Surgical subtype and survival in stage I chondrosarcoma: A National Cancer Database (NCDB) analysis

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Background: Chondrosarcoma is one of the most common primary malignancies of bone and commonly presents in adults in its early stages. Standard of care for chondrosarcoma is currently surgical intervention, with radiation therapy for cases where complete resection is not possible; chemotherapy is minimally effective. To the authors’ knowledge, there is little literature regarding different surgical subtypes for chondrosarcoma patients. To address this, the aim of our study is to assess survival outcomes in stage I chondrosarcoma patients based off of different surgical subtypes. Methods: Using the NCDB, patients diagnosed with stage I chondrosarcoma between 2004-2018 were identified using ICD-O-3 histology codes 9220 and 9221. The cohort was analyzed to determine if they received any form of surgical intervention and which surgical subtype they received. We then performed univariate analysis to assess patient length of survival for each surgical subtype. Data was analyzed using SPSS and statistical significance was set at α = 0.05. Results: A total of 5186 patients were included that had survival data, of which 4752 received surgical intervention. The mean survival time was 152.1 months for all patients. Surgical patients survived an average of 156.6 months while nonsurgical patients survived just 97.7 months (p < .0001). Analysis of surgical types revealed local destruction and local excision had the longest mean survival but were not different from each other (p > .05). Local excision had significantly longer survival than radical excision with limb sparing (p < .05). Local, partial, and radical excision all resulted in longer survival than limb and major amputations (all p < .01). Patients who underwent major amputation survived longer than limb amputation, but this difference was not significant (p > .05). Conclusions: This study found that receipt of surgery is associated with improved survival in chondrosarcoma patients. Receiving different surgical interventions may influence survival as patients receiving local excision survived longer than radical excision with limb sparing. Future studies should investigate additional variables that may influence receipt of surgery such as patient demographics, insurance status, and treatment facility type.[Table: see text]

Primary site and survival in chondrosarcoma: A National Cancer Database analysis

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Background: Chondrosarcoma is one of the most common primary malignancies of bone, accounting for around a fifth of all primary malignant bone tumors. These tumors typically affect the pelvis, hip, and shoulder but can arise anywhere that there is bone and cartilage (e.g. hands, feet, skull, etc.). To the authors’ knowledge, other primary sites have not been investigated in relation to its effect on survival outcomes. The aim of this study is to investigate this effect and see if there is any difference in survival amongst different primary sites in this patient population. Methods: Using the NCDB, patients diagnosed with chondrosarcoma between 2004-2018 were identified using ICD-O-3 histology codes 9220 and 9221. We analyzed the cohort to investigate survival outcomes in different primary sites. Univariate analysis was performed using SPSS to assess patient length of survival for each primary site. Statistical significance was set at α = 0.05. Results: A total of 7681 patients with known primary site that had survival data were included. The mean survival of the cohort was 140.3 months. The sites with the longest survival were the upper limb and the skull, face, and mandible, each of which had significantly longer survival than all other primary sites (all p < .01). The lower limb and ribs, sternum, and clavicle had the next highest survival which was significantly longer than the vertebral column and pelvis, sacrum, and coccyx (all p < .01). The vertebral column was the primary site with shortest survival with a median of 121 months. Conclusions: This study found significant survival differences between patients diagnosed with chondrosarcoma of different primary sites. Of all sites analyzed, the upper limb had the highest median survival of 187 months and showed statistical significance versus all other primary sites, and the vertebral column had the lowest median survival of 121 months. Future studies could be done regarding primary site to further elicit why there is such a large difference in survival, and can look at different imaging modalities used, time to treatment, and demographic and socioeconomic variables in each cohort.[Table: see text]

Primary site and survival in ewing sarcoma: A National Cancer Database (NCDB) analysis

