Cancer-directed Surgery Research Articles

Differences in Cancer Care Expenditures and Utilization for Surgery by Hospital Type Among Patients With Private Insurance

With rising expenditures on cancer care outpacing other sectors of the US health system, national attention has focused on insurer spending, particularly for patients with private insurance, for whom price transparency has historically been lacking. The type of hospital at which cancer care is delivered may be an important factor associated with insurer spending for patients with private insurance. To examine differences in spending and utilization for patients with private insurance undergoing common cancer surgery at National Cancer Institute (NCI) centers vs community hospitals. This retrospective cross-sectional study included adult patients with an incident diagnosis of breast, colon, or lung cancer who underwent cancer-directed surgery from 2011 to 2014. Mean risk-adjusted spending and utilization outcomes were examined for each hospital type using multilevel generalized linear mixed-effects models, adjusting for patient, hospital, and region characteristics. Data were collected from the Health Care Cost Institute's national multipayer commercial claims data set, which encompasses claims paid by 3 of the 5 largest commercial health insurers in the United States (ie, Aetna, Humana, and UnitedHealthcare). Data analyses were conducted from February 2018 to February 2019. Hospital type at which cancer surgery was performed: NCI, non-NCI academic, or community. Spending outcomes were surgery-specific insurer prices paid and 90-day postdischarge payments. Utilization outcomes were length of stay (LOS), emergency department (ED) use, and hospital readmission within 90 days of discharge. The study included 66 878 patients (51 569 [77.1%] women; 31 585 [47.2%] aged ≥65 years) with incident breast (35 788 [53.5%]), colon (21 378 [32.0%]), or lung (9712 [14.5%]) cancer undergoing cancer surgery at 2995 hospitals (5522 [8.3%] at NCI centers; 10 917 [16.3%] at non-NCI academic hospitals; 50 439 [75.4%] at community hospitals). Treatment at NCI centers was associated with higher surgery-specific insurer prices paid compared with community hospitals ($18 526 [95% CI, $16 650-$20 403] vs $14 772 [95% CI, $14 339-$15 204]; difference, $3755 [95% CI, $1661-$5849]; P < .001) and 90-day postdischarge payments ($47 035 [95% CI, $43 289-$50 781] vs $41 291 [95% CI, $40 350-$42 231]; difference, $5744 [95% CI, $1659-9829]; P = .006). There were no significant differences in LOS, ED use, or hospital readmission within 90 days of discharge. In this cross-sectional study, surgery at NCI centers vs community hospitals was associated with higher insurer spending for a surgical episode without differences in care utilization among patients with private insurance undergoing cancer surgery. A better understanding of the factors associated with prices and spending at NCI cancer centers is needed.

Impact of surgeon type and rurality on treatment and survival of ovarian cancer patients

