Receipt Of Surgery Research Articles

Evaluating the Relationship Among Erectile Dysfunction, Prostate Cancer Treatment Type and Inflatable Penile Prosthesis (IPP) Implantation

ABSTRACT Introduction Sexual health problems affect approximately 60% of male cancer survivors in the U.S. Erectile dysfunction (ED) is the most common sexual health condition men seek professional help for after cancer treatment with some studies reporting ED rates as high as 85% in these men. Inflatable penile prosthesis (IPP) implantation is a safe and highly effective form of ED treatment for patients who fail or cannot tolerate medical therapies. A 2011 study suggested that IPPs are under-utilized by urologists, as less than 1% of men with prostate cancer and ED received IPP following radical prostatectomy or external beam radiation. Objective To better characterize the utilization of IPP treatment, we examined the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort. Methods We performed a retrospective review of older SEER-Medicare patients who were diagnosed with local/regional prostate cancer between 2006 and 2011 and treated with surgery or radiation for it, with and without ED. Using ICD9/CPT/HCPCS codes we created a cohort of patients who has receipt of surgery or radiation within 3 months of cancer diagnosis as well as diagnosed ED within 5-years after undergoing treatment. Chi-square/Wilcoxon tests were used to detect significant differences between the surgical and radiation treatment groups for ED rates and use of IPP among those with ED. Results Of the 31,854 patients in our cohort, 10,475 (32.9%) received surgery and 21,152 (66.4%) received radiation only. Overall, ED was significantly more common for surgical (65.2%) than for radiation patients (33.8%, p<.001). For the subset of 14,121 patients with ED (overall IPP use=2.5%), IPP implantation was significantly more frequent for surgical patients (n=6,976, IPP use= 3.6%) than for radiation patients (n=7,145, IPP use=1.4%, p<.001). Conclusions Shockingly few (2.5%) prostate cancer patients with ED received IPP, with only 1.4% of radiation patients undergoing IPP vs. 3.6% of RALP patients. IPP under-utilization may be due to greater clinical focus on cancer treatment rather than quality-of-life issues. Discrepancies in ED rates between radiation and surgery may also be partially explained by lack of follow-up standardization and highly variable sexual dysfunction reporting, especially in the radiation literature. These findings highlight the importance of thorough counseling about all treatment options including penile prosthesis surgery for prostate cancer patients with ED. Disclosure No

Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival.

During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes. Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP). A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001). Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.

Abstract P3-14-14: A mediation analysis of racial disparity in breast cancer survival

