Deyo Score Research Articles

Clinico–pathologic factors and survival of patients with breast cancer diagnosed with de novo brain metastasis: a national cancer database analysis

PurposePatients with Breast Cancer (BC) with Brain Metastasis (BCBM) have poor survival outcomes. We aimed to explore the clinico–pathologic and therapeutic factors predicting the survival in patients with de novo BCBM using the National Cancer Database (NCDB).Patients and methodsThe NCDB was queried for patients with BC between 2010 and 2020. Survival analysis with Kaplan–Meier curves and log rank tests were used to find median overall survival (OS) in months (95% CI) across the different variables. A multivariate cox regression model was computed to identify significant predictors of survival.ResultsOut of n = 2,610,598 patients, n = 9005 (0.34%) had de novo BCBM. A trend of decreasing OS was observed with increasing age, Charlson–Deyo score (CDS), and number of extracranial metastatic sites. The highest median OS was observed in the Triple Positive and the lowest OS in the Triple Negative subgroup. Based on treatment regimen, combination of systemic therapy and local therapy achieved the highest OS. A positive trend in OS was observed in the BC subgroup analysis with targeted therapy demonstrating a survival benefit when added to systemic therapy.The multivariate cox regression model showed that age, race, ethnicity, insurance, median income, facility type, CDS, BC subtype, metastatic location sites, and treatment combinations received were significantly associated with risk of death. Receiving only local treatment for BM without systemic therapy more than doubled the risk of death compared to combining it with systemic therapy.ConclusionsThis analysis suggests that treatment of systemic disease is the major factor influencing survival in patients with BCBM. Moreover, targeted therapy with anti–HER2 increased survival when added to systemic therapy explaining the highest median OS noted in the Triple Positive subgroup.

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis

BackgroundThe traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. MethodsAdults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004–2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan–Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. ResultsA total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%–4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35–1.60, P < .001), higher Charlson–Deyo score (score ≥3: 1.79, 1.58–2.04, P < .001), stage II cancer (1.22, 1.17–1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. ConclusionDespite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Patient and provider factors predict non-surgical management for complex upper gastrointestinal cancers

BackgroundSurgery is the only potentially curative treatment for non-metastatic upper gastrointestinal cancers. We analyzed patient and provider characteristics associated with non-surgical management. MethodsWe queried the National Cancer Database for patients with upper gastrointestinal cancers from 2004 to 2018 who underwent surgery, refused surgery, or for whom surgery was contraindicated. Multivariate logistic regression identified factors associated with surgery being refused or contraindicated, and Kaplan-Meier curves assessed survival. ResultsWe identified 249,813 patients based on our selection criteria—86.3% had surgery, 2.4% refused, and for 11.3%, surgery was contraindicated. Median overall survival was 48.2 months for patients who underwent surgery versus 16.3 and 9.4 months for the refusal and contraindicated groups. Medical and non-medical factors predicted both surgery refusals and contraindications, such as increasing age (odds ratio = 1.07 and 1.03, respectively, P < .001), Black race (odds ratio = 1.72 and 1.45, P < .001), comorbidities (Charlson–Deyo score 2+, odds ratio = 1.18 and 1.66, P < .001), low socioeconomic status (odds ratio = 1.70 and 1.40, P < .001), no health insurance (odds ratio = 3.26 and 2.34, P < .001), community cancer programs (odds ratio = 1.43 and 1.40, P < .001), low volume facilities (odds ratio = 1.82 and 1.52, P < .001), and stage 3 disease (odds ratio = 1.51 and 6.50, P < .001). On subset analysis (excluding patients age >70, Charlson–Deyo score 2+, and stage 3 cancer), non-medical predictors of both outcomes were similar. ConclusionRefusal of and medical contraindications for surgery profoundly impact overall survival. The same factors (ie, race, socioeconomic status, hospital volume, and hospital type) predict these outcomes. These findings suggest variation and potential bias that may exist between physicians and patients discussing cancer surgery.

P51 A national analysis of demographic features associated with spindle cell melanoma