<h3>Objectives:</h3> We aimed to determine if rurality impacts type of surgeon and estimate if the interaction between rurality and type of surgeon impacts cytoreductive surgery, chemotherapy initiation, and survival. <h3>Methods:</h3> Our population-based cohort of Iowan (N=675) ovarian cancer patients included women diagnosed with histologically confirmed stages IB-IV cancer in 2010-2016 at the ages of 18-89 years old and who received cancer-directed surgery in Iowa. Multivariable logistic regression analysis was used to determine the independent impact of rurality on type of surgeon, and the interaction between rurality and type of surgeon on cytoreductive surgery and chemotherapy initiation. Cox proportional hazards models were used to assess if the interaction between rurality and type of surgeon impacted 3-year all-cause and cause-specific mortality. <h3>Results:</h3> 83% (N=563) of Iowans who received in-state surgical care had a gynecologic oncologist surgeon. Rural patients had lower odds of having a gynecologic oncologist (adjusted odds ratio (aOR) 0.48; 95% confidence interval (CI) 0.30-0.78). Compared to rural patients with a non-gynecologic oncologist, rural and urban patients with a gynecologic oncologist surgeon were more likely to receive guideline-recommended cytoreduction (aOR 2.84, 2.58; 95% CI 1.31-6.14, 1.29-5.16, respectively) and chemotherapy (aORs 4.22, 7.94; 95% CI 1.82-9.78, 3.64-17.3, respectively). Compared to urban patients with a non-gynecologic oncologist, rural and urban patients with a gynecologic oncologist were more likely to receive cytoreduction (aORs 4.60, 4.19; 95% CI 2.13-9.94, 2.11-8.33, respectively) and urban patients with a gynecologic oncologist were more likely to receive chemotherapy (aOR 4.03; 95% CI 1.73-9.37). Rural patients with a non-gynecologic oncologist had the lowest 3-year cause-specific survival estimates controlling for patient/tumor factors. Urban patients with a non-gynecologic oncologist had higher 3-year cause-specific survival estimates than urban patients with a gynecologic oncologist. These differences became non-significant when controlling for treatment covariates. <h3>Conclusions:</h3> Rural patients were less likely to receive surgery from a gynecologic oncologist. Patients with non-gynecologic oncologist surgeons had lower odds of chemotherapy initiation and cytoreductive surgery. Gynecologic oncologist-provided surgery conferred a 3-year cause-specific survival advantage among rural patients and a survival disadvantage among urban patients in the model without treatment covariates. The significance dissipated when treatment variables were added to the model. The variation in the gynecologic oncologist survival advantage may be due to treatment differences, referral differences and/or differences in non-gynecologic oncologist volume or specialty by rurality. This is the first study to investigate the ovarian cancer survival advantage of having a gynecologic oncologist surgeon by rurality. Interventions are needed to determine the cause of variation by rurality and to ensure rurality does not impact treatment or survival.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study.

The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Hormone Receptor Status May Impact the Survival Benefit Between Medullary Breast Carcinoma and Atypical Medullary Carcinoma of the Breast: A Population-Based Study.

BackgroundA rare subtype of breast cancer, atypical medullary carcinoma of the breast (AMCB), shows a highly adverse prognosis compared to medullary carcinoma of the breast (MBC). The current study aimed to establish a correlated nomogram for the identification of the prognostic factors of AMCB and MBC.MethodsKaplan–Meier and Cox regression analyses were applied to data acquired from the Surveillance, Epidemiology and End Results (SEER) database for 2004 to 2013 to analyse tumour characteristics and overall survival. Propensity score matching (PSM) analysis was performed to determine the overall survival (OS) among those with AMCB and MBC. A predictive nomogram was created, and the concordance index (C-index) was used to predict accuracy and discriminative ability.ResultsA total of 2,001 patients from the SEER database were diagnosed with MBC between 2004 and 2013, including 147 patients diagnosed with AMCB. The number of diagnoses gradually increased in both groups. Cox analysis of multivariate and Kaplan–Meier analysis showed that older age (HR = 3.005, 95% CI 1.906–4.739) and later stage were significantly associated with poor prognosis, while cancer-directed surgery was an independent protective factor (HR = 0.252, 95% CI 0.086–0.740). In the HR-negative stratification analysis, older age (HR = 2.476, 95% CI 1.398–4.385), later stage and histological type (HR=0.381, 95% CI 0.198-0.734) were found to be independent prognostic factors for low standard survival. The log-rank analysis demonstrated significantly worse prognostic factors for patients with AMCB than for those with MBC (P = 0.004). A nomogram (C-index for survival = 0.75; 95% CI 0.69–0.81) was established from four independent prognostic factors after complete identification.ConclusionsMBC is rare, and cancer-directed surgery, older age, and later stage are independently linked with prognosis. In the HR negative population, AMCB patients show a worse survival gain than those with MBC.

