 10.1016/j.suronc.2023.101994] [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] [Received: 06/06/2023] [Revised: 08/31/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The prognostic utility of Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) in ampullary adenocarcinoma is unclear. We sought to evaluate the association between initial tumor marker levels and survival in patients with resected ampullary adenocarcinoma. METHODS This was a single-institution, retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma from 1999 to 2021. CA 19-9 was assessed after biliary decompression. Contal and O'Quigley method determined optimal biomarker cutoff levels which were correlated with overall survival (OS) using the Kaplan-Meier method and Cox Proportional Hazards Regression. RESULTS A total of 180 patients underwent pancreatoduodenectomy. Patients with CA 19-9 >100 U/mL had a shorter median OS (28 vs. 132 months, p < 0.001) compared to patients with CA 19-9 ≤ 100 U/mL at diagnosis. Survival was similar between pancreaticobiliary and intestinal tumor subtypes when CA 19-9 was >100 U/mL (OS:25 vs. 33 months, p = 0.415). By Cox regression analysis, CA 19-9 >100 U/mL was independently associated with worse OS (HR 2.8, p = 0.001). CONCLUSIONS Preoperative CA 19-9 >100 U/mL was associated with shorter OS in patients with resected ampullary adenocarcinoma. CA 19-9 may be useful when counseling patients about prognosis or when considering the role of perioperative systemic therapy.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Iasiello JA, Rajan A, Zervos E, Parikh AA, Snyder RA. Racial Differences in Patient-Reported Access to Telehealth: An Important and Unmeasured Social Determinant of Health. JCO Oncol Pract 2023; 19:1215-1223. [PMID: 37844269 DOI: 10.1200/op.23.00006] [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] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 10/18/2023] Open
Abstract
PURPOSE The COVID-19 pandemic expanded opportunities for remote oncology telehealth visits. However, reliable internet connectivity, digital literacy, and patient comfort with virtual medical visits may differ among patients, especially socially disadvantaged groups. The primary aim of this study was to identify barriers that might limit access to telehealth video services. METHODS First, retrospective analysis was performed of composite administrative data of all patient visits to a large regional cancer center during the pandemic (March 2020 to April 2022). Second, a prospective, cross-sectional study was conducted of patients with known or suspected malignancy over a 6-month period (November 2021 to April 2022). A survey regarding video telehealth accessibility was verbally administered to patients at their clinic visit. RESULTS Administrative data demonstrated that although Black patients comprised 43% (n = 9,021) of all patient visits (n = 20,953), the proportion of telehealth visits conducted among Black patients was significantly lower compared with White patients (29% v 71%; P < .0001). Of the prospective, cross-sectional study cohort (n = 148), 51.4% of patients (n = 76) were Black, 38.5% (n = 57) resided in a rural county, and 8.1% (n = 12) were Medicaid-insured. Black participants were more likely to self-report lack of internet access (73.7% v 90.4%; P < .01) and were less likely to report having access to or actively using a patient portal (29.0% v 47.2%; P < .001) compared with White patients. The independent association of race and internet access (P < .05) and patient portal use (P = .001) persisted after multivariable analysis. CONCLUSION Black patients disproportionately underparticipated in telehealth visits, suggesting underlying structural disparities in access to digital care. A greater proportion of Black participants self-reported lack of internet access and access to a patient portal compared with White patients. Ensuring equal internet access and digital literacy will be critical to reduce disparities in cancer care among racial minorities.
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Affiliation(s)
- John A Iasiello
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Arvind Rajan
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Emmanuel Zervos
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Alexander A Parikh
- Department of Surgery, The University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, TX
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Hao SB, Jilcott Pitts SB, Iasiello J, Mejia C, Quinn AW, Popowicz P, Mitsakos A, Parikh AA, Snyder RA. A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice. Ann Surg Oncol 2023; 30:7299-7308. [PMID: 37606839 DOI: 10.1245/s10434-023-14124-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/24/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. METHODS Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. RESULTS Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black (n = 46), 48.2% rural (n = 54), 4.5% uninsured (n = 5), and 6.3% Medicaid-insured (n = 7) patients. Median visit time was 97 min (95% CI 70-107 min) before and 100 min after implementation (95% CI 75-119 min; p = 0.95). In total, 95.5% (n = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. CONCLUSIONS Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.
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Affiliation(s)
- Scarlett B Hao
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | | | - John Iasiello
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Christopher Mejia
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ashley W Quinn
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Patrycja Popowicz
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Anastasios Mitsakos
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Division of Surgical Oncology, Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
- Department of Public Health, East Carolina University, Greenville, NC, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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17
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Hao SB, Parikh AA, Snyder RA. ASO Author Reflections: Baby Steps: Building the Foundation for Defining, Identifying, and Intervening on Social Determinants of Health in Routine Oncology Care. Ann Surg Oncol 2023; 30:7321-7322. [PMID: 37598119 DOI: 10.1245/s10434-023-14206-8] [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: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Scarlett B Hao
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
- Division of Surgical Oncology, Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Boyev A, Jain AJ, Newhook TE, Prakash LR, Chiang YJ, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm. JAMA Surg 2023; 158:e234154. [PMID: 37672236 PMCID: PMC10483385 DOI: 10.1001/jamasurg.2023.4154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 09/07/2023]
Abstract
Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Hao SB, Jilcott Pitts SB, Iasiello J, Mejia C, Quinn AW, Popowicz P, Mitsakos A, Parikh AA, Snyder RA. ASO Visual Abstract: A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice. Ann Surg Oncol 2023; 30:7329. [PMID: 37635190 DOI: 10.1245/s10434-023-14173-0] [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] [Indexed: 08/29/2023]
Affiliation(s)
- Scarlett B Hao
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Stephanie B Jilcott Pitts
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - John Iasiello
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Christopher Mejia
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Ashley W Quinn
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Patrycja Popowicz
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Anastasios Mitsakos
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
- Division of Surgical Oncology, Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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20
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Sherry AD, Corrigan KL, Kouzy R, Jaoude JA, Yang Y, Patel RR, Totten DJ, Newman NB, Das P, Taniguchi C, Minsky B, Snyder RA, Fuller CD, Ludmir E. Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research. Cancer 2023; 129:3430-3438. [PMID: 37382235 DOI: 10.1002/cncr.34929] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time. METHODS This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials. RESULTS Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01). CONCLUSIONS In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials. PLAIN LANGUAGE SUMMARY Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.