Abstract Spindle cell melanoma (SCM) is a rare morphological subtype of melanoma, characterized histologically by atypical, spindled, malignant melanocytes (Weissinger SE, Keil P, Silvers DN et al. A diagnostic algorithm to distinguish desmoplastic from spindle cell melanoma. Mod Pathol 2014; 27:524–34). SCM often manifests as a broad metastatic illness, is frequently amelanotic and can arise nearly anywhere on the body, making diagnosis challenging (Xu Z, Shi P, Yibulayin F et al. Spindle cell melanoma: incidence and survival, 1973–2017. Oncol Lett 2018; 16:5091–9). Given the rarity of SCM, the epidemiology is not yet well explored. The National Cancer Database (NCDB) is a nationwide oncology outcome database for &amp;gt; 1500 commission-accredited cancer programmes in the US and Puerto Rico. This study aimed to investigate the demographic factors associated with patients diagnosed with SCM by analysis of the NCDB. A retrospective cohort analysis utilizing data from the NCDB from 2004 to 2020 included patients diagnosed with histologically confirmed SCM (n = 7556). Sociodemographic factors (sex, age, race, Hispanic status, insurance type, urban/rural designation, facility location, facility type, education, income, distance from residence to facility and Charlson–Deyo score) were analysed using Pearson χ2-tests, and multivariate analysis was performed via binary logistic regression. Since 2004, an average (SD) of 480.8 (63.7) cases have been diagnosed annually. Most patients were male (66.5%), White (97.6%), not Hispanic (95.2%) and insured by Medicare (56.3%) and lived in an urban area (98.5%). Mean (SD) age at diagnosis was 67.9 (14.5) years, with an average (SD) Charlson–Deyo comorbidity score of 0.3 (0.6) and a mean (SD) distance of 37.3 (113.4) miles from the patient’s residence to the hospital. The most common primary site for SCM was the skin of the upper limb and shoulder (22.6%), followed by skin of the scalp and neck (19.0%), skin of other and unspecified parts of face (17.9%), and skin of the trunk (17.3%). On multivariate analysis, males were more likely than females to be diagnosed at an older age [69.3 vs. 65.3 years, 95% confidence interval (CI) 0.979–0.990; P &amp;lt; 0.001], receive treatment at an academic facility (45.9% vs. 42.7%, 95% CI 1.018–1.270; P = 0.023) and have a Charlson–Deyo score of ≥ 3 (2.1% vs. 1.3%, 95% CI 0.374–0.924; P = 0.21). Given the lack of literature on SCM, this study serves as a valuable tool for understanding the demographic factors associated with the diagnosis. Future studies within the laboratory aim to determine the effect of these factors on overall survival with propensity score matching for other variables to identify disparities.

Survival outcomes in node-positive non-metastatic bladder cancer: An analysis of the national cancer database

ABSTRACT Introduction Clinically node-positive non-metastatic bladder cancer (cN+) has been the target of several studies aiming to establish a standard of care for this population. Limited studies have shown a survival benefit for various multimodal therapy approaches. The role of radiation therapy has not been well established. Our study aims to study the trends of the reported treatment options offered to patients with cN+ bladder cancer in a national database and to evaluate the effect of various treatments, including radiation, on survival. Methods The National Cancer Database (NCDB) was used to identify cN+ bladder cancer patients who received chemotherapy alone or in combination with radical cystectomy (RC) or radiotherapy. 3,481 patients were included and divided into 4 groups: chemotherapy only, chemotherapy and RC, chemotherapy and radiation therapy, and chemotherapy, RC, and radiation therapy. Demographic data was compared using ANOVA for continuous variables, and Chi-square for categorical variables. Multivariable analysis was done to compare groups using a multinomial logistic regression model. Kaplan-Meier test was used for survival analysis and Cox-Regression was used for multivariable survival analysis. Results Patients undergoing RC were significantly younger (P <0.001). There was a significant difference between the groups regarding racial distribution, facility-type and insurance status. There was no difference in gender, Charlson\\Deyo score, financial or educational status. Patients who underwent combination therapy with chemotherapy and RC were found to have the longest median survival time at 27 months. Multivariable analysis showed that final treatment, age, sex, Charlson\\Deyo comorbidity score, TNM edition and facility-type were significant survival predictors. Race, insurance and financial status failed to maintain significance. There was no survival difference between the chemotherapy group and chemo-radiotherapy group. Conclusions The combination of surgery and chemotherapy achieves statistically significant superior survival in cN+ bladder cancer. Adding radiotherapy to chemotherapy did not improve survival in this group of patients. Abbreviations (cN+): Clinically node-positive non-metastatic, (MIBC): Muscle invasive bladder cancer, (NCDB): National Cancer Database, (NAC): Neoadjuvant chemotherapy, (RC): Radical Cystectomy

Select octogenarians with stage IIIa non–small cell lung cancer can benefit from trimodality therapy

ObjectivesCurrently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non–small cell lung cancer (NSCLC) in patients 80 years of age or older. MethodsThe National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson–Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan–Meier survival analyses were performed. ResultsFrom the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group. ConclusionsSelected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.