Location Matters in Nodal Diffuse Large B-Cell Lymphoma

▪Diffuse large B-cell lymphoma (DLBCL) is the most common type of B-cell lymphoma in the United States. The introduction of rituximab has significantly improved outcomes in the treatment of DLBCL. However, relapsed and refractory cases still pose a challenge. More recently, our understanding of the biology of DLBCL has evolved such that assessment of molecular risk through evaluation of the cell of origin and specific genetic mutations are being incorporated into prognostication and treatment decisions. The location of extranodal involvement has been implicated in the prognosis, but the prognostic relevance of the location of lymphadenopathy has not been extensively investigated.MethodsWe used the Surveillance, Epidemiology, and End Results (SEER) database to extract cases of nodal DLBCL from 1983 to 2014. The SEER database considers spleen and Waldeyer's Ring (WR) as nodal, so they were included in the extraction. A total of 71,132 cases were identified. Cases without follow-up, with unknown Ann-Arbor stage (extranodal involvement is not included in the database), with more than one primary tumor, without histologic confirmation of the disease, and with an unspecified location or lymph nodes in multiple regions, were excluded. Age was categorized into the following groups: 20-39,40-59, 60-75, and >75 years. Treatment characteristics for included patients were extracted and cases were dichotomized based on the year of diagnosis; 2000 was used as a cut-off because the first landmark study evaluating R-CHOP was presented at the American Society of Hematology (ASH) meeting in December of that year. Survival curves were estimated by the Kaplan-Meier method and were compared using the log-rank test. A Cox proportional hazard model was constructed to identify the hazard ratios (HR) for each location. ANOVA was used to adjust for age, stage, gender, race, year of diagnosis, administration of chemotherapy, administration of radiation, and cancer-directed surgery. A chi-square test was utilized to compare categorical variables. Proportionality was tested with Schoenfeld residuals. Statistical analysis was performed with R statistics.ResultsA total of 18,870 cases were included in the analysis. The majority of these cases were located in the head/face neck (28%) and abdomen/retroperitoneum (27%).The overall 5-year DLBCL-specific survival (DSS) was 65%. The location of lymphadenopathy was predictive of outcome after adjusting for all other factors (p<.001). In the total cohort, involvement of WR was associated with better survival (79%) and involvement of the abdomen with the poorest survival (51%). Similar results were produced by the Cox model with WR having the best survival (referent) whereas the abdomen had the worst (hazard ratio 1.92, 95% CI 1.69-2.18). When comparing the pre-rituximab and post-rituximab data, the survival of patients from all locations improved, apart from patients who had pelvic lymphadenopathy (HR 0.77, 95% CI 0.55-1.08, p= 0.12). WR and abdomen retained the best and the worst survival, respectively, in both eras. Kaplan-Meier curves for all cases since 1983 are presented in Figure A, whereas the results of the Cox model are presented in Table B . Patients who were diagnosed with DLBCL in the thorax were much younger than all other patients combined (39% vs 8% in 20-39 years, p < .001).ConclusionsThis is the first large study demonstrating a statistically significant difference in survival for patients with nodal DLBCL depending on the primary location of their disease. One possible explanation is that patients with intrathoracic or intraabdominal disease are more vulnerable to vital organ compromise. WR cases probably include cases of large B-cell lymphoma with IRF4 rearrangement, which have a better prognosis. In addition, primary mediastinal B-cell lymphoma was a separate entity in SEER after 2001, so many cases of thoracic DLBCL prior to that date could actually be the former. Further investigation and validation in other cohorts incorporating molecular studies is warranted before this information can be incorporated into prognostic tools. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Barriers to web-based symptom management systems (web-SyMS).

6545 Background: Web-SyMS can reduce the burdens of cancer and its treatment. While patients frequently express willingness to use these systems, only a subset actively engages with them. Some patients may lack the tools and confidence needed to benefit from web-SyMS. We sought to characterize these barriers among community-based cancer patients receiving care across six diverse healthcare systems. Methods: We surveyed patients receiving chemotherapy at three healthcare systems (Baptist, TN; Maine Medical, ME; Dana-Farber, MA) and patients recovering from cancer-directed surgery at three healthcare systems (West Virginia University, WV; Dartmouth-Hitchcock, NH; Lifespan, RI). Surveys were conducted as part of a pre-implementation analysis of eSyM – an EHR-embedded web-SyMS that collects, tracks, and manages patient reported outcomes during cancer therapy. Results: Among 563 respondents, access to tech devices (i.e., tablet, computer, or smartphone) was high: 78% reported access to ≥2 devices and only 5% reported access to no devices. However, confidence using tech devices to accomplish online tasks varied: 45% very confident, 38% somewhat confident, 11% little-no confidence. Compared to medical oncology patients, surgery patients were more likely to report being very confident (57% vs. 31%). There were significant differences based on patients’ self-reported tech confidence (Chi-square P&lt;.05 for all values in the table). Conclusions: Low self-reported tech confidence may identify patients who are at high risk for experiencing the burdens of cancer but may be less likely to benefit from web-SyMS. Addressing this barrier is critical to improving outcomes and addressing disparities. Clinical trial information: NCT03850912. [Table: see text]