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Affiliation(s)
- Alexander D Sherry
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelsey L Corrigan
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ramez Kouzy
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Abi Jaoude
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yumeng Yang
- Department of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Roshal R Patel
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Douglas J Totten
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neil B Newman
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Prajnan Das
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cullen Taniguchi
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Division of Radiation Oncology, Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruce Minsky
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca A Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C David Fuller
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ethan Ludmir
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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21
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Snyder RA, Burtness B, Cho M, Del Rivero J, Doroshow DB, Hitchcock KE, Kalyan A, Kim CA, Lukovic J, Parikh AR, Sanford NN, Singh B, Shen C, Shroff RT, Vijayvergia N, Goodman KA, Kunz PL. The room where it happens: addressing diversity, equity, and inclusion in National Clinical Trials Network clinical trial leadership. J Natl Cancer Inst 2023; 115:1132-1138. [PMID: 37364007 PMCID: PMC11009492 DOI: 10.1093/jnci/djad121] [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] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/09/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023] Open
Abstract
Many multicenter randomized clinical trials in oncology are conducted through the National Clinical Trials Network (NCTN), an organization consisting of 5 cooperative groups. These groups are made up of multidisciplinary investigators who work collaboratively to conduct trials that test novel therapies and establish best practice for cancer care. Unfortunately, disparities in clinical trial leadership are evident. To examine the current state of diversity, equity, and inclusion across the NCTN, an independent NCTN Task Force for Diversity in Gastrointestinal Oncology was established in 2021, the efforts of which serve as the platform for this commentary. The task force sought to assess existing data on demographics and policies across NCTN groups. Differences in infrastructure and policies were identified across groups as well as a general lack of data regarding the composition of group membership and leadership. In the context of growing momentum around diversity, equity, and inclusion in cancer research, the National Cancer Institute established the Equity and Inclusion Program, which is working to establish benchmark data regarding diversity of representation within the NCTN groups. Pending these data, additional efforts are recommended to address diversity within the NCTN, including standardizing membership, leadership, and publication processes; ensuring diversity of representation across scientific and steering committees; and providing mentorship and training opportunities for women and individuals from underrepresented groups. Intentional and focused efforts are necessary to ensure diversity in clinical trial leadership and to encourage design of trials that are inclusive and representative of the broad population of patients with cancer in the United States.
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Affiliation(s)
- Rebecca A Snyder
- Departments of Surgical Oncology and Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Burtness
- Department of Internal Medicine, Section of Medical Oncology, and Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - May Cho
- Department of Medicine, Division of Hematology/Oncology, University of California, Irvine, Irvine, CA, USA
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Deborah B Doroshow
- Department of Medicine, Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kathryn E Hitchcock
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Aparna Kalyan
- Department of Medicine, Division of Hematology & Oncology and Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Christina A Kim
- Department of Internal Medicine, Section of Medical Oncology and Hematology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jelena Lukovic
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network and Department of Radiation Oncology, University of Toronto, ON, Canada
| | - Aparna R Parikh
- Massachusetts General Cancer Center, Division of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nina N Sanford
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bhuminder Singh
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chan Shen
- Departments of Surgery and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Rachna T Shroff
- Department of Medicine, Division of Hematology/Oncology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Namrata Vijayvergia
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pamela L Kunz
- Department of Internal Medicine, Section of Medical Oncology, and Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
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22
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Boyev A, Azimuddin A, Prakash LR, Newhook TE, Maxwell JE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Katz MHG, Tzeng CWD. Classification of Post-Pancreatectomy Readmissions and Opportunities for Targeted Mitigation Strategies. Ann Surg 2023:00000658-990000000-00659. [PMID: 37791481 DOI: 10.1097/sla.0000000000006112] [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: 10/05/2023]
Abstract