Abstract Introduction: Non-Hispanic Black (African American, AA) women have the worst breast cancer outcomes of any racial/ethnic group. In comparison to non-Hispanic white (white) women, disparities in breast cancer survival for AA women have persisted over the past several decades, although there has been some recent improvement both at the national level and for AA women in Florida. However, we recently reported that AA women in Florida still have twice the rate of breast cancer death compared to their white counterparts. Therefore, more targeted approaches are needed to eliminate survival disparities for AA women diagnosed with breast cancer. The purpose of this study was to conduct a multiple mediation analysis to identify the most important factors causing the disparity in breast cancer survival for AA women. Identifying the most important mediators will provide opportunities for targeted policies, programs, and interventions to ultimately eliminate the prognostic effect of race/ethnicity for Florida women diagnosed with breast cancer. Methods: The study population is comprised of women in Florida diagnosed with breast cancer between 2004 and 2015 who were reported to the Florida Cancer Data System. The following putative mediators were analyzed in this study: residence in high poverty neighborhoods, having Medicaid or no insurance, advanced disease stage at diagnosis, high tumor grade, negative hormone receptor status, and receipt of surgery, based on our causal diagram. The outcome of interest was 5-year breast cancer-specific death. Sociodemographic and clinical characteristics were compared between African American and white women. The Cox model was used to obtain hazard ratios (HR) with 95% confidence intervals (CI) for the direct effect of AA race/ethnicity and indirect effects via mediators. Age was treated as a confounder in the model and mediators were treated as independent. The relative effect for African American ethnicity and each mediator, which is the percentage of the total effect of AA race/ethnicity explained (directly and indirectly) on breast cancer survival, are also provided. Results: African American women were more likely to be younger at diagnosis, living in high poverty neighborhoods, to be insured via Medicaid or uninsured, to have more advanced disease (stage, grade) with hormone receptor negative tumors, and less likely to receive surgery as treatment. From our mediation model, after accounting for all potential mediators, the direct effect associated with African American ethnicity was a 17% (HR = 1.17: 95% CI, 1.11-1.23) increased rate of breast cancer death, which represented 3.9% of the total racial/ethnic effect. The indirect and relative effects of mediators are provided in Table 1. Conclusions: This analysis identified receipt of surgery, advanced disease stage, hormone receptor negative disease, insurance status, and high tumor grade as the most important mediators of the racial/ethnic disparity in breast cancer survival for African American women in Florida. These results have ramifications for increasing access to screening services, providing options for health insurance, and ensuring prompt receipt of curative surgery to eliminate the prognostic effect of race/ethnicity for African American women diagnosed with breast cancer in the Florida. Study limitations are that these results are hypothesis generating based on the current status of methodology to examine multiple mediators in survival models. Table 1.Direct and Indirect Effects for the Association of African American Race/Ethnicity with 5-year Breast Cancer-Specific SurvivalDirect &amp; indirect effectsCox Proportional Hazard ModelHR95%. CIrel effAA race/ethnicity (Direct Effect)1.171.11, 1.233.9%Surgery3.182.93, 3.4728.3%Advanced stage3.092.84, 3.3627.5%Hormone receptor negative1.581.51, 1.6511.1%Medicaid-Uninsured1.481.40, 1.579.6%High grade1.471.42, 1.539.4%High poverty1.341.23, 1.477.2%Hormone treatment1.111.09, 1.142.5%Immunotherapy1.081.02, 1.151.9%Radiation1.041.03, 1.051.0%Chemotherapy0.910.89, 0.92Total Effect60.1050.8, 71.1100.0%Abbreviations: AA, African American; HR, hazard ratio; CI, confidence interval. Citation Format: Robert B. Hines, Xiang Zhu, Eunkyung Lee, Carolyn Rapp, Albert Volk, Asal M. Johnson. A mediation analysis of racial disparity in breast cancer survival [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-14.

Abstract P3-19-20: Are traditional indications for radiation therapy appropriate for small cell carcinoma of the breast: An NCDB outcomes analysis and treatment utilization report