Crohn’s disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions

BackgroundJoint involvement is a common extraintestinal manifestation of Crohn’s Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients. MethodsWe retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009–2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080–0084) and split into 2 groups with or without CD (5550–5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes. ResultsA total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 [95% CI 1.1–2.0] p < 0.01), acute renal failure (OR 1.7 [95% CI 1.1–2.6] p = 0.03), and pulmonary embolism (OR 2.5 [95% CI 1.3–4.6] p = 0.01). ConclusionPatients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.

High-Risk Features Are Prognostic in dMMR/MSI-H Stage II Colon Cancer.

BackgroundHigh-risk features, such as T4 disease, bowel obstruction, poorly/undifferentiated histology, lymphovascular, perineural invasion, and <12 lymph nodes sampled, indicate poor prognosis and define high-risk stage II disease in proficient mismatch repair stage II colon cancer (CC). The prognostic role of high-risk features in dMMR/MSI-H stage II CC is unknown. Similarly, the role of adjuvant therapy in high-risk stage II CC with dMMR/MSI-H (≥1 high-risk feature) has not been studied in prospective trials. The aim of this analysis of the National Cancer Database is to evaluate the prognostic value of high-risk features in stage II dMMR/MSI-H CC.MethodsUnivariate (UVA) and multivariate (MVA) Cox proportional hazards (Cox-PH) models were built to assess the association between clinical and demographic characteristics and overall survival. Kaplan–Meier survival curves were generated with log-rank tests to evaluate the association between adjuvant chemotherapy in high-risk and low-risk cohorts separately.ResultsA total of 2,293 stage II CC patients have dMMR/MSI-H; of those, 29.5% (n = 676) had high-risk features. The high-risk dMMR/MSI-H patients had worse overall survival [5-year survival and 95%CI, 73.2% (67.3–78.1%) vs. 80.3% (76.7–83.5%), p = 0.0001]. In patients with stage II dMMR/MSI-H CC, the high-risk features were associated with shorter overall survival (OS) along with male sex, positive carcinoembryonic antigen, Charlson–Deyo score >1, and older age. Adjuvant chemotherapy administration was associated with better OS, regardless of the high-risk features in dMMR/MSI-H (log-rank test, p = 0.001) or not (p = 0.0006). When stratified by age, the benefit of chemotherapy was evident only in patients age ≥65 with high-risk features.ConclusionHigh-risk features are prognostic in the setting of dMMR/MSI-H stage II CC. Adjuvant chemotherapy may improve survival specifically in patients ≥65 years and with high-risk features.

Neoadjuvant Endocrine Therapy as an Alternative to Neoadjuvant Chemotherapy Among Hormone Receptor-Positive Breast Cancer Patients: Pathologic and Surgical Outcomes.

BackgroundNeoadjuvant chemotherapy (NCT) is considered more effective in downstaging hormone receptor-positive (HR+) breast cancer than neoadjuvant endocrine therapy (NET), particularly in node-positive disease. This study compared breast and axillary response and survival after NCT and NET in HR+ breast cancer.MethodsBased on American College of Surgeons Oncology Group (ACOSOG) Z1031 criteria, women age 50 years or older with cT2-4 HR+ breast cancer who underwent NET or NCT and surgery were identified in the National Cancer Database 2010–2016. Chi-square and logistic regression analysis determined differences between the NCT and NET groups and therapy response, including downstaging and pathologic complete response (pCR, ypT0/is and ypN0).ResultsOf 19,829 patients, 14,025 (70.7%) received NCT and 5804 (29.3%) received NET. The NET patients were older (mean age, 68.9 vs. 60.3; P < 0.001) and had greater comorbidity (1+ Charlson–Deyo score, 21% vs. 16%; P < 0.001). Therapy achieved T downstaging (any) for 58% of the patients with NCT versus 40.5% of the patients with NET, and in-breast pCR was achieved for 9.3% of the NCT versus 1.3% of the NET patients (P < 0.001). Approximately half of the mastectomy procedures could have been potentially avoided for the patients with in-breast pCR (53.6% of the NCT and 43.8% of the NET patients). For the cN+ patients, N downstaging (any) was 29% for the NCT patients versus 18.3% for the NET patients (P < 0.001), and nodal pCR was achieved for 20.3% of the NCT versus 13.5% of the NET patients (P < 0.001). Among those with nodal pCR, axillary lymph node dissection (ALND) still was performed for 56% of the patients after NCT and 45% of the patients after NET.ConclusionsAlthough the response rates after NCT were higher, NET achieved both T and N downstaging and pCR. Neoadjuvant endocrine therapy can be used to de-escalate surgery for patients who cannot tolerate NCT or when chemotherapy may not be effective based on genomic testing.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-10459-3.

Nephrectomy Delay of More than 10 Weeks from Diagnosis Is Associated with Decreased Overall Survival in pT3 RCC.