Investigating reasons for discontinuation of first-line adjuvant chemotherapy among ovarian cancer patients in the midwestern United States.

e17523 Background: Receipt of surgery and adjuvant chemotherapy greatly impact survival outcomes for ovarian cancer, the deadliest gynecologic malignancy with a high recurrence/progression rate. Most patients receive first-line, platinum-based chemotherapy. Platinum-based chemotherapy causes severe side effects, including nephrotoxicity and myelosuppression. Evidence for other chemotherapeutic agents is lacking and options are limited for women who cannot tolerate first-line chemotherapy. We aimed to determine the prevalence of premature first-line chemotherapy discontinuation and to detail reasons for discontinuation. Methods: We used the population-based cohort, Patterns of Ovarian Cancer Care and Survival in the Midwestern Region of the United States—a CDC Investigation, comprised of women diagnosed with histologically confirmed, stage IB-IV ovarian cancer in 2010-2012 in the Midwestern United States (i.e., Iowa, Kansas and Missouri) between the ages of 18 and 89 years. We limited the cohort to patients who received cancer-directed surgery and initiated adjuvant chemotherapy. Chemotherapy lines, completion, and reasons for discontinuation were abstracted from patient medical records by cancer registrars using standardized protocols. Results: Nineteen percent (N= 107/559) of ovarian cancer patients who initiated adjuvant chemotherapy did not complete first-line treatment. Reasons for chemotherapy discontinuation included toxicity or other kinds of intolerance (39%), poor quality of life or comorbid conditions (19%) or exhibited no response (17%) (Table). No significant differences were observed between gynecologic oncologists and non-gynecologic oncologist chemotherapy providers (p=0.109). Conclusions: One in 5 women who initiated did not complete first-line chemotherapy. Reasons were varied and suggested that lack of tolerance is not the only factor in discontinuation. Lack of response and the presence of comorbid conditions are considerations that can be taken into account during decision-making processes for treatment. More clinical research into additional chemotherapy options that may be useful in these patients is necessary.[Table: see text]

Association of rurality and race with surgical treatment and outcomes for nonmetastatic colon cancer.

e18536 Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure was rurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days of surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR=1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR=0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. The association between rurality and 90-day outcomes differed by race/ethnicity (p-interaction=0.001 for surgical complications and mortality, see Table). Hispanics and other races had higher odds of 90-day surgical complications in non-metro versus metro areas but there was no notable difference for white patients. Likewise, compared to metro areas, racial/ethnic minorities had higher odds of 90-day mortality in small town/rural areas but white patients had lower odds. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and worse outcomes, especially among non-white patients. The compounded effect of sociodemographic factors should be further studied to develop targeted policies and improve care for rural cancer patients.[Table: see text]

Malignant pleural mesothelioma: Comparison of surgery-based trimodality therapy to medical therapy at two tertiary academic institutions

ObjectivesMedical management based on palliative chemotherapy is currently the standard of care in malignant pleural mesothelioma (MPM). Median survival of 12–16 months has been reported with modern chemotherapy regimens with or without anti-angiogenic agents. Multimodality therapy incorporating cytoreductive surgery, systemic chemotherapy and radiotherapy has been offered for years to fit patients with early-stage disease, but its role remains debated. Our objective was to compare overall survival in patients offered multimodality therapy in a specialized clinic setting in London, UK to that of patients offered exclusively medical treatment at another academic institution in Quebec, Canada. Materials and MethodsWe retrospectively compared the survival rates of 2 separate cohorts of patients treated consecutively: Cohort 1 (n = 106) received multimodality therapy including systemic chemotherapy, extended pleurectomy/decortication (P/D) and prophylactic radiotherapy in London (United Kingdom) between 2009 and 2016, while Cohort 2 (n = 98) received medical treatment at the Quebec Heart and Lung Institute (Canada) during the same period. ResultsIn Cohort 1, all patients but two completed trimodality therapy. In cohort 2, 51 % received palliative care only and 40 % received systemic chemotherapy. Median survival was 32 months vs 10 months in Cohort 1 and Cohort 2, respectively (hazard ratio with age, gender, pathology and TNM staging as covariates: 3.81; 95 % CI: 2.67–5.45; p < 0.0001). Similar results were obtained in sensitivity analyses, after excluding those who received best supportive care only and in a propensity score-matched analysis. ConclusionAggressive therapy of MPM using cancer-directed surgery, systemic chemotherapy and prophylactic radiotherapy may provide a significant survival benefit in selected patients.