Abstract Background: Small-cell carcinomas (SCC) are poorly differentiated neuroendocrine tumors arising primarily in the lung. Extra-pulmonary SCC composes roughly 6% of all SCCs, with SCC arising in the breast (SCCB) accounting for roughly 4% of all extra-pulmonary sites. Due to its rarity, current practice is guided by traditional breast cancer studies and small-cell lung cancer experience. Prior database analyses of extra-pulmonary SCC’s have revealed mixed results regarding the effect of radiation therapy. The remaining literature regarding the treatment of SCCB is limited to case reports and small case series with no agreed upon “standard” radiation dose or regimen. Method: Using the NCDB, a retrospective observational cohort study was performed investigating survival outcomes and prognostic indicators for SCCB patients. Using cases from 2004-2017, females with primary SCCB and only one lifetime malignancy were included. Patients with in-situ or metastatic disease were excluded. Kaplan Meier method, log-rank test, and Cox proportional hazards regression were performed to determine characteristics associated with OS. Results: A total of 153 patients met criteria for descriptive analysis, with 142 patients having all outcomes information for survival analysis. Median age at diagnosis was 59 years. The majority of patients were white (79%), followed by Black (16%), with other reported races accounting for &amp;lt;1% each. The cohort was composed of 19% stage I, 57.5% stage II, and 23.5% stage III patients. Triple negative (ER, PR, and HER2 negative) malignancies composed the largest group (37%), followed by ER or PR positive, HER2 negative cancers (28%), with ER or PR positive, HER2 positive group making up only 2%, and 33% having an unreported molecular subtype. Regarding surgical intervention, 42% received breast conserving surgery, 42% received mastectomy, and 16% had no surgery. Chemotherapy was administered to 82% of patients. Radiation therapy was administered to 65% of the cohort with a median dose of 6000cGy and a median of 33 fractions. Hormone therapy was administered to 19%. With median follow-up of 32 months, median survival was not met for stage I (75th percentile was 101 months) and was 57 months (95% CI 23-91) and 17 months (95% CI 6-28) for stage II and III respectively. On multivariate analysis (MVA), Age greater than 60 years old had a hazard ratio (HR) of 1.97 (95% CI 1.2-3.4, p = 0.01). When compared to stage I, stage II had a HR of 5.4 (95% CI 1.6-18.3, p = 0.007) and stage III a HR 5.8 (95% CI 1.6-21.3, p = 0.008). Receipt of hormone therapy had a HR of 0.32 (95% CI 0.15-0.72, p = 0.006). When compared to no surgery, breast conserving surgery (BCS) had a HR of 0.17 (95% CI 0.08-0.39 p = 0.0001) and mastectomy had a HR of 0.43 (95% CI 0.23-0.81 p = 0.009). Neither receipt of radiation or chemotherapy reached statistical significance. However, when looking at patients with traditional indications for radiation therapy, i.e., BCS or mastectomy with positive lymph nodes on pathology, the receipt of radiation was associated with better overall survival (median OS was 16.7 months (95% CI 0-36) without radiation versus 114 months (95% CI 93-137) with a p-value of 0.003). Conclusion: In one of the largest cohorts reported to date for SCCB, median survival was not met for stage I (75th percentile of 101 months) and was 57 months (95% CI 23-91) and 17 months (95% CI 6-28) for stage II and III respectively. Age &amp;lt; 60, lower stage, use of hormone therapy, and receipt of surgery were positive prognostic factors on MVA. Receipt of radiation was associated with a significantly longer survival in patients possessing traditional indications for radiotherapy (BCS or mastectomy with positive lymph nodes). Median radiation dose was 6000cGy and median number of fractions was 33. Citation Format: James Nathan Cantrell, Patricia Pius, Pawan Acharya, Sara Vesely, Christina Henson, Ozer Algan. Are traditional indications for radiation therapy appropriate for small cell carcinoma of the breast: An NCDB outcomes analysis and treatment utilization report [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-20.

Abstract P5-14-05: Are neighborhood and community factors associated with refusing breast cancer surgery?