OBJECTIVE Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement. SUMMARY BACKGROUND DATA Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics. METHODS We performed a single-institution case-control study of consecutive pancreatectomy patients (October 2016 - April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions. RESULTS A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/835) distal pancreatectomies, and 3% (21/835) other resections. 24% (204/835) of patients were readmitted. Primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed non-invasively. During the index hospitalization, benign pathology (OR 1.8, P=0.049), biochemical pancreatic leak (OR 2.3, P=0.001), bile/gastric/chyle leak (OR 6.4, P=0.001), organ-space infection (OR 3.4, P=0.007), undrained fluid on imaging (OR 2.4, P=0.045), and increasing white blood cell count (OR 1.7, P=0.045) were independently associated with odds of readmission. CONCLUSIONS Most readmissions following pancreatectomy were technical in origin. Patients with complications during index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at highest risk for readmission. Pre-discharge risk-stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Snyder RA, Dueck AC, Fruth B, Shi Q, Hubbard JM, Herman JM, O'Reilly EM, Katz MHG. Patient-reported Adverse Events During Neoadjuvant Therapy in a Phase 2 Borderline Resectable Pancreatic Cancer Clinical Trial (Alliance A021501). Ann Surg 2023; 278:598-608. [PMID: 37334719 PMCID: PMC10527167 DOI: 10.1097/sla.0000000000005958] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE We sought to evaluate symptomatic adverse event (AE) rates among patients with pancreatic cancer receiving neoadjuvant therapy on clinical trial (A021501) using the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE). BACKGROUND To date, pancreatic cancer clinical trials have measured AEs using standard physician reporting [Common Terminology Criteria for Adverse Events (CTCAE)]. Patient-reported symptomatic AEs have been incompletely characterized. METHODS A021501 (December 31, 2016-January 1, 2019) randomized patients with borderline resectable pancreatic ductal adenocarcinoma to 8 doses of mFOLFIRINOX (Arm 1) or 7 doses of mFOLFIRINOX+hypofractionated radiotherapy (Arm 2), followed by pancreatectomy and adjuvant FOLFOX6. Patients completed PRO-CTCAE assessments at baseline, on day 1 of each chemotherapy cycle, and daily during radiotherapy. RESULTS Of 126 patients, 96 (76%) initiated treatment and completed a baseline plus at least 1 postbaseline PRO-CTCAE assessment. Diarrhea and fatigue were the only symptomatic grade 3 or higher AEs identified in at least 10% of patients using CTCAE. At least 10% of all patients reported an adjusted PRO-CTCAE composite grade 3 AE during neoadjuvant treatment for 10 of 15 items: anxiety (10%), bloating of abdomen (16%), decreased appetite (18%), diarrhea (13%), dry mouth (21%), fatigue (36%), nausea (18%), generalized pain (16%), abdominal pain (21%), and problems tasting (32%). Decreased appetite was higher in Arm 2 than in Arm 1 ( P =0.0497); no other differences between study arms were observed. CONCLUSION Symptomatic AEs during neoadjuvant therapy were common and were reported more frequently by patients using PRO-CTCAE than were recorded by clinicians using standard CTCAE.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amylou C Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Scottsdale, AZ
| | - Briant Fruth
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Qian Shi
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | | | | | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX
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24
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Boyev A, Prakash LR, Chiang YJ, Childers CP, Jain AJ, Newhook TE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Katz MHG, Tzeng CWD, Maxwell JE. Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy. J Gastrointest Surg 2023; 27:2135-2144. [PMID: 37468733 DOI: 10.1007/s11605-023-05751-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care. METHODS A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF. RESULTS A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%. CONCLUSION Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Christopher P Childers
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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25
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Allen CJ, Snyder RA, Horn DM, Hudson MF, Barber A, Smieliauskas F, Spears PA, Edge S, Greenup RA. Defining Priorities in Value-Based Cancer Care: Insights From the Alliance for Clinical Trials in Oncology National Cooperative Group Survey. JCO Oncol Pract 2023; 19:932-938. [PMID: 37651652 PMCID: PMC10615548 DOI: 10.1200/op.23.00159] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/26/2023] [Accepted: 06/08/2023] [Indexed: 09/02/2023] Open
Abstract
PURPOSE We determine how stakeholders prioritize the importance of oncologic outcomes, patient-reported outcomes (PROs), and cancer-related health care costs. METHODS A survey was distributed to the National Clinical Trials Network Alliance for Clinical Trials in Oncology cooperative group membership from May 14 to June 30, 2022. Respondents were asked to rate (5-point Likert scale) and rank (1-9) evidence-based value domains: overall survival, treatment toxicities/complications, quality of life (QOL), financial toxicity, access to care, compliance with evidence-based care, health system performance, scientific discovery and innovation, and cost to the health care system. RESULTS A total of 514 members responded, including researchers (24.7%), nurses (19.5%), medical oncologists (17.9%), administrators (9.3%), surgical and radiation oncologists (9.1%), patient advocates (3.1%), and nonphysician providers (16.4%). Participants represented various practice settings including National Cancer Institute-designated cancer centers (29.8%), university-affiliated academic cancer centers (21%), hospital-owned oncology practices (21.8%), and others (27.4%). There was agreement in how respondents prioritized value domains (W = 0.39, P < .001). Respondents ranked patient QOL (mean rank: 2.6 ± 1.9) as most important above all other metrics including survival (mean rank: 3.5 ± 0.3) and access to care (mean rank: 3.5 ± 2.1; P < .001). Members engaged in direct patient care also ranked access to care of higher importance than nonclinicians (P = .026). Cost to the health care system (mean rank: 7.5 ± 2.1) and health system performance (mean rank: 7 ± 2) were ranked as least important (P < .001). Inclusion of PROs into therapeutic assessment (59.3%) was the most frequently selected priority of future cooperative group initiatives. CONCLUSION Oncology community stakeholders deemed patient-centered value domains as most important and considered patient QOL the highest priority. Inclusion of PROs into clinical trials was endorsed as an important component of therapeutic assessment. These findings can be taken into consideration when creating a value framework for inclusion in cancer clinical trials.