Refusal of cancer-directed surgery in male breast cancer.

It has been reported that some male breast cancer patients may refuse the recommended surgery, but the incidence rate in the United States is not clear. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with the rejection of such cancer-directed surgery.We collected data on 5860 patients with male breast cancer (MBC) from the Surveillance, Epidemiology, and End Results database, including 50 patients refusing surgery as recommended. Kaplan–Meier survival analysis and Cox proportional hazard regression were used to identify the effects of refusing surgery on cancer-specific survival (CSS) and overall survival (OS). The association between acceptance or rejection of surgery and mortality were estimated by nested Cox proportional hazards regression models with adjustment for age, race, clinical characteristics, and radiation.Of the 5860 patients identified, 50 (0.9%) refused surgery. Old age (≥65: hazard ratio [HR]: 3.056, 95% confidence interval [CI]: 1.738–5.374, P < .0001), higher AJCC stage (III: HR: 3.283, 95% CI: 2.134–5.050, P < .0001, IV: HR: 14.237, 95% CI: 8.367–24.226, P < .0001), progesterone receptor status (negative: HR: 1.633, 95% CI: 1.007–2.648, P = .047) were considered risk factors. Compared with the surgery group, the refusal group was associated with a poorer prognosis in both OS and CSS (χ2 = 94.81, P < .001, χ2 = 140.4, P < .001). Moreover, significant differences were also observed in OS and CSS among 1:3 matched groups (P = .0002, P < .001).Compared with the patients undergoing surgery, the patients who refused the cancer-directed surgery had poor prognosis in the total survival period, particularly in stage II and III. The survival benefit for undergoing surgery remained even after adjustment, which indicates the importance of surgical treatment before an advanced stage for male breast cancer patients.

Survivorship and prognostic factors for pleomorphic liposarcoma: a population-based study

BackgroundPleomorphic liposarcoma is the least common but most aggressive subtype of liposarcoma. Very few studies have presented data on pleomorphic liposarcoma specifically, often including a limited number of cases and short-term follow-up. As a result, the survivorship and prognostic characteristics of this tumor remain incompletely identified.Study design and settingCross-sectional analysis of the Surveillance Epidemiology and End Results database (1996–2015).ResultsOverall survival for the entire series was 54% (95% confidence interval [CI], 49–58%) and 40% (95% CI, 35–45%) at 5 and 10 years, respectively. Disease-specific survival for the entire series was 60% (95% CI, 56–65%) and 53% (95% CI, 48–58%) at 5 and 10 years, respectively. Patients who survived 10 years or more were more likely to die of events unrelated to pleomorphic liposarcoma. Univariate and multivariate analysis demonstrated that not receiving cancer-directed surgery was an independent poor prognostic factor. Older age (≥ 65 years old) was associated with worse overall survival but not disease-specific survival. Tumor stage and radiotherapy showed different impact on survival depending on tumor size. In comparison to localized staged tumors, regional stage only predicts poor survival in patients with tumor size less than 5 cm, while distant stage is an independent worse prognosis factor. Radiotherapy only benefits patients with tumor size larger than 10 cm. These results were confirmed in competing risk analysis.ConclusionSurvival rates of patients with pleomorphic liposarcoma has not changed over the past 20 years. Patients with distant stage have poor prognosis; regional stage indicates worse survival in patients with tumor size less than 5 cm. Receiving surgery could prolong the survival, while radiotherapy only benefits patients with large tumor size (> 10 cm). Older age is associated with poor overall survival but not disease-specific survival. Routine patient surveillance following initial diagnosis should at least be 10 years for pleomorphic liposarcoma.