Abstract Background: The importance of an individual’s community impacts cancer disparities and is intimately related to social determinants of health. Surgery refusal is associated with a high disease-specific mortality. Studies of factors associated with refusal of treatment for potentially curable breast cancer show personal factors including age, marital status, and insurance are at play. However, few studies have investigated whether community or area-based characteristics may affect receipt of surgery. Methods: We selected all women diagnosed with non-metastatic (Stage I-III) breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database. We focused on those who refused surgery comparing racial and ethnic differences between Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic all races. Yost index calculated as neighborhood socio-economic status (nSES- divided into tertiles) and RUCA code-derived rural-urban status were based on an NCI census tract-level index, a composite score that includes income, education, housing, and employment; the remaining community factor measures were based on county-level index. Sociodemographic and community differences were analyzed using Pearson’s Chi-Square tests and analysis of variance. Multivariate logistic regression of predictors of refusal of surgery and Cox-proportional hazard model of disease-specific mortality were performed. A p-value of 0.05 was considered statistically significant. Results: 2,155 (0.7%) of 322,538 people refused surgery (NHW: 1,435 (66.6%), NHB: 353(16.3%), Hispanic all races: 166(7.7%)). Surgery refusers were more likely to live in areas with high poverty (&amp;lt;200% level), lower education attainment, lower unemployment, higher percentage urban population, higher percentage foreign-born, higher rates of language isolation, and lower rates of women over 40 having undergone mammography in the previous two years. Multivariate analysis shows surgery refusal is associated with high percentage of having a bachelor’s degree or higher (OR: 1.29, 95% CI:1.05-1.60, p-value &amp;lt;0.05), high percentage of poverty (&amp;lt;200% of poverty) (OR: 1.50, 95% CI:1.04-2.16, p-value &amp;lt;0.05), and high percentage of urban population (OR: 1.26, 95% CI:1.06-1.49, p-value &amp;lt;0.01). Surgery refusal rates declined with increasing nSES. Breast cancer-specific mortality increased significantly for those who refused surgery (HR:3.92, 95% CI: 3.41-4.51, p-value &amp;lt;0.01). Conclusion: Risk of refusing surgery for an otherwise curable breast cancer is associated with residence in communities with the lowest nSES. These are communities disproportionately populated by racial and ethnic minorities. Given the high mortality associated with refusing surgery, further investigation into the reasons why women decline treatment is necessary. For women living in impoverished communities, culturally sensitive education on benefits of care may be appropriate, while women of means may face different challenges such as utilization of alternative medicine. Citation Format: Theresa Relation, Oindrila Bhattacharyya, Jay Fisher, Yaming Li, Allan Tsung, Ahmad Hamad, Amara Ndumele, Bridget Oppong. Are neighborhood and community factors associated with refusing breast cancer surgery? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-05.

The prevalence of common KRAS variants and associated outcomes in patients with metastatic colorectal cancer (mCRC).

173 Background: KRAS is the most common driver oncogene in mCRC. Comprehensive analysis of KRAS variants prevalence and the relationship between variants and outcomes are lacking. Herein, we aimed to examine the impact of KRAS variants on outcomes in patients (pts) with mCRC. Methods: A retrospective review of pts with mCRC with known KRAS mutation status was performed. Fisher’s exact test was used to analyze the association between KRAS variants. Cox Proportional Hazard modeling was used to study the relationship between KRAS variants and overall survival (OS). Kaplan-Meier method was used to assess OS. Results: A total of 423 pts diagnosed with mCRC from 2014-2020 with available extended KRAS status were evaluated. Median age at diagnosis was 59.8 yrs (22.3-92 range), 57% were male, 22% were Black, and 75% presented with de novo metastatic disease. A majority (56%) of tumors harbored KRAS mutations. The most frequent KRAS variants were G12D 47% (111), G12V 12% (28), G12C 13% (31), G13D 9% (21), and 20% (47) were other variants. In univariate analyses, the presence of a KRAS mutation, Black race, de novo metastatic disease, age, receipt of chemotherapy, and receipt of surgery were associated with OS. Tumor location was not associated with OS. In multivariable analyses, mutation type was a significant predictor of death and the presence of G12D was associated with an increased risk of death compared to G12V and KRAS wildtype. There was no increased risk of death in pairwise comparisons of G12D and G13D or other KRAS variants. Black race, de novo metastatic disease, and no receipt of surgery were additional independent predictors of death (Table). With a median follow-up of 25.7 months (mo.), median OS was 35.5 mo. (95% CI 10.5-50.9) with G12C, Not Reached (NR) (95% CI 21-NR) with G12V, 36.2 mo. (95%CI 14.9-58.5) with G13D, 26.2 mo. (95% CI 21.8-37) with G12D, 39.6 mo. (95% CI 22.4-47.9) for other KRAS mutations, and 59.6 mo. (95%CI 48.2-NA) for KRAS wildtype, respectively (p=0.0003). Conclusions: Our findings highlight differences in unadjusted overall survival when comparing G12D to some other KRAS variants. Codon and amino acid-specific mutations of KRAS should be considered when evaluating prognosis and further study on treatment effects and sequencing is warranted. [Table: see text]

Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care.