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Background: Ewing sarcoma is the one of the most common primary malignancies of bone, with an incidence of about 1 case per million in the United States. Ewing sarcoma typically affects the pelvis, axial skeleton, and femur. However, this cancer can affect other bony regions and, to the author’s knowledge, all possible primary sites have not been investigated in-depth in regards to tumor location and the effect it may have on outcomes. The aim of this study is to conduct such an investigation to see whether or not the primary site of the tumor in osteosarcoma patients may have an effect on survival. Methods: Using the NCDB, patients diagnosed with Ewing sarcoma between 2004-2018 were identified using ICD-O-3 histology code 9260. The cohort was analyzed to investigate survival outcomes in different primary sites. Univariate analysis was then performed assessing patient length of survival for each primary site subtype. Data was analyzed using SPSS and statistical significance was set at α = 0.05. Results: A total of 4284 patients with known primary site that had survival data were included. The sites with the best survival were the skull, face, and mandible and upper limb. Patients with primary tumor of the skull, face, and mandible survived significantly longer than all groups other than the upper limb (all p < .01). Upper limb patients survived significantly longer than all groups other than the skull, face, and mandible and lower limb (all p < .05). The labeled primary site with the lowest survival was the pelvis, sacrum, and coccyx and significantly lower than the lower limb, vertebral column, and ribs, sternum, and clavicle (all p < .01). Survival of patients with primary site of the upper limb versus lower limb, and vertebral column versus ribs, sternum, and clavicle did not differ (each p > .05). Conclusions: This study found numerous survival differences between patients diagnosed with Ewing sarcoma of different primary sites. Labeled primary sites of the skull, face, and mandible and upper limb were associated with best survival while the pelvis, sacrum, and coccyx were associated with worst survival. Future studies may benefit from investigations into variables that may impact the survival differences we have presented including staging, treatments, time from diagnosis to treatment, and insurance status.[Table: see text]

Socioeconomic disparities in the receipt of palliative care in biliary tract cancers

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Background: Biliary tract cancers are tumors arising from epithelial cells lining the biliary tract including the intrahepatic bile duct, extrahepatic bile duct, gall bladder, and ampulla of Vater. The incidence of biliary tract cancers has over the years. While there have been several advances in the diagnosis and treatment of biliary tract cancers, palliative treatment remains important in the management of these cancers. This study aims to analyze the patterns associated with the receipt of palliative care in patients with biliary tract cancers. Methods: We conducted a retrospective review of 150,007 patients in the National Cancer Database diagnosed with biliary tract cancer between 2004-2018 using ICD-O3 codes. Chi-square tests were used to assess the differences between palliative care recipients and non-recipients. Logistic regression was used to assess which variables influence the likelihood of receiving palliative care. Statistical analyses were performed using SPSS. Results: The overall palliative care utilization amongst patients with biliary tract cancers was 13%. The use of palliative care in biliary tract cancers gradually increased over the years. Patients with gall bladder cancers were less likely to receive palliative care than those with intra-hepatic biliary duct cancers (OR 0.60 p < 0.001). Our study also found significant differences in the utilization of palliative care based on race. Blacks were less likely to use palliative care than whites (OR 0.89 p = 0.001). Hispanic patients were less likely to utilize palliative care than whites (OR 0.70 95% CI 0.64-0.76). There was no statistically significant difference between the use of PC between Whites and Asians (OR 1.04 95% CI 0.95-1.13 p < 0.441). Privately insured patients were less likely to receive palliative care than uninsured patients (OR 0.88 p = 0.029). There were no statistically significant differences between the receipt of palliative care in uninsured patients and Medicare or Medicaid patients (OR 0.98 p = 0.69; OR 1.00 p = 0.93). Patients belonging to households with a median income (> $63,333) were less likely to receive palliative care than those in low-income (< $40,000) household (OR 0.67 p < 0.001). There was an increased likelihood of receiving palliative care in patients from communities with higher educational status. Patients who received treatment at academic/research programs were more likely to receive palliative care than those at community cancer programs (OR 1.18 95% CI 1.08-1.29). Conclusions: Our study identified disparities in the receipt of palliative care in biliary tract cancers based on socioeconomic status. Blacks and Hispanics were less likely to receive palliative care than whites. Interestingly, uninsured patients were more likely to receive palliative care than privately insured patients. As part of quality improvement, future research should address the drivers behind these reported disparities.

Odds of stage IV bone cancer diagnosis based on socioeconomic and geographical factors