P10.03 Health Insurance Coverage and Racial Disparities in Early-Stage Detection and Treatment of Lung Cancer: A Causal Mediation Analysis

Racial minority patients were more likely to be diagnosed an advanced-stage disease at presentation, and received less cancer-directed surgery and other standard care. We hypothesized that access to adequate health insurance coverage among patients with lung cancer play an important role in these racial disparities, because many previous studies have shown a significant association between lack of insurance status and poor cancer outcomes. A total of 346,733 patients with lung cancer diagnosed between 2007-2015 from the Surveillance, Epidemiology, and End Results 18 registry were enrolled in our analyses. We conducted univariate and multivariate and logistic regressions to assess the association between race and the risk of being diagnosed at advanced-stage lung cancer (AJCC stage III, or IV), receipt of cancer-direct surgery and no treatment. Mediation analyses were conducted to quantify the proportion of which health insurance coverage is a factor in these racial disparities of lung cancer outcomes. Patients from Asian or Pacific Islander, NHB, and Hispanic were more likely to present with advanced-stage lung cancer compared with NHW patients. About 10-20% of the disparity between patients from racial/ethnic minority and NHW could be explained by having no insurance or only Medicaid. Cancer-directed surgery was less conducted for racial/ethnic minorities than NHW patients. Over 30% of the effect was mediated by the insurance status for Asian or Pacific Islander and Hispanic patients. Patients from and Hispanic received significantly less treatment than NHW patients, and up to 36% and 42% of the total effect was mediated by lack of insurance or having Medicaid for NHB and Hispanic separately. Our study found that health insurance significantly affects the racial disparities of advanced-stage lung cancer detection and receipt of cancer-direct surgery and other treatment. Narrowing the racial disparities might require expansion of access to adequate insurance coverage.

Primary squamous cell carcinoma of pancreas: a population-based study

Primary squamous cell carcinoma of pancreas (SCCP) is an extremely rare pathological subtype of pancreatic cancer of ductal origin. Due to its rarity, most previous studies on SCCP focused on case reports or series and the clinio-pathological characteristics of SCCP patients remain unclear. A retrospective analysis of SCCP patients registered in the Surveillance, Epidemiology and End Results (SEER) database from 1988 to 2016 were performed, and clinical characteristics and prognosis of these patients were also further determined. A total of 373 patients diagnosed with SCCP were identified. Most SCCP patients 154/243 (63.4%) SCCP patients had distant metastases. The prognosis of SCCP patients was poor with a median overall survival (mOS) of only 3.0 months (95% CI, 2.0-5.0). The 6-month, 1-year and 2-years survival rate were 25.6%, 13.2% and 5.7%, respectively. The prognosis of SCCP patients became much worse with the increasing age (P=0.01) and distant metastases (P<0.01). Cancer-directed surgery, chemotherapy and radiotherapy could significantly prolong the survival time for SCCP patients (P<0.01 for all). Multivariate Cox analysis showed that only distant metastases were independent prognostic factors of worse survival in SCCP patients (HR =1.58, 95% CI, 1.18-2.12). Conversely, both cancer-directed surgery and chemotherapy were an independent protective factor that decreased the risk of death by 66% (HR =0.18, 95% CI, 0.11-0.29) and 46% (HR =0.54, 95% CI, 0.43-0.68) for SCCP patients. SCCP is a rare type of pancreatic malignancies with poor prognosis. The present study could provide some useful information for future management and prospective studies for SCCP patients.

Cancer-directed surgery in malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication

Malignant pleural mesothelioma (MPM) is a primary solid malignancy related to inhalational asbestos exposure. Despite advances in therapy, MPM remains challenging to treat with a post-treatment survival of only 15% at 5-year. In recent years, extra-pleural pneumonectomy has decreased in popularity due to a high morbidity rate and mortality compared to pleurectomy/decortication and other therapeutic alternatives. In this review, we will discuss both procedures, outcomes, ongoing studies, and the roles of surgery in the future treatment of this disease.