In this study, we aimed to evaluate the impact of surgical wait time (SWT) on outcomes of patients with renal cell carcinoma (RCC), and to investigate risk factors associated with prolonged SWT. Using the National Cancer Database, we retrospectively reviewed the records of patients with pT3 RCC treated with radical or partial nephrectomy between 2004 and 2014. The cohort was divided based on SWT. The primary outcome was 5-year overall survival (OS). Logistic regression analysis was used to investigate the risk factors associated with delayed surgery. Cox proportional hazards models were fitted to assess relations between SWT and 5-year OS after adjusting for confounding factors. A total of 22,653 patients were included in the analysis. Patients with SWT > 10 weeks had higher occurrence of upstaging. Using logistic regression, we found that female patients, African-American or Spanish origin patients, treatment in academic or integrated network cancer center, lack of insurance, median household income of <$38,000, and the Charlson–Deyo score of ≥1 were more likely to have prolonged SWT. SWT > 10 weeks was associated with decreased 5-year OS (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.15–1.33). This risk was not markedly attenuated after adjusting for confounding variables, including age, gender, race, insurance status, Charlson–Deyo score, tumor size, and surgical margin status (adjusted HR, 1.13; 95% CI, 1.04–1.24). In conclusion, the vast majority of patients underwent surgery within 10 weeks. There is a statistically significant trend of increasing SWT over the study period. SWT > 10 weeks is associated with decreased 5-year OS.

Validation of the 8th Edition American Joint Commission on Cancer (AJCC) Gallbladder Cancer Staging System: Prognostic Discrimination and Identification of Key Predictive Factors.

Simple SummaryDespite implementing numerous changes in the American Joint Committee on Cancer (AJCC) staging system for gallbladder cancer (GBC), the ability to accurately prognosticate survival in these patients has not been vigorously evaluated. The purpose of our study was to compare the prognostic ability of AJCC 7th and 8th edition, investigate the effect of AJCC 8th edition nodal status on the survival, and identify risk factors associated with the survival after N reclassification in GBC patients. We used the largest cancer database in the United States and determined that the updated AJCC 8th edition GBC staging system was comparable to the 7th edition, with no major improvements in survival discrimination. The recently implemented changes in N classification do not appear to improve the prognostic performance of the AJCC cancer staging system with regard to survival in GBC patients.The scope of our study was to compare the predictive ability of American Joint Committee on Cancer (AJCC) 7th and 8th edition in gallbladder carcinoma (GBC) patients, investigate the effect of AJCC 8th nodal status on the survival, and identify risk factors associated with the survival after N reclassification using the National Cancer Database (NCDB) in the period 2005–2015. The cohort consisted of 7743 patients diagnosed with GBC; 202 patients met the criteria for reclassification and were denoted as stage ≥III by AJCC 7th and 8th edition criteria. Overall survival concordance indices were similar for patients when classified by AJCC 8th (OS c-index: 0.665) versus AJCC 7th edition (OS c-index: 0.663). Relative mortality was higher within strata of T1, T2, and T3 patients with N2 compared with N1 stage (T1 HR: 2.258, p < 0.001; T2 HR: 1.607, p < 0.001; Τ3 HR: 1.306, p < 0.001). The risk of death was higher in T1–T3 patients with Nx compared with N1 stage (T1 HR: 1.281, p = 0.043, T2 HR: 2.221, p < 0.001, T3 HR: 2.194, p < 0.001). In patients with AJCC 8th edition stage ≥IIIB GBC and an available grade, univariate analysis showed that higher stage, Charlson–Deyo score ≥ 2, higher tumor grade, and unknown nodal status were associated with an increased risk of death, while year of diagnosis after 2013, academic center, chemotherapy. and radiation therapy were associated with decreased risk of death. Chemotherapy and radiation therapy were associated with decreased risk of death in patients with T3–T4 and T2–T4 GBC, respectively. In conclusion, the updated AJCC 8th GBC staging system was comparable to the 7th edition, with the recently implemented changes in N classification assessment failing to improve the prognostic performance of the staging system. Further prospective studies are needed to validate the T2 stage subclassification as well as to clarify the association, if any is actually present, between advanced N staging and increased risk of death in patients of the same T stage.

Impact of race on care, readmissions, and survival for patients with glioblastoma: an analysis of the National Cancer Database.