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Background: There are significant differences in prognosis for osteosarcoma, Ewing Sarcoma, chondrosarcoma, & chordomas based on stage at diagnosis. 5-year survival at early stage vs late stage is as follows; osteosarcoma 75% vs 27%, Ewing sarcoma 82% vs 39%, chondrosarcoma 78% vs 22%, and chordomas 87% vs 55%. This study seeks to evaluate the socioeconomic and geographical factors that affect the odds of late-stage bone cancer diagnosis. Methods: This study retrospectively evaluated the risk of stage I vs stage IV cancer at diagnosis in patients with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma & chordoma) diagnosed and recorded in the National Cancer Database (NCDB) between 2004 and 2018. Patients were identified by ICD-O-3 codes and patients with other malignancies were excluded. Cross Tabulations with Chi-square analysis was performed to evaluate frequencies of different socioeconomic and geographical characteristics between groups. Multivariable binary logistic regression was performed to evaluate relationships between socioeconomic and geographical factors and the odds of stage IV cancer. Statistical significance was set at α = 0.05. Results: 11,945 patients with stage I or stage IV primary malignant bone tumors were identified. Odds of stage IV bone cancer at diagnosis increased in patients of greater age (odds ratio [OR] = 1.011, 95% confidence interval [CI]: 1.003-1.018). Odds of stage IV bone cancer at diagnosis were decreased with female sex (OR = 0.747, 95% CI: 0.647-0.862), private insurance (OR = 0.519, 95% CI: 0.367-0.732), Medicare insurance (OR = 0.664, 95% CI: 0.456-0.965), or with diagnosis at comprehensive cancer center programs (OR = 0.549, 95% CI: 0.371-0.814), academic/research programs (OR = 0.339, 95% CI: 0.232-0.495), or integrated cancer network programs (OR = 0.392, 95% CI: 0.261-0.587). No significant relationship was identified between stage at diagnosis and race, ethnicity, Charlson-Deyo score, income, education, region, travel distance, or urban/rural status. Conclusions: Odds of stage IV bone cancer at diagnosis are greater with increasing age, male sex, non-private or non-Medicare insurance status, or treatment at community cancer programs.

Non-hepatocellular carcinoma management: A SEER database analysis

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Background: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, however, chronic viral hepatitis and cirrhosis place patients at an increased risk for non-HCC malignancies as well. A major treatment option for these tumors is local tumor destruction via a number of minimally invasive techniques available to interventional radiologists. This study assessed the prognostic impact of various liver-directed local tumor therapies in the management of non-HCC liver cancer. Methods: We searched the SEER-18 database for malignant liver cancers not coded as HCC (8170-8175) that were diagnosed between 2000-2018. Patients were excluded if the cause of death was not associated with their cancer according to SEER’s cancer-specific death categorization. The SEER database tracks survival up to 60 months. SPSS was used for all descriptive and univariate survival statistics. Results: A total of 228 patients were collected from this search. 59.6% of cases were from males and the average age was 64 years old (median = 65). 60.1% were in non-Hispanic White patients, followed by Hispanic (16.2%), non-Hispanic Asian or Pacific Islander (14.0%), and non-Hispanic Black (9.2%) patients. Of the 170 patients with staging coded, 62.9% were local, 24.7% were regional, and 12.4% were distant. 36.8% of patients received some form of chemotherapy, while only 3.1% received radiation. When grouped by age range (< 49, 50-69, 70+), survival did not differ between groups. Sex also did not influence survival (p = .325). Patients that received chemotherapy had worse outcomes, likely due to worse staging which was negatively associated with survival (p < .05). Radiation did not significantly improve survival. Of the local tumor destruction therapies, Heat-Radio-Frequency ablation (RFA) (n = 150) improved survival significantly in comparison to: local tumor destruction not otherwise specified (n = 42), photodynamic therapy (n = 1), electrocautery (n = 4), cryosurgery (n = 4), and ultrasound or acetic acid (n = 15) (all p < 0.05). Laser surgery (n = 3) and intratumoral injection of alcohol (n = 9) had no significant outcome differences. RFA had an estimated mean survival time of 35.7 months while all other interventional radiology modalities combined had a mean estimated survival time of 21.4 months (p < .000). Conclusions: Though limitations of a small sample size and univariate statistical analyses were present in this study, RFA likely has improved survival compared to other interventional radiology modalities used in the treatment of non-HCC liver cancer.

Survey of Palliative Care Use in Primary Malignant Bone Tumors: A National Cancer Database Review

Background/Objectives: Palliative care (PC) has been associated with reduced patient symptom burden, improved physician satisfaction, and reduced cost of care. However, its use in primary bone tumors has not been well classified. Design/Setting and Subjects: Patients diagnosed with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma, and chordoma) between 2004 and 2018 were identified in the National Cancer Database. Cross tabulations with chi-square analysis were performed to evaluate frequencies of PC use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of PC. Results: Around 24,401 patients were identified. Overall, 2.52% had any form of PC utilization. Of those receiving PC, 55.5-65.1% were treated with only noncurative surgery, radiation, chemotherapy, or any combination of these modalities. Odds of PC utilization were decreased for patients with chordomas, patients living >24 miles from the treatment facility, or patients with private insurance, Medicare, or unknown insurance status. Odds of PC utilization were increased in patients with greater tumor diameter or unknown tumor size, tumors in midline, increased tumor grade, stage IV tumors, or living in urban areas. Conclusion: PC use in patients with primary bone tumors increases with tumor stage, tumor grade, tumor size, and if the tumor is midline, and in patients living in urban areas. However, overall utilization remains markedly low. Future studies should be done to investigate these patterns of care and help expand the utilization of PC.