Pancreatic Carcinosarcoma Clinical Outcome Analysis of the National Cancer Institute Database

BackgroundPancreatic carcinosarcomas (PCS) are rare aggressive biphasic malignancies with a poor prognosis. We aimed to improve the understanding of PCS by analyzing variables that influence the mortality of PCS patients. MethodsThe Surveillance, Epidemiology, and End Results database was queried for cases of PCS from 1973 to 2016. Cases were analyzed for patient demographics, tumor characteristics, and surgical intervention. Kaplan-Meier and Cox regression analyses were applied to investigate the overall survival (OS) and prognostic factors. ResultsThirty-nine cases of PCS were identified along with the disease demographics and characteristics. The majority of patients had a regionally invasive or metastatic disease. There was a significant decrease in OS with the increase of the tumor extension. Conversely, surgery showed to improve OS in the crude analysis, including patients that underwent lymphadenectomy. In addition, the unadjusted Cox regression results showed decreased hazard ratios with a local disease versus distant metastasis and with cancer-directed surgery versus no surgery. Nevertheless, the adjusted Cox regression results revealed that metastatic disease was the only significant predictor of survival. ConclusionsThis population-based study provides some insight to a very rare disease by analyzing 39 cases of PCS. Our finding suggests considering PCS as a nonsurgical disease and reserving surgery solely for patients with a localized disease in combination or after neoadjuvant therapy. Consequently, there is a need to further investigate novel therapies for this aggressive malignancy.

Development and validation of a nomogram to predict overall survival for patients with metastatic renal cell carcinoma

BackgroundHeterogeneity of metastatic renal cell carcinoma (RCC) constraints accurate prognosis prediction of the tumor. We therefore aimed at developing a novel nomogram for accurate prediction of overall survival (OS) of patients with metastatic RCC.MethodsWe extracted 2010 to 2016 data for metastatic RCC patients in the Surveillance, Epidemiology, and End Results (SEER) database, and randomly stratified them equally into training and validation sets. Prognostic factors for OS were analyzed using Cox regression models, and thereafter integrated into a 1, 3 and 5-year OS predictive nomogram. The nomogram was validated using the training and validation sets. The performance of this model was evaluated by the Harrell’s concordance index (C-index), calibration curve, integrated discrimination improvement (IDI), category-free net reclassification improvement (NRI), index of prediction accuracy (IPA), and decision curve analysis (DCA).ResultsOverall, 2315 metastatic RCC patients in the SEER database who fulfilled our inclusion criteria were utilized in constructing a nomogram for predicting OS of newly diagnosed metastatic RCC patients. The nomogram incorporated eight clinical factors: Fuhrman grade, lymph node status, sarcomatoid feature, cancer-directed surgery and bone, brain, liver, and lung metastases, all significantly associated with OS. The model was superior to the American Joint Committee on Cancer (AJCC) staging system (7th edition) both in training (C-indices, 0.701 vs. 0.612, P < 0.001) and validation sets (C-indices, 0.676 vs. 0.600, P < 0.001). The calibration plots of the nomogram corresponded well between predicted and observed values. NRI, IDI, and IPA further validated the superior predictive capability of the nomogram relative to the AJCC staging system. The DCA plots revealed reliable clinical application of our model in prognosis prediction of metastatic RCC patients.ConclusionsWe developed and validated an accurate nomogram for individual OS prediction of metastatic RCC patients. This nomogram can be applied in design of clinical trials, patient counseling, and rationalizing therapeutic modalities.

Dual Primary Cancer Patients With Lung Cancer as a Second Primary Malignancy: A Population-Based Study.