BackgroundThe objective of this study was to explore racial/ethnic factors that may be associated with survival in patients with glioblastoma by querying the National Cancer Database (NCDB).MethodsThe NCDB was queried for patients diagnosed with glioblastoma between 2004 and 2014. Patient demographic variables included age at diagnosis, sex, race, ethnicity, Charlson–Deyo score, insurance status, and rural/urban/metropolitan location of zip code. Treatment variables included surgical treatment, extent of resection, chemotherapy, radiation therapy, type of radiation, and treatment facility type. Outcomes included 30-day readmission, 30- and 90-day mortality, and overall survival. Multivariable Cox regression analyses were performed to evaluate variables associated with race and overall survival.ResultsA total of 103 652 glioblastoma patients were identified. There was a difference in the proportion of patients for whom surgery was performed, as well as the proportion receiving radiation, when stratified by race (P < .001). Black non-Hispanics had the highest rates of unplanned readmission (7.6%) within 30 days (odds ratio [OR]: 1.39 compared to White non-Hispanics, P < .001). Asian non-Hispanics had the lowest 30- (3.2%) and 90-day mortality (9.8%) when compared to other races (OR: 0.52 compared to White non-Hispanics, P = .031). Compared to White non-Hispanics, we found Black non-Hispanics (hazard ratio [HR]: 0.88, P < .001), Asian non-Hispanics (HR: 0.72, P < .001), and Hispanics (HR: 0.69, P < .001) had longer overall survival.ConclusionsDifferences in treatment and outcomes exist between races. Further studies are needed to elucidate the etiology of these race-related disparities and to improve outcomes for all patients.

Thymic Neuroendocrine Tumors and Thymic Carcinoma: Demographics, Treatment, and Survival.

Although rare, thymic neuroendocrine tumors (TNET) and thymic carcinoma (TC) are the most common thymic nonthymomatous malignancies; their survival outcomes have not been thoroughly compared. We analyzed the clinical, treatment, and survival characteristics of TNET and TC. We retrospectively identified patients with a histologic diagnosis of TNET or TC in the National Cancer Database (2004 to 2015). Exclusion criteria were age <18 years and unstaged tumors. Descriptive statistics, survival analysis, and multivariable Cox regression analyses were used in elucidating associations. One thousand four hundred eighty-nine patients were included (TNET: 19.8%). Patients with TNET were significantly younger (57 vs 62.5 years), more likely to be male (70.5% vs 60.0%), and have localized tumors (45.4% vs 32.3%). Patients with TC more frequently underwent chemotherapy (56.1% vs 34.9%), radiation (56.9% vs 39.3%), and trimodality therapy (21.3% vs 11.5%), while resection rates were similar (55.3% vs 58.3%). The 5-year survival was 62% for TNET and 52% for TC, but comparable following multivariable adjustment. Age, stage, and Charlson-Deyo score were negative predictors of survival, while surgery and trimodality therapy were positive predictors. On subanalysis, adjuvant radiation therapy (ART) improved the survival of margin-positive tumors and was an independent predictor of survival for both tumor types (hazard ratio = 0.5). Our analysis of the largest series of TNET and TC showed a survival rate surpassing 50% at 5 years. These outcomes seem to be influenced by surgical resection and ART. Standardized staging and surgical protocols including lymph node sampling are still warranted to better elucidate the treatment algorithm of these tumors.

Age-related outcomes in patients with esophageal cancer: A propensity score matched analysis.

326 Background: Esophageal cancer is increasing in incidence worldwide. It is estimated that there will be 17,650 new cases of esophageal cancer diagnosed, with 16,080 dying from the disease in the United States in 2019. There has been an increase in younger patients diagnosed with esophageal cancer. We sought to evaluate the outcomes in younger patients diagnosed with esophageal cancer. Methods: Utilizing the National Cancer Database we identified patients with esophageal cancer. We then stratified by age &lt; 50, 51-60, 61-70, and &gt; 70 years. Baseline univariate comparisons were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method. All statistical tests were two-sided and p &lt; 0.05 was significant. Propensity score matched analysis was performed and only exact matches were allowed. Results: We identified 20,324 patients ( &lt; 50, 2157), (51-60, 5387), (61-70, 7853), and ( &gt; 70, 4927). T-stages and N stages were higher in the younger age groups p &lt; 0.001 and p &lt; 0.001 respectively. Median lymph nodes positive were highest in the &lt; 50 group (2.2 vs 1.8 vs 1.6 vs 1.7) p &lt; 0.001. Additionally, tumor size was largest in this age cohort (3.7 vs 3.5 vs 3.5 vs 3.2) p = 0.002. Neoadjuvant therapy was administered in 69.4% of patients in the &lt; 50, 68.5% (51-60), 65.5% (61-70), and 49.5% &gt; 70 patients, p &lt; 0.001. The &lt; 50 age group was however more likely to receive adjuvant therapy (22.9% vs 20.5% vs 16.9% vs 13.4%) p &lt; 0.001. Median and overall survival was 49.8 mo and 45% ( &lt; 50), 45.4mo and 43% (51-60), 45.4mo and 43% (61-70), and 35.8mo and 39% &gt; 70, p &lt; 0.001. After propensity score matching, multivariate analysis found that age &lt; 50, male gender, GEJ tumor location, grade, Charleson Deyo score, T-stage N stage, margin, facility volume, neoadjuvant and adjuvant therapy were predictors of survival. Conclusions: Although younger patients present with larger tumors, higher T-stages, and N stages, they are more likely to receive neoadjuvant and adjuvant therapies. It is these therapies which are most likely contributing to improved survival compared to their older counterparts.