Dalhousie honors sir charles tupper

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Surgical subtypes and survival in Ewing sarcoma: A National Cancer Database (NCDB) analysis

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Background: Ewing sarcoma (EWS) is the one of the most common primary malignancies of bone, more commonly affecting the pediatric population Standard of care for EWS currently involves surgical intervention in combination with chemotherapy, in addition to the potential use of preoperative and/or postoperative radiation on a case by case basis. To date, there is not much in the literature reported regarding different surgical subtypes in these patients. Thus, this study aims to analyze survival outcomes amongst the different surgical subtypes in EWS patients. Methods: Using the NCDB, patients diagnosed with EWS between 2004-2018 were identified using ICD-O-3 histology code 9260. The cohort was analyzed to determine if they received any surgical intervention and, if so, which surgical subtype was used. Univariate analysis was then performed assessing patient length of survival for each surgical subtype. Data was analyzed using SPSS and statistical significance was set at α = 0.05. Results: A total of 2208 patients were included that had survival data and had received surgical intervention. The mean survival time of all patients was 118.1 months. Surgical patients survived an average of 137.2 months while nonsurgical patients survived 96.0 months on average (p < .00001). Analysis of surgical subtypes revealed significantly longer survival in patients who underwent radical excision with limb salvage compared to patients who underwent partial resection (p < .05). Patients who received a partial limb amputation survived significantly longer than patients who received a total limb amputation (p < .01). Patients who underwent local tumor excision or radial excision with limb salvage also survived significantly longer than patients with total limb amputation (p < .05 and p < .01, respectively). Conclusions: This study found that receipt of surgery is associated with longer survival in Ewing sarcoma patients. Further, different surgical interventions may influence survival in Ewing sarcoma as patients receiving radical excision with limb salvage fared better than partial resection and partial limb amputation better than total limb amputation. Future studies would benefit from investigating additional variables that may influence receipt of surgical interventions including patient demographics, socioeconomic status, and surgical center type.[Table: see text]

Survival trends of patients with Paget disease of the breast: A National Cancer Database (NCDB) study

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Background: Paget disease of the breast is a malignant tumor that comprises only 1-3% of all breast carcinomas. It may coexist with an underlying ductal carcinoma in situ or present alone without additional carcinomas. Due to the rarity of this carcinoma and minimal literature available, we intend to identify potentially important prognostic factors, particularly those of socioeconomic origin. Methods: We performed a retrospective investigation of 5,918 patients diagnosed with Paget Disease of the breast from the NCDB between 2004-2018. Patient demographic and clinical characteristics such as household income, insurance status, treatment center type, and treatment center location were extracted from the database. Survival rates were compared using Kaplan-Meier curves, log-rank test, univariate and chi-square analysis. Data were analyzed using SPSS statistics 27. Results: African American patients had higher mortality rates than Caucasian patients (p < 0.005). Patients with underlying intraductal carcinoma of the breast had the highest survival rates (p < 0.001). Patients who received immunotherapy as part of the treatment plan had a significantly higher survival rate than those who did not (136.97 vs. 144.24 months respectively, p < 0.001). Patients coming from lower median household incomes had significantly lower survival rates. Specifically, patients with a household income of less than $38,000 had a lower mean survival rate compared to those with a household income of greater than $63,000 (122.74 months compared to 140.63, respectively, p < 0.001). Those with private insurance had a higher mean survival time than those with Medicaid and no insurance (170.60, 138.13, and 130.69 months respectively, p < 0.001). Patients from counties in metro areas with populations of 1 million or more had a significantly higher survival rate than those from counties in metro areas with less than 1 million (p < 0.003). In addition, patients treated at academic centers had a higher mean survival rate than those treated at non-academic centers (p < 0.001). Conclusions: Our results show significant variation in survival rates among patients based on their socioeconomic and treatment center characteristics. Additional research targeting patients with these characteristics can lead to improved clinical outcomes.