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Affiliation(s)
- Casey J Allen
- Division of Surgical Oncology, Institute of Surgery, Allegheny Health Network Cancer, Pittsburgh, PA
| | - Rebecca A Snyder
- Departments of Surgical Oncology and Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Matthew F Hudson
- Prisma Health Cancer Institute and University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Anne Barber
- Cancer Control Program of the Alliance for Clinical Trials in Oncology and Cancer Programs of the American College of Surgeons, Chicago, IL
| | - Fabrice Smieliauskas
- Department of Economics and Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Patty A Spears
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen Edge
- Roswell Park Comprehensive Cancer Center and Jacobs School of Medicine, University at Buffalo, Buffalo, NY
| | - Rachel A Greenup
- Department of Surgery and Smilow Cancer Hospital, Yale School of Medicine, New Haven, CT
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26
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Bondzi-Simpson A, Ribeiro T, Benipal H, Barabash V, Lofters A, Sutradhar R, Snyder RA, Clarke C, Coburn NG, Hallet J. Integration of the social determinants of health into quality indicators for colorectal cancer surgery: a scoping review protocol. BMJ Open 2023; 13:e075270. [PMID: 37751959 PMCID: PMC10533733 DOI: 10.1136/bmjopen-2023-075270] [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] [Accepted: 08/22/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Quality monitoring is a critical component of high-performing cancer care systems. Quality indicators (QIs) are standardised, evidence-based measures of healthcare quality that allow healthcare systems to track performance, identify gaps in healthcare delivery and inform areas of priority for strategic planning. Social structures and economic systems that allow for unequal access to power and resources that shape health and health inequities can be described through the social determinants of health (SDoH) framework. Therefore, granular analysis of healthcare quality through SDoH frameworks is required to identify patient subgroups who may experience health inequity. Given the high burden of disease of colorectal cancer (CRC) and well-defined cancer care pathways, CRC is often the first disease site targeted by health systems for quality improvement. The objective of this review is to examine how SDoH have been integrated into QIs for CRC surgery. This review aims to address three primary questions: (1) Have SDoH been integrated into the development, reporting and assessment of CRC surgery QIs? (2) When integrated, what measures and statistical methods have been applied? (3) In which direction do individual SDoH influence QIs outputs? METHODS This review will follow Arksey and O'Malley frameworks for scoping reviews. We will search MEDLINE, EMBASE, HealthSTAR databases for papers that examine QIs for CRC surgery applicable to healthcare systems from database inception until January 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. ETHICS & DISSEMINATION No ethics approval is required for this review. Results will be disseminated through scientific presentation and relevant conferences targeted for researchers examining healthcare quality and equity in cancer care. REGISTRATION DETAILS osf.io/vfzd3-Open Science Framework.
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Affiliation(s)
- Adom Bondzi-Simpson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tiago Ribeiro
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Harsukh Benipal
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Barabash
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Aisha Lofters
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Rebecca A Snyder
- Departments of Surgical Oncology and Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Callisia Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Jain AJ, Maxwell JE, Katz MHG, Snyder RA. Surgical Considerations for Neoadjuvant Therapy for Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:4174. [PMID: 37627202 PMCID: PMC10453019 DOI: 10.3390/cancers15164174] [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] [Received: 06/25/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a challenging disease process with a 5-year survival rate of only 11%. Neoadjuvant therapy in patients with localized pancreatic cancer has multiple theoretical benefits, including improved patient selection for surgery, early delivery of systemic therapy, and assessment of response to therapy. Herein, we review key surgical considerations when selecting patients for neoadjuvant therapy and curative-intent resection. Accurate determination of resectability at diagnosis is critical and should be based on not only anatomic criteria but also biologic and clinical criteria to determine optimal treatment sequencing. Borderline resectable or locally advanced pancreatic cancer is best treated with neoadjuvant therapy and resection, including vascular resection and reconstruction when appropriate. Lastly, providing nutritional, prehabilitation, and supportive care interventions to improve patient fitness prior to surgical intervention and adequately address the adverse effects of therapy is critical.
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Affiliation(s)
| | | | | | - Rebecca A. Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.J.J.)
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Allen CJ, Johnson FM, In H, Katz MHG, Snyder RA. Shifting the Focus: Value-Based Care in Surgical Oncology. Ann Surg Oncol 2023; 30:3871-3874. [PMID: 37014556 DOI: 10.1245/s10434-023-13369-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/01/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Casey J Allen
- Division of Surgical Oncology, Institute of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Fabian M Johnson
- Division of Surgical Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Haejin In
- Division of Surgical Oncology, The Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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29
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Ayabe RI, Prakash LR, Bruno ML, Newhook TE, Maxwell JE, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Differential Gains in Surgical Outcomes for High-Risk vs Low-Risk Pancreaticoduodenectomy with Successive Refinements of Risk-Stratified Care Pathways. J Am Coll Surg 2023; 237:4-12. [PMID: 36786469 DOI: 10.1097/xcs.0000000000000652] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND The use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes. STUDY DESIGN A prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE). RESULTS Of 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients. CONCLUSIONS Risk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.