Evaluation of the current treatment strategies for pancreatic neuroendocrine tumors.

611 Background: The management of pancreatic neuroendocrine tumors (PNET) varies between observation (O), pancreatic resection (PR) and enucleation (E). Currently, size, grade and location are used to determine which treatment strategy may be employed. We sought to evaluate each strategy and further clarify the role for surgery. Methods: Utilizing the National Cancer Database we identified patients with pancreatic neuroendocrine tumors. Tumors were stratified based upon size &lt;1cm, 1-2cm and &gt;2 cm. Mann-Whitney U and Kruskal were used to compare continuous variables and Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method. Multivariate analysis (MVA) was performed to identify predictors of survival. All statistical tests were two-sided and p&lt;0.05 was considered significant. Results: We identified 17,921 patients. (&lt;1cm, 1214, 1-2cm, 4325, and &gt;2cm, 12,382) with a median age of 61.5 (18-90). Males more often presented with tumors &gt;2cm, 56% vs 44%, &lt;0.001. Tumors &gt;2cm were more likely to be poorly differentiated (PD), p&lt;0.001, have node positive disease, p&lt;0.001 and less likely to undergo R0 resection, p&lt;0.001. Tumors &lt;1cm and well differentiated (WD) the median and overall 5-year survival in the O group was not reached (NR) (77%) vs 142.6 months (87%) in the surgery groups, p&lt;0.04; in the 1-2 cm WD group 95.7 months and 60% vs NR and 94%, p&lt;0.001. Similarly in the PD tumors &lt;1cm the median and overall survival was 32.9 months and 24% in the O vs NR and 81%, p&lt;001; in the 1-2 cm group 14.8 months and 19% vs NR and 73%, p&lt;0.001. There were no differences in survival in patients undergoing PR or E, p=0.09. MVA revealed age, grade, Charleson Deyo score, tumor size, tumor location, and surgery (PR or E) were all independent predictors of survival. Conclusions: While observation is currently an acceptable option for the management of small &lt;1cm WD PNET, we found an improvement in survival in the patients undergoing surgery. Additionally, 1-2 cm PNET benefited from the surgical approach. Enucleation and pancreatic resection did not differ in overall survival. Surgery for PNET should be considered as the first line treatment of these patients.

17. The impact of preoperative cannabis on outcomes following cervical spinal fusion: a propensity score-matched analysis

BACKGROUND CONTEXT Cannabis is the most commonly used illicit drug in the United States with 4 million Americans meeting clinical criteria for cannabis dependence or abuse in 2015. With recent state-level legalization efforts and changing public perception, its use is expected to grow. Considering these changes and the reported medicinally beneficial effects, studies evaluating cannabis use and its impact on outcomes following cervical fusion (CF) are quite limited; further detailed study is warranted. PURPOSE This study sought to identify if adverse outcomes, such as complications, readmissions, and revisions, are comparable between cannabis users and noncannabis users undergoing CF. We compared 90-day complication and readmission rates and 2-year revision rates between baseline cannabis users and nonusers following CF. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively collected database. PATIENT SAMPLE All patients who underwent CF between January 2009 and September 2013 in the New York Statewide Planning and Research Cooperative System (SPARCS) were identified. Patients were included if they had ≤90-day follow-up for complications and readmissions, or ≥2-year follow-up for revisions. Patients with a preoperative ICD-9-CM diagnosis of cannabis abuse (Cannabis) or dependence were identified. Patients were excluded for systemic disease, osteomyelitis, cancer, trauma, or concomitant substance or polysubstance abuse/dependence. OUTCOME MEASURES Demographic information, fusion approach, fusion levels, complications, readmissions, and revisions. METHODS All patients aged ≥18y who underwent CF from 2009-13 were identified via the SPARCS database and included if they had ≤90D follow-up for complications and readmissions or 2Y follow-up for revisions. Pts with preoperative cannabis abuse/dependence identified (Cannabis). Pts were excluded for systemic disease, osteomyelitis, cancer, trauma, or concomitant substance or polysubstance abuse/dependence. Following patient selection in the SPARCS database, Cannabis patients were 1:1 propensity score-matched by age, gender, race, Deyo score, fusion levels and approach, and tobacco use to nonusers (Non-Cannabis). These groups were compared for hospital-related parameters, rates of 90-day complications and readmissions, and 2-year revisions. Multivariate binary stepwise logistic regression models identified independent predictors of these outcomes. RESULTS A total of 432 pts (n=216 each) were identified, with comparable age, sex, Deyo scores, tobacco use rates, and distribution of anterior or posterior approach (all p>0.05). Cannabis patients were more frequently African American (27.8% vs 12.0%), primarily utilized Medicaid (29.6% vs 12.5%), and incurred longer lengths of stay (3.0 vs 1.9 days), all p≤0.001. Both cohorts experienced comparable rates of 90-day medical, surgical and overall complications (5.6% vs 3.7%) and 2-year revisions (4.3% vs 2.8%), p≤0.430. Cannabis users experienced higher 90-day readmission rates (11.6% vs 6.0%, p=0.042). Cannabis use was an independent predictive factor of 90-day readmission (OR=2.0, 95%CI, 1.0-4.1, p=0.049), but did not predict any 90-day complications or 2-year revisions (all p>0.05). CONCLUSIONS Baseline cannabis dependence/abuse was associated with increased 90-day readmission odds following CF. Further investigation of the physiologic impact of cannabis on musculoskeletal patients may identify what measurable or overlooked patient factors contribute to this association. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