This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010-2015). This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery. 6574 lung cancer patients and 5355 colorectal cancer patientswere included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR]=1.46; 95 % confidence interval [CI]=1.22-1.76) and lower odds of receiving surgery (OR=0.48; 95 % CI=0.34-0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR=1.53; 95 % CI=1.17-2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR=0.69; 95 % CI= 0.50-0.94 and OR= 0.68; 95 % CI= 0.52-0.89; respectively) than their non-Hispanic White and urban counterparts. After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients' presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

The Impact of Treatment at Minority-serving Hospitals on Outcomes for Pancreatic Cancer

Introduction: Healthcare for racial minorities is densely concentrated within a small subset of hospitals in the United States. Understanding outcomes at these minority-serving hospitals (MSH) is highly relevant to the study of racial disparities in cancer care. Our aim was to identify the impact of receiving treatment at an MSH on overall survival (OS) and on receipt of definitive treatment for minority patients with pancreatic cancer. Methods: Using the National Cancer Database, we identified all patients diagnosed with non-metastatic biopsy-proven pancreatic adenocarcinoma between 2004-2014. MSH were defined as institutions in the top decile of proportion of Black and Hispanic patients within the cohort. Univariate and multivariate analyses were performed to assess the influence of patient- and hospital-level factors on OS and receipt of definitive treatment for pancreatic cancer. Results: 21,452 Black and Hispanic patients were included. 4,103(19.1%) were treated at MSH. There was no difference in the proportion of patients undergoing resection(p=0.353). On adjusted analysis, there was no difference in OS for patients treated at MSH versus those treated at non-MSH (Hazard Ratio[HR]=0.99, 95%Confidence Interval[CI]:0.95–1.04;p=0.79). Significant factors associated with a decreased likelihood of death were receipt of surgery (HR 0.44, 95%CI:0.42-0.45), administration of systemic chemotherapy (HR 0.90, 95%CI:0.86-0.94), and high income (HR 0.86, 95%CI:0.80-0.92). Conclusions: For Black and Hispanic patients with non-metastatic pancreatic cancer, there was no difference in OS associated with receipt of treatment at MSH, despite differences in patient demographics and hospital characteristics. Further study is required to identify sources and impact of disparities in cancer care.

Abstract PO-118: Patient and county level determinants of surgical treatment for non-small cell lung cancer: A SEER-Medicare analysis

Abstract Introduction: Rural lung cancer patients experience worse survival than urban lung cancer patients. Worse survival in early-stage rural lung cancer patients may be due lower utilization of surgical treatment compared to their urban counterparts. We examined patient- and county-level determinants of surgical treatment for non-small cell lung cancer, focusing on rural vs. urban disparities. Methods: Our sample included 63,767 localized and regional NSCLC cases diagnosed between 2003-2011 using SEER-Medicare data. Predictors examined included demographics, clinical characteristics, and county factors (urban versus rural designation, percent of the population ≥65 years old below 100% Federal Poverty Limit, and designation as a Medically Underserved Area). Patient characteristics were nested within counties in multilevel logistic regression models stratified by stage at diagnosis, predicting receipt of surgical treatment. Results: Rural residents were less likely to receive surgical treatment than urban residents (42.0% vs. 46.8%, p&amp;lt;0.01), and black patients were less likely than white patients to receive surgery (32.9% vs. 47.1%, p&amp;lt;0.01). Rurality did not remain a significant factor in the final adjusted model. The final model showed an odds of surgical treatment decreased for every 5% increase in county-level poverty for both local stage (OR=0.83, 95% CI:0.77-0.91) and regional stage (OR=0.84, 95%CI: 0.79-0.90). Other patient factors associated with lower likelihood of surgical treatment included older age, male sex, non-married, dual Medicare/Medicaid enrollment, and more comorbidities. Conclusions: Rurality was not associated with receipt of surgery in the final multilevel model, but patient race and county-level poverty were significantly associated with a lower odds of surgery. Future research is needed to understand the causes of these disparities in surgical treatment of lung cancer to maximize survival for all populations. Citation Format: Cassie Lewis Odahowski, Anthony J. Alberg, Mario Schootman, Jiajia Zhang, Jan M. Eberth. Patient and county level determinants of surgical treatment for non-small cell lung cancer: A SEER-Medicare analysis [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-118.