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Affiliation(s)
- Reed I Ayabe
- From the Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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30
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Honaker MD, Irish W, Parikh AA, Snyder RA. ASO Visual Abstract: Association of Rural Residence and Receipt of Guideline Concordant Care for Locoregional Colon Cancer. Ann Surg Oncol 2023; 30:3548. [PMID: 36995453 DOI: 10.1245/s10434-023-13403-9] [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: 03/31/2023]
Affiliation(s)
- Michael D Honaker
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - William Irish
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
- Department of Surgery, The University of Texas San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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31
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D’Angelica MI, Ellis RJ, Liu JB, Brajcich BC, Gönen M, Thompson VM, Cohen ME, Seo SK, Zabor EC, Babicky ML, Bentrem DJ, Behrman SW, Bertens KA, Celinski SA, Chan CHF, Dillhoff M, Dixon MEB, Fernandez-del Castillo C, Gholami S, House MG, Karanicolas PJ, Lavu H, Maithel SK, McAuliffe JC, Ott MJ, Reames BN, Sanford DE, Sarpel U, Scaife CL, Serrano PE, Smith T, Snyder RA, Talamonti MS, Weber SM, Yopp AC, Pitt HA, Ko CY. Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA 2023; 329:1579-1588. [PMID: 37078771 PMCID: PMC10119777 DOI: 10.1001/jama.2023.5728] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood. Objective To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics. Design, Setting, and Participants Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment. Intervention The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care). Main Outcomes and Measures The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program. Results The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32). Conclusions and Relevance In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy. Trial Registration ClinicalTrials.gov Identifier: NCT03269994.
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Affiliation(s)
| | - Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, New York
- American College of Surgeons, Chicago, Illinois
| | - Jason B. Liu
- American College of Surgeons, Chicago, Illinois
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Mithat Gönen
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily C. Zabor
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | | | | | | | | | | | | | - Paul J. Karanicolas
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harish Lavu
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Umut Sarpel
- Mount Sinai Medical Center, New York, New York
| | | | | | | | | | | | | | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas
| | - Henry A. Pitt
- American College of Surgeons, Chicago, Illinois
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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32
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Martin AN, Snyder RA. Invited commentary on conversion of unresectable to resectable colorectal liver metastases: Even the best predictive models cannot substitute for surgical evaluation. Surgery 2023; 173:1518-1519. [PMID: 37029017 DOI: 10.1016/j.surg.2023.02.029] [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: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Allison N Martin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. https://twitter.com/globalsurgallie
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
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33
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Honaker MD, Irish W, Parikh AA, Snyder RA. ASO Author Reflections: Rural-Urban Disparities in Colon Cancer Care: Trying to Close the Gap. Ann Surg Oncol 2023; 30:3547. [PMID: 37000357 DOI: 10.1245/s10434-023-13381-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Affiliation(s)
- Michael D Honaker
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - William Irish
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
- Department of Surgery, The University of Texas San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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34
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Honaker MD, Irish W, Parikh AA, Snyder RA. Association of Rural Residence and Receipt of Guideline-Concordant Care for Locoregional Colon Cancer. Ann Surg Oncol 2023; 30:3538-3546. [PMID: 36933082 DOI: 10.1245/s10434-023-13340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/19/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Incidence and mortality rates of colon cancer (CC) are higher in rural populations. This study aimed to determine whether rural residence is associated with differences in guideline-concordant care for patients with locoregional CC. METHODS Patients with stages I-III CC from 2006 to 2016 were identified in the National Cancer Database. Guideline-concordant care (GCC) was defined as resection with negative margins, adequate nodal harvest, and receipt of adjuvant chemotherapy for patients with high-risk stage II or III disease. Multivariable logistic regression (MVR) was performed to evaluate the association between rural residence and the odds of receiving GCC. Effect modification was evaluated using a two-way interaction for rurality by insurance status. RESULTS Of 320,719 identified patients, 6191 (2%) were rural. The rural patients had lower income and lower educational status than the urban patients and were more often Medicare-insured (p < 0.001). The rural patients traveled farther (44.5 vs. 7.5 miles; p < 0.001), although time to surgery was similar (8 vs. 9 days). The two cohorts had similar resection rates (98.8% vs. 98.0%), margin positivity (5.4% vs. 4.8%), adequate lymphadenectomy (80.9% vs. 83.0%), adjuvant chemotherapy (stage III: 69.2% vs. 68.7%), and receipt of GCC (66.5% vs. 68.3%). In the MVR, the odds of receiving GCC did not differ between the rural and urban patients (odds ratio, 0.99; 95% confidence interval, 0.94-1.05%). Insurance status did not differentially influence the receipt of GCC by the rural versus the urban patients (interaction: p = 0.83). CONCLUSIONS Rural and urban patients with locoregional CC are equally likely to receive GCC, suggesting that differences in cancer care delivery may not explain rural-urban disparities.