P150. The impact of preoperative cannabis use on outcomes following thoracolumbar spinal fusion: a propensity score-matched analysis

BACKGROUND CONTEXT Cannabis is the most commonly used illicit drug in the United States, and with changing state legislation, the use of cannabis is expected to expand. Although other literature has noted potentially medicinally beneficial effects of cannabis, there is limited literature evaluating the impact of cannabis on outcomes for patients following spinal surgery. With shifting public sentiment, expanding decriminalization, and a dearth of knowledge on the potential surgical implications of cannabis, it is imperative we take a closer, objective look at how cannabis dependence or abuse impacts the outcomes of common orthopedic procedures, such as thoracolumbar fusion. PURPOSE To determine if adverse outcomes would be comparable between baseline cannabis users and non-cannabis users undergoing thoracolumbar spinal fusion. We compared the rates of 90-day outcomes and complications and 2-year revisions between baseline cannabis users and non-users following thoracolumbar spinal fusion. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively-collected database. PATIENT SAMPLE The New York State Statewide Planning and Research Cooperative System (SPARCS) was queried to identify all patients from January 2009 to September 2013 who underwent thoracolumbar spinal fusion. Patients were included if they had ≤90-day follow-up for complications and readmissions or ≥2-year follow-up for revisions. Patients with preoperative cannabis abuse/dependence were identified. Patients were excluded for systemic disease, osteomyelitis, cancer, trauma, or concomitant substance or polysubstance abuse/dependence. OUTCOME MEASURES Demographic information, fusion approach, fusion levels, complications, readmissions, and revisions. METHODS The NYS SPARCS database was queried to identify all patients ≥18y who underwent thoracolumbar spinal fusion from 2009-13. Patients were included if they had ≤90D FU for complications and readmissions or 2Y FU for revisions. Patients with preoperative cannabis abuse/dependence were identified. Patients were excluded for systemic disease, osteomyelitis, cancer, trauma, or concomitant substance or polysubstance abuse/dependence. Following patient identification in the SPARCS database, patients with ICD-9-CM diagnosed cannabis use were 1:1 propensity score-matched by age, gender, race, Deyo score, fusion levels and approach and tobacco use to non-cannabis users. These groups were compared for hospital-related parameters, rates of 90-day complications and readmissions and 2-year revisions. Multivariate binary stepwise logistic regression models identified independent predictors of outcomes. RESULTS A total of 628 patients (n=314 each) were identified and included; patients had comparable age, gender, fusion approaches and fusion levels distribution. More cannabis patients were African American (19.7 vs 7.6%) and primarily utilized Medicaid (24.2% vs 11.5%), all p≤0.001. Non-cannabis patients incurred lower 90-day overall and medical complication rates (5.1% vs 12.1%; 4.5% vs 9.9%), all p CONCLUSIONS Cannabis was a protective factor against postoperative anemia and any medical complication, and baseline cannabis use was not associated with increased surgical or overall 90-day complications and readmissions or 2-year revision rates. These findings underscore that baseline cannabis use in the absence of acute intoxication may not necessarily require delays in preoperative clearance. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Spinal Fusion in Parkinson's Disease Patients: A Propensity Score-Matched Analysis With Minimum 2-Year Surveillance.