BackgroundResearch on patients with lung cancer as a second primary malignancy (LCSPM) remains limited. This study aims to determine the clinical characteristics, prognosis, and temporal relationship of other cancers to lung cancer in these patients.MethodsThis study retrospectively analyzed 3465 patients with dual primary cancers from the 5253 patients with LCSPM retrieved from the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2015.Results2285 eligible patients were further analyzed in this study cohort with 59.3% of 1-year OS, 34.7% of 3-year OS, and 25.2% of 5-year OS. The most common first primary cancer (FPC) in dual primary cancer patients with LCSPM was prostate cancer, followed by female breast cancer and urinary bladder cancer. In the entire study population, the median interval between the two primary malignancies was 21 months (range: 3.5–52 months). Age, sex, FPC location, surgery, stage, and histology of lung cancer were regarded as independent prognostic factors for these patients. The prognosis of patients with urinary bladder cancer as FPC was the worst in the univariate (p = 0.024) and multivariate (p < 0.001) Cox analyses. Lung cancer-directed surgery could significantly improve long-term survival (HR = 0.22, p < 0.001). Additionally, the C-index of the established nomogram with acceptable calibration curves was 0.760 (95% CI: 0.744–0.776) in the training cohort and was 0.759 (95% CI: 0.737–0.781) in the validation cohort, showing an ideal model discrimination ability. The corresponding decision curve analysis (DCA) indicated the nomogram had relatively ideal clinical utility.ConclusionsCancer patients still have the risk of developing a new primary lung cancer. Close, lifelong follow-up is recommended for all these patients. Early detection for surgical treatment will significantly improve the prognosis of dual primary cancer patients with LCSPM. The nomogram developed to predict 1-, 3-, and 5-year OS rates has relatively good performance.

Association between travel distance for ovarian cancer and short- and long-term outcomes

Objective: Studies from other tumor sites have suggested that survival is improved in patients who travel a greater distance to undergo cancer-directed surgery. We examined the association between travel distance and short- and long-term outcomes in women with ovarian cancer who underwent primary surgery.

Socioeconomic and Racial Disparities in Cancer Stage at Diagnosis, Tumor Size, and Clinical Outcomes in a Large Cohort of Women with Breast Cancer, 2007-2016.

Socioeconomic and treatment factors contribute to diagnosis of early-stage (local-stage) breast cancer, as well as excess deaths among African American women. We evaluated socioeconomic and treatment predictive factors for early-stage breast cancer among African American women compared to Caucasian women. A secondary aim evaluated predictors and overall risks associated with all-cause and breast cancer-specific mortality. We used retrospective cohort population-based study data from the Surveillance, Epidemiology, and End Results (SEER) Program on 547,703 women aged ≥ 20years diagnosed with breast cancer primary tumors from 2007 to 2016. Statistical analysis used logistic regression to assess predictors of early-stage breast cancer and Cox proportional hazards regression for mortality risks. African American women were more likely to be diagnosed at advanced-stage, had larger tumor size at diagnosis, and received less cancer-directed surgery, but more chemotherapy than Caucasian women. Insured women (> 50%) were more likely to be diagnosed at early-stage and to have smaller tumors (p < 0.05). Education level, poverty level, and household income had no impact on racial disparities or socioeconomic disparities in women diagnosed at early stage. We found increased risks for all-cause mortality (hazard ratio = 1.18; 95% confidence interval, 1.16-1.21) and breast cancer-specific mortality (HR = 1.22; 95% CI, 1.19-1.25) among African American women compared to Caucasian women after adjusting for demographic, socioeconomic, and treatment factors. In this population-based study using the most recent SEER data, African American women with breast cancer continued to exhibit higher all-cause mortality and breast cancer-specific mortality compared to Caucasian women.

The religious/spiritual beliefs and needs of cancer survivors who underwent cancer-directed surgery.

We sought to characterize patients' preferences for the role of religious and spiritual (R&S) beliefs and practices during cancer treatment and describe the R&S resources desired by patients during the perioperative period. A cross-sectional survey was administered to individuals who underwent cancer-directed surgery. Data on demographics and R&S beliefs/preferences were collected and analyzed. Among 236 participants, average age was 58.8 (SD = 12.10) years; the majority were female (76.2%), white (94.1%), had a significant other or spouse (60.2%), and were breast cancer survivors (43.6%). Overall, more than one-half (55.9%) of individuals identified themselves as being religious, while others identified as only spiritual (27.9%) or neither (16.2%). Patients who identified as religious wanted R&S integrated into their care more often than patients who were only spiritual or neither (p < 0.001). Nearly half of participants (49.6%) wanted R&S resources when admitted to the hospital including the opportunity to speak with an R&S leader (e.g., rabbi; 72.1%), R&S texts (64.0%), and journaling materials (54.1%). Irrespective of R&S identification, 68.0% of patients did not want their physician to engage with them about R&S topics. Access to R&S resources is important during cancer treatment, and incorporating R&S into cancer care may be especially important to patients that identify as religious. R&S needs should be addressed as part of the cancer care plan.