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Affiliation(s)
- Michael D Honaker
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - William Irish
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.,Department of Surgery, The University of Texas San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA. .,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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35
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Ogobuiro I, Collier AL, Khan K, de Castro Silva I, Kwon D, Wilson GC, Schwartz PB, Parikh AA, Hammill C, Kim HJ, Kooby DA, Abbott D, Maithel SK, Snyder RA, Ahmad SA, Merchant NB, Datta J. ASO Visual Abstract: Racial Disparity in Pathologic Response Following Neoadjuvant Chemotherapy in Resected Pancreatic Cancer-A Multi-institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2023; 30:1498-1499. [PMID: 36564655 DOI: 10.1245/s10434-022-12912-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amber L Collier
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Khadeja Khan
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iago de Castro Silva
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY, USA
| | - Gregory C Wilson
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Patrick B Schwartz
- University of Wisconsin School of Medicine, Carbone Cancer Center, Madison, WI, USA
| | | | - Chet Hammill
- Washington University School of Medicine, St. Louis, MO, USA
| | - Hong J Kim
- University of North Carolina School of Medicine, Lineberger Cancer Center, Chapel Hill, NC, USA
| | - David A Kooby
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Daniel Abbott
- University of Wisconsin School of Medicine, Carbone Cancer Center, Madison, WI, USA
| | - Shishir K Maithel
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Rebecca A Snyder
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Syed A Ahmad
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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36
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Ogobuiro I, Collier AL, Khan K, de Castro Silva I, Kwon D, Wilson GC, Schwartz PB, Parikh AA, Hammill C, Kim HJ, Kooby DA, Abbott D, Maithel SK, Snyder RA, Ahmad SA, Merchant NB, Datta J. Racial Disparity in Pathologic Response following Neoadjuvant Chemotherapy in Resected Pancreatic Cancer: A Multi-Institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2023; 30:1485-1494. [PMID: 36316508 DOI: 10.1245/s10434-022-12741-4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Major pathologic response (MPR) following neoadjuvant therapy (NAT) in pancreatic ductal adenocarcinoma (PDAC) patients undergoing resection is associated with improved survival. We sought to determine whether racial disparities exist in MPR rates following NAT in patients with PDAC undergoing resection. METHODS Patients with potentially operable PDAC receiving at least 2 cycles of neoadjuvant FOLFIRINOX or gemcitabine/nab-paclitaxel ± radiation followed by pancreatectomy (2010-2019) at 7 high-volume centers were reviewed. Self-reported race was dichotomized as Black and non-Black, and multivariable models evaluated the association between race and MPR (i.e., pathologic complete response [pCR] or near-pCR). Cox regression evaluated the association between race and disease-free (DFS) and overall survival (OS). RESULTS Results of 486 patients who underwent resection following NAT (mFOLFIRINOX 56%, gemcitabine/nab-paclitaxel 25%, radiation 29%), 67 (13.8%) patients were Black. Black patients had lower CA19-9 at diagnosis (median 67 vs. 204 U/mL; P = 0.003) and were more likely to undergo mild/moderate chemotherapy dose modification (40 vs. 20%; P = 0.005) versus non-Black patients. Black patients had significantly lower rates of MPR compared with non-Black patients (13.4 vs. 25.8%; P = 0.039). Black race was independently associated with worse MPR (OR 0.26, 95% confidence interval [CI] 0.10-0.69) while controlling for NAT duration, CA19-9 dynamics, and chemotherapy modifications. There was no significant difference in DFS or OS between Black and non-Black cohorts. CONCLUSIONS Black patients undergoing pancreatectomy appear less likely to experience MPR following NAT. The contribution of biologic and nonbiologic factors to reduced chemosensitivity in Black patients warrants further investigation.
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Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Amber L Collier
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Khadeja Khan
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Iago de Castro Silva
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Deukwoo Kwon
- Department of Surgery, Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Patrick B Schwartz
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Alexander A Parikh
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Chet Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Hong J Kim
- Department of Surgery, Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Daniel Abbott
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Rebecca A Snyder
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Nipun B Merchant
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Jashodeep Datta
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA.
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37
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Concors SJ, Snyder RA. Accepting Our Technical Limitations: Intraoperative Bile Duct Margin in Perihilar Cholangiocarcinoma Reflects Disease Biology. Ann Surg Oncol 2023; 30:3180-3181. [PMID: 36737529 DOI: 10.1245/s10434-023-13200-4] [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: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Seth J Concors
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA.
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38
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Snyder RA, Katz MHG. Fundamentals of Conducting Cooperative Group Trials Through the National Clinical Trials Network. Surg Oncol Clin N Am 2023; 32:1-12. [PMID: 36410910 DOI: 10.1016/j.soc.2022.07.002] [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: 11/06/2022]
Abstract
This review discusses the benefits of performing multidisciplinary trials through the cooperative group mechanism, outlines the process from trial concept to activation, and discusses opportunities for surgeons to become involved in cancer cooperative trials.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite 4S-24, Greenville, NC 27834, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, Unit 1484, The University of Texas at MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Snyder RA. Survival Benefit of Neoadjuvant Therapy for Extrahepatic Cholangiocarcinoma: Real or Artifact? Ann Surg Oncol 2023; 30:15-17. [PMID: 35948852 DOI: 10.1245/s10434-022-12352-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East, Carolina University, 600 Moye Boulevard, Suite 4S-24, Greenville, NC, 27834, USA.
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Quinn AW, Snyder RA, Fu Y, Irish W, Parikh AA. Missed Appointments in Surgical Oncology: An Unmeasured but Important Outcome. J Am Coll Surg 2022. [DOI: 10.1097/01.xcs.0000894948.20919.84] [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: 11/25/2022]
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina
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Hao S, Mitsakos A, Popowicz P, Irish W, Snyder RA, Parikh AA. Differential effects of the Affordable Care Act on the stage at presentation and receipt of treatment for pancreatic adenocarcinoma. J Surg Oncol 2022; 126:698-707. [PMID: 35699593 DOI: 10.1002/jso.26984] [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: 03/28/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES For pancreatic ductal adenocarcinoma (PDAC) which lacks a recommended screening modality, the benefit of the Affordable Care Act (ACA) may not be an earlier diagnosis, but rather improved rates of treatment. The objective of this study was to examine change in the stage of PDAC presentation and treatment disparities following the ACA. METHODS A retrospective cohort study of patients with primary PDAC identified in the 2004-2017 National Cancer Database was divided into pre- and post-ACA, for which the primary outcomes of a stage of presentation, receipt of surgical resection, and systemic therapy (termed multimodality) (Stage I-II), and receipt of systemic therapy (Stage III-IV) were compared by multivariable analysis. RESULTS 228,015 patients were included. Odds of presenting with Stage I-II PDAC were significantly higher in 2011-2017 versus 2004-2010 (odds ratio 1.44, 95% confidence interval 1.40-1.47). Black patients with early-stage disease had a lower likelihood of multimodality therapy and those with advanced disease were less likely to receive systemic therapy, before and after the ACA. Uninsured patients were less likely to receive any therapy compared with insured patients; this disparity increased in the post-ACA period. CONCLUSIONS An earlier presentation of PDAC increased following the ACA. However, racial, insurance, and socioeconomic treatment disparities persist.