Retrospective analysis. To compare outcomes and complication rates between patients with and without Parkinson's disease (PD) patients undergoing surgery for adult spinal deformity (ASD). There is limited literature evaluating the impact of PD on long-term outcomes after thoracolumbar fusion surgery for ASD. Patients admitted from 2009 to 2011 with diagnoses of ASD who underwent any thoracolumbar fusion procedure with a minimum 2-year follow-up surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. A 1:1 propensity score-match by age, Deyo score, and number of fused vertebral levels was conducted before comparing surgical outcomes of patients with ASD with and without PD. Univariate analysis compared demographics, complications, and subsequent revision. Multivariate binary stepwise logistic regression models identified independent predictors of these outcomes (covariates: age, sex, Deyo Index score, and PD diagnosis). A total of 576 propensity score-matched patients were identified (PD: n = 288; no-PD: n = 288), with a mean age of 69.7 years (PD) and 70.2 years (no-PD). Each cohort had comparable distributions of age, sex, race, insurance provider, Deyo score, and number of levels fused (all P > 0.05). Patients with PD incurred higher total charges across ASD surgery-related visits ($187,807 vs. $126,610, P < 0.001), yet rates of medical complications (35.8% PD vs. 34.0% no-PD, P = 0.662) and revision surgery (12.2% vs. 10.8%, P > 0.05) were comparable. Postoperative mortality rates were comparable between PD and no-PD cohorts (2.8% vs. 1.4%, P = 0.243). Logistic regression identified nine-level or higher spinal fusion as a significant predictor for an increase in total complications (odds ratio = 5.64); PD was not associated with increased odds of any adverse outcomes. Aside from higher hospital charges incurred, patients with PD experienced comparable overall complication and revision rates to a propensity score-matched patient cohort without PD from the general population undergoing thoracolumbar fusion surgery. These results can support management of concerns and postoperative expectations in this patient cohort. 3.

The Impact of Comorbid Mental Health Disorders on Complications Following Adult Spinal Deformity Surgery With Minimum 2-Year Surveillance.

Retrospective analysis. To compare long-term outcomes between patients with and without mental health comorbidities who are undergoing surgery for adult spinal deformity (ASD). Recent literature reveals that one in three patients admitted for surgical treatment for ASD has comorbid mental health disorder. Currently, impacts of baseline mental health status on long-term outcomes following ASD surgery have not been thoroughly investigated. Patients admitted from 2009 to 2013 with diagnoses of ASD who underwent more than or equal to 4-level thoracolumbar fusion with minimum 2-year follow-up were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System (SPARCS). Patients were stratified by fusion length (short: 4-8-level; long: ≥9 level). Patients with comorbid mental health disorder (MHD) at time of admission were selected for analysis (MHD) and compared against those without MHD (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between cohorts for each fusion length. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: fusion length, age, female sex, and Deyo score). Six thousand twenty patients (MHD: n = 1631; no-MHD: n = 4389) met inclusion criteria. Mental health diagnoses included disorders of depression (59.0%), sleep (28.0%), anxiety (24.0%), and stress (2.3%). At 2-year follow-up, MHD patients with short fusion had significantly higher complication rates (P = 0.001). MHD patients with short or long fusion also had significantly higher rates of any readmission and revision (all P ≤ 0.002). Regression modeling revealed that comorbid MHD was a significant predictor of any complication (odds ratio [OR]: 1.17, P = 0.01) and readmission (OR: 1.32, P < 0.001). MHD was the strongest predictor of any revision (OR: 1.56, P < 0.001). Long fusion most strongly predicted any complication (OR: 1.87, P < 0.001). ASD patients with comorbid depressive, sleep, anxiety, and stress disorders were more likely to experience surgical complications and revision at minimum of 2 years following spinal fusion surgery. Proper patient counseling and psychological screening/support is recommended to complement ASD treatment. 3.

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013

BackgroundLimited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate.Materials and methodsThis is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications.ResultsSeven hundred thirty patients were included (ORIF, n = 662 vs ARTH, n = 68). ORIF patients were younger (p < 0.001), more likely to be males (p < 0.001), and had a lower Deyo score (p = 0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p = 0.535), lengths of stay (7.86 days vs 7.44 days, p = 0.833), hospital charges ($76,998 vs $64,133, p = 0.360), and mortality rates (0.2% vs 0%, p = 0.761). Type of surgery was not a predictor of any complications (OR = 0.67 [95% CI 0.33–1.35], p = 0.266), extended length of stay (OR = 1.01 [95% CI 0.58–1.78], p = 0.967), or high hospital charges (OR = 1.39 [95% CI 0.68–2.86], p = 0.366).ConclusionWe revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures.Level of evidenceLevel III.