Colorectal cancer treatment in people with severe mental illness: a systematic review and meta-analysis.

People with severe mental illness (SMI) have a greater risk of dying from colorectal cancer (CRC), even though the incidence is lower or similar to that of the general population This pattern is unlikely to be solely explained by lifestyle factors, while the role of differences in cancer healthcare access or treatment is uncertain. We undertook a systematic review and meta-analysis on access to guideline-appropriate care following CRC diagnosis in people with SMI including the receipt of surgery, chemo- or radiotherapy. We searched for full-text articles indexed by PubMed, EMBASE, PsychInfo and CINAHL that compared CRC treatment in those with and without pre-existing SMI (schizophrenia, schizoaffective, bipolar and major affective disorders). Designs included cohort or population-based case-control designs. There were ten studies (sample size = 3501-591 561). People with SMI had a reduced likelihood of surgery (RR = 0.90, 95% CI 0.92-0.97; p = 0.005; k = 4). Meta-analyses were not possible for the other outcomes but in results from individual studies, people with SMI were less likely to receive radiotherapy, chemotherapy or sphincter-sparing procedures. The disparity in care was greatest for those who had been psychiatric inpatients. People with SMI, including both psychotic and affective disorders, receive less CRC care than the general population. This might contribute to higher case-fatality rates for an illness where the incidence is no higher than that of the general population. The reasons for this require further investigation, as does the extent to which differences in treatment access or quality contribute to excess CRC mortality in people with SMI.

Cardiac surgery receipt and outcomes for people using secondary mental healthcare services: Retrospective cohort study using a large mental healthcare database in South London.

Patients diagnosed with mental health problems are more predisposed to cardiovascular disease, including cardiac surgery. Nevertheless, health outcomes after cardiac surgery for patients with mental health problems as a discrete group are unknown. This study examined the association between secondary care mental health service use and postoperative health outcomes following cardiac surgery. We conducted a retrospective observational research, utilizing data from a large South London mental healthcare supplier linked to national hospitalization data. OPCS-4 codes were applied to classify cardiac surgery. Health results were compared between those individuals with a mental health disorder diagnosis from secondary care and other local residents, including the length of hospital stay (LOS), inpatient mortality, and 30-day emergency hospital readmission. Twelve thousand three hundred and eighty-four patients received cardiac surgery, including 1,481 with a mental disorder diagnosis. Patients with mental health diagnosis were at greater risk of emergency admissions for cardiac surgery (odds ratio [OR] 1.60; 1.43, 1.79), longer index LOS (incidence rate ratio 1.28; 1.26, 1.30), and at higher risk of 30-day emergency readmission (OR 1.53; 1.31, 1.78). Those who underwent pacemaker insertion and major open surgery had worse postoperative outcomes during index surgery hospital admission while those who had major endovascular surgery had worse health outcomes subsequent 30-day emergency hospital readmission. People with a mental health disorder diagnosis undertaking cardiac surgery have significantly worse health outcomes. Personalized guidelines and policies to manage preoperative risk factors require consideration and evaluation.

Facility-level national trends in racial disparities of surgical therapy for early-stage lung cancer