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Affiliation(s)
- Scarlett Hao
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Anastasios Mitsakos
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Patrycja Popowicz
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - William Irish
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Rebecca A Snyder
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Alexander A Parikh
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
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Wercholuk AN, Parikh AA, Snyder RA. The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population. JCO Oncol Pract 2022; 18:652-662. [DOI: 10.1200/op.22.00122] [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
Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.
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Affiliation(s)
- Ashley N. Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Alexander A. Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Rebecca A. Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC
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Hao S, Mitsakos A, Irish W, Tuttle‐Newhall JE, Parikh AA, Snyder RA. Differences in receipt of multimodality therapy by race, insurance status, and socioeconomic disadvantage in patients with resected pancreatic cancer. J Surg Oncol 2022; 126:302-313. [PMID: 35315932 PMCID: PMC9545601 DOI: 10.1002/jso.26859] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND METHODS: Racial and socioeconomic disparities in receipt of adjuvant chemotherapy affect patients with pancreatic cancer. However, differences in receipt of neoadjuvant chemotherapy among patients undergoing resection are not well-understood. A retrospective cross-sectional cohort of patients with resected AJCC Stage I/II pancreatic ductal adenocarcinoma was identified from the National Cancer Database (2014-2017). Outcomes included receipt of neoadjuvant versus adjuvant chemotherapy, or receipt of either, defined as multimodality therapy and were assessed by univariate and multivariate analysis. RESULTS Of 19 588 patients, 5098 (26%) received neoadjuvant chemotherapy, 9624 (49.1%) received adjuvant chemotherapy only, and 4757 (24.3%) received no chemotherapy. On multivariable analysis, Black patients had lower odds of neoadjuvant chemotherapy compared to White patients (OR: 0.80, 95% CI: 0.67-0.97) but no differences in receipt of multimodality therapy (OR: 0.89, 95% CI: 0.77-1.03). Patients with Medicaid or no insurance, low educational attainment, or low median income had significantly lower odds of receiving neoadjuvant chemotherapy or multimodality therapy. CONCLUSIONS Racial and socioeconomic disparities persist in receipt of neoadjuvant and multimodality therapy in patients with resected pancreatic adenocarcinoma. DISCUSSION Policy and interventional implementations are needed to bridge the continued socioeconomic and racial disparity gap in pancreatic cancer care.
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Affiliation(s)
- Scarlett Hao
- Department of SurgeryBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Anastasios Mitsakos
- Department of SurgeryBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
| | - William Irish
- Department of SurgeryBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
- Department of Public HealthBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
| | | | - Alexander A. Parikh
- Department of SurgeryBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Rebecca A. Snyder
- Department of SurgeryBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
- Department of Public HealthBrody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
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Snyder RA, Hu CY, DiBrito SR, Chang GJ. Association of Medicaid Expansion with Racial Disparities in Cancer Stage at Presentation. Cancer 2022; 128:3340-3351. [PMID: 35818763 DOI: 10.1002/cncr.34347] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study evaluates the independent association of Medicaid expansion on stage of presentation among patients of Black and White race with colorectal (CRC), breast, or non-small cell lung cancer (NSCLC). METHODS A cohort study of patients with CRC, breast cancer, or NSCLC (2009-2017) in the National Cancer Database was performed. Difference-in-differences (DID) analysis was used to compare changes in tumor stage at diagnosis between Medicaid expansion (MES) and non-expansion states (non-MES) before and after expansion. Predictive margins were calculated by race, year, and insurance status to account for effect heterogeneity. Stage migration was determined by measuring the combined proportional increase in stage I and decrease in stage IV disease at diagnosis. RESULTS Black patients gained less Medicaid coverage than White patients (6.0% vs 13.1%, p < 0.001) after expansion. Among Black and White patients, there was a shift towards increased early-stage diagnosis (DID 3.5% and 3.5%, respectively; p < 0.001) and decreased late-stage diagnosis (DID White: -3.5%; Black -2.5%; p < 0.001) in MES compared to non-MES following expansion. Overall stage migration was greater for White compared to Black patients with CRC (10.3% vs. 5.1%) and NSCLC (8.1% vs. 6.7%) after expansion. Stage migration effects in patients with breast cancer were similar by race (White 4.8% vs. Black 4.5%). CONCLUSION An increased proportion of Black and White patients residing in Medicaid expansion states presented with earlier stage cancer following Medicaid expansion. However, because the proportion of Black patients is higher in non-expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.,Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Chung-Yuan Hu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sandra R DiBrito
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Snyder RA, O'Reilly EM. Venous Thromboprophylaxis in Surgical Oncology Patients: The Importance of Risk Assessment in the Context of Limited Evidence. J Clin Oncol 2022; 40:2510-2511. [PMID: 35580296 DOI: 10.1200/jco.21.02935] [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: 11/20/2022] Open
Affiliation(s)
- Rebecca A Snyder