Treatment facility: Effects on stage IV osteosarcoma survival

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Background: Osteosarcoma is a malignant, bone-forming tumor that makes up approximately 20% of bone cancers. Osteosarcoma has an overall 5-year survival of 68%, so to see significant changes in survival, this study looks only at Stage IV osteosarcoma. Osteosarcoma is most commonly treated with a combination of chemotherapy and surgery, but no studies have been conducted to investigate the facility type at which treatment is received and its effect on survival outcomes. The goal of this study is to investigate the survival of patients with stage IV osteosarcoma based on treatment facility type. Methods: There were 1,634 patients with stage IV osteosarcoma identified in the National Cancer Database (NCDB), with 657 including data on facility type. SPSS version 27 was used to generate both descriptive statistics regarding demographics and Kaplan-Meier curves to determine the impact treatment facility type has on overall survival. Results: Stage IV osteosarcoma was more common in males (59.5%) and white race (77%) with 55.4% receiving treatment at academic centers, 22.5% at comprehensive community programs, 16.9% at integrated cancer programs, and 5.2% at community cancer programs. Patients on Medicare also demonstrated a decreased overall survival when compared to all other insurance types (p < 0.001). In stage IV osteosarcoma patients, there were statistically significant differences in survival outcomes when comparing each facility type to each other (with p values all < 0.05), except for the comparison between comprehensive community cancer programs and integrated network cancer programs. Patients who received treatment at academic/research programs demonstrated the best overall survival with a median of 7.29 months when compared to community center programs, comprehensive community cancer programs, and integrated network programs (with p values of < 0.001, 0.046, and 0.03, respectively). Patients treated at academic research programs were more likely to be white males with private insurance or Medicare. Conclusions: Patients treated at academic centers for stage IV osteosarcoma had better survival outcomes compared to those treated at nonacademic facilities. These patients were more likely to be white, insured individuals. African Americans and Medicare patients were associated with increased risk of mortality from stage IV osteosarcoma. Future studies can be done with multivariate analyses to determine other variables that may affect outcomes in this patient population.[Table: see text]

Ethics, jurisprudence, and economics in the medical school curriculum

Medical ethics, medical jurisprudence, and medical economics are recognized as important components of a medical school curriculum. These subjects were introduced through a course given at the University of California, Davis, School of Medicine. Four aspects of the format and content of the course were instrumental to its success. Teaching principles of medical ethics within the context of jurisprudence and economics permitted the students to gain an understanding of the institutions and processes that act as positive and negative constraints on physicians' clinical and professional behavior. The course was offered during the fourth year following required clinical rotations so that all aspects of the course could be based on the clinical experiences of the students. It was presented in a continuing medical education format away from the normal teaching environment of first- and second-year classrooms and third-year clerkships. Finally, the course was designed by a multidisciplinary, multidepartmental planning group that included students.

Extent of Surgery and Survival of Osteosarcoma: A Retrospective Population-Based Study

Background Osteosarcoma (OSC) is the most common primary bone tumor and is often managed surgically. Few prior investigations have assessed differences in OSC survival by specific surgical techniques at a national registry level. We sought to compare survival based on surgical subtypes for OSC patients in the Surveillance, Epidemiology, and End Results (SEER) database. Methodology We searched the SEER database for malignant OSCs diagnosed between 2000 and 2019 which were surgically managed. Separate survival comparisons were made for one and five years for wide excision (local tumor destruction or resection versus partial resection) and radical excision (radical resection with limb-sparing versus limb amputation with or without girdle resection). Results A total of 4,303 patients were included, of whom 3,587 were surgically managed. There were no survival differences between local destruction and partial resection (hazard ratio = 0.826, p = 0.303). However, younger age, lower staging, and management without radiation were associated with improved survival. The radical excision comparison showed limb amputation was associated with worse survival than limb-sparing surgery (hazard ratio = 1.531, p < 0.001). Younger age, female sex, lower stage, receipt of chemotherapy, and neoadjuvant plus adjuvant chemotherapy were associated with improved survival while Black and American Indian or Alaska Native were associated with worse survival. Conclusions Our findings show that patients managed with limb-sparing radical resection survived significantly compared to limb amputation. There were no differences in survival for wide excision surgeries. The use of a combination of neoadjuvant and adjuvant chemotherapy also yields improved survival. OSC survival may be optimized with limb-sparing surgery with a combination of neoadjuvant and adjuvant chemotherapy.