- Rebecca A. Snyder, MD, MPH, Brody School of Medicine at East Carolina University, Greenville, NC; and Eileen M. O'Reilly, MD, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Rebecca A. Snyder, MD, MPH, Brody School of Medicine at East Carolina University, Greenville, NC; and Eileen M. O'Reilly, MD, Memorial Sloan Kettering Cancer Center, New York, NY
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Snyder RA. Clinical Trial Eligibility Criteria: A Structural Barrier to Diversity in Clinical Trial Enrollment. J Clin Oncol 2022; 40:2183-2185. [PMID: 35427183 DOI: 10.1200/jco.22.00537] [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: 11/20/2022] Open
Affiliation(s)
- Rebecca A Snyder
- Brody School of Medicine at East Carolina University, Greenville, NC
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Lim SA, Hao SB, Boyd BA, Mitsakos A, Irish W, Burke AM, Parikh AA, Snyder RA. Opportunity Costs of Surgical Resection and Perioperative Chemotherapy for Locoregional Pancreatic Adenocarcinoma. JCO Oncol Pract 2022; 18:302-309. [PMID: 34709961 DOI: 10.1200/op.21.00311] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/16/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Given the perioperative morbidity and intensity of multimodality treatment, patients with resected pancreatic ductal adenocarcinoma (PDAC) spend a substantial amount of time in clinical care. The primary aim was to determine total time spent in multimodality care for patients with locoregional PDAC. METHODS A cohort study of all patients who underwent curative-intent resection for PDAC at a single-institution, tertiary care center was performed (2015-2019). Exact times for all relevant visits were abstracted from the primary medical record, and travel time was calculated. Care time was divided into preoperative, surgical, radiation, and systemic therapy phases of care. Primary outcome measures were the percentage of total survival time (TST) and percentage of overall survival (OS) days spent in receipt of care. RESULTS One hundred seven patients were included. Patients spent a median of 5.0% (interquartile range [IQR] 2.4%-10.1%) of TST and 11.0% (IQR, 5.7%-20.4%) of OS days in receipt of clinical care. Preoperative, surgical, radiation, and systemic therapy phases of care comprised a median of 0.9% (IQR, 0.4%-2.2%), 3.0% (IQR, 1.9%-6.8%), 4.4% (IQR, 3.6%-6.3%), and 10.0% (IQR, 6.2%-14.1%) of OS days. The median per-visit travel time was 60 minutes (IQR, 32-120), and the median cumulative travel time was 22.0 hours (IQR, 12.0-51.5). 12.1% (n = 13) and 7.8% (n = 4) of patients spent > 10% of TST in receipt of surgical and systemic therapy care, respectively. CONCLUSION Patients with locoregional pancreatic cancer spend a considerable percentage of their survival time in receipt of oncologic care. Further research to determine predictors of increased time burden is warranted to better inform shared decision making.
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Affiliation(s)
- Szu-Aun Lim
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Scarlett B Hao
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Breana A Boyd
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Anastasios Mitsakos
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - William Irish
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Aidan M Burke
- Department of Radiation Oncology, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Alexander A Parikh
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC
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Snyder RA. A Soft Spot. J Clin Oncol 2022; 40:2061-2062. [PMID: 35298292 DOI: 10.1200/jco.22.00068] [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: 11/20/2022] Open
Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
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Hao S, Reis HL, Wercholuk AN, Snyder RA, Parikh AA. Prehabilitation for Older Adults Undergoing Liver Resection: Getting Patients and Surgeons Up to Speed. J Am Med Dir Assoc 2022; 23:547-554. [PMID: 35247359 DOI: 10.1016/j.jamda.2022.01.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/09/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Morbidity rates following liver resection are high, especially among older adult patients. This review aims to evaluate the evidence surrounding prehabilitation in older patients anticipating liver resection and to describe how prehabilitation may be implemented. DESIGN Problem-based narrative review with case-based discussion. SETTING AND PARTICIPANTS All older adults anticipating liver resection inclusive of benign and malignant etiologies in the United States. METHODS Literature search was performed using MeSH terms and keywords in MEDLINE via PubMed, followed by a manual second search for relevant references within selected articles. Articles were excluded if not available in the English language or did not include patients undergoing hepatectomy. RESULTS Prehabilitation includes a range of activities including exercise, nutrition/dietary changes, and psychosocial interventions that may occur from several weeks to days preceding a surgical operation. Older adult patients who participate in prehabilitation may experience improvement in preoperative candidacy as well as improved postoperative quality of life and faster return to baseline; however, evidence supporting a reduction in postoperative length of stay and perioperative morbidity and mortality is conflicting. A variety of modalities are available for prehabilitation but lack consensus and standardization. For a provider desiring to prescribe prehabilitation, multidisciplinary assessments including geriatric, cardiopulmonary, and future remnant liver function can help determine individual patient needs and select appropriate interventions. CONCLUSIONS AND IMPLICATIONS In the older adult patient undergoing liver resection, the current body of literature suggests promising benefits of prehabilitation programs inclusive of functional assessment as well as multimodal interventions. Additional research is needed to determine best practices.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Heidi L Reis
- Health Sciences Library, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Ashley N Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA; Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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