ObjectiveThe racial gap in surgical treatment for early-stage non–small cell lung cancer (NSCLC) has been narrowing at the population level, but it is unknown if this trend persists at the facility level. Patients and MethodsWe queried the National Cancer Database Participant User File from 2006 to 2016 for patients with stage I NSCLC. Facilities were grouped by type, location, and resection volume. The cumulative surgery rate for Black and White patients in each group was calculated, and an incidence rate difference of receipt of surgery was determined. Logistic regression with estimation of marginal effects was used to assess the probability difference of receiving surgery in Black versus White patients in each year. ResultsIn total, 315,474 patients were included; 287,585 (91.2%) were White and 27,889 (8.8%) were Black. The surgery rate was greater for White patients (60.2% vs 55.8%, P < .001). For most groups, the surgery disparity narrowed over the study period. The disparity widened in community cancer programs; facilities in the New England, West North Central, and Pacific regions; and the lowest volume facilities. The probability difference for receiving surgery was significantly smaller in 2016 versus 2006 in the Middle Atlantic region and community cancer programs; the difference was unchanged for all other groupings. ConclusionsTrends in disparities in the use of resection for early-stage NSCLC are not universal across facility groupings. As efforts are made toward addressing racial disparities in surgical care for NSCLC, it will be important to remember that population-level analyses may mask lack of progress in certain facility groups.

From street address to survival: Neighborhood socioeconomic status and pancreatic cancer outcomes

BackgroundNeighborhood factors may influence cancer care through physical, economic, and social means. This study assesses the impact of neighborhood socioeconomic status on diagnosis, treatment, and survival in pancreatic cancer. MethodsPatients with pancreatic adenocarcinoma were identified in the 2010–2016 Surveillance Epidemiology and End Results database. Neighborhood socioeconomic status (divided into tertiles) was based on an National Cancer Institute census tract-level composite score, including income, education, housing, and employment. Multivariate models predicted metastasis at time of diagnosis and receipt of surgery for early-stage disease. Overall survival compared via Kaplan-Meier and Cox proportional hazards. ResultsFifteen thousand four hundred and thirty-six patients (29.7%) lived in low neighborhood socioeconomic status, 17,509 (33.7%) in middle neighborhood socioeconomic status, and 19,010 (36.6%) in high neighborhood socioeconomic status areas. On multivariate analysis, neighborhood socioeconomic status was not associated with metastatic disease at diagnosis (low neighborhood socioeconomic status odds ratio 1.02, 95% confidence interval 0.97–1.07; ref: high neighborhood socioeconomic status). However, low neighborhood socioeconomic status was associated with decreased likelihood of surgery for localized/regional disease (odds ratio 0.60, 95% confidence interval 0.54–0.68; ref: high neighborhood socioeconomic status) and worse overall survival (low neighborhood socioeconomic status hazard ratio 1.18, 95% confidence interval 1.15–1.21; ref: high neighborhood socioeconomic status). ConclusionPatients from resource-poor neighborhoods are less likely to receive stage-appropriate therapy for pancreatic cancer and have an 18% higher risk of death.

Validity of breast cancer surgery treatment information in a state-based cancer registry.

PurposeSurgery is an important part of early stage breast cancer treatment that affects overall survival. Many studies of surgical treatment of breast cancer rely on data sources that condition on continuous insurance coverage or treatment at specified facilities and thus under-sample populations especially affected by cancer care inequities including the uninsured and rural populations. Statewide cancer registries contain data on first course of cancer treatment for all patients diagnosed with cancer but the accuracy of these data are uncertain.MethodsPatients diagnosed with stage I–III breast cancer between 2003 and 2016 were identified using the North Carolina Central Cancer Registry and linked to Medicaid, Medicare, and private insurance claims. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and Kappa statistics for receipt of surgery and type of surgery (breast conserving surgery or mastectomy) using the insurance claims as the presumed gold standard. Analyses were stratified by race, insurance type, and rurality.ResultsOf 26,819 patients who met eligibility criteria, 23,125 were identified as having surgery in both the claims and registry for a sensitivity of 97.9% (95% CI 97.8%, 98.1%). There was also strong agreement for surgery type between the cancer registry and the insurance claims (Kappa: 0.91). Registry treatment data validity was lower for Medicaid insured patients than for Medicare and commercially insured patients.ConclusionsCancer registry treatment data reliably identified receipt and type of breast cancer surgery. Cancer registries are an important source of data for understanding cancer care in underrepresented populations.

Association of race and health insurance in treatment disparities of colon cancer: A retrospective analysis utilizing a national population database in the United States.

Both health insurance status and race independently impact colon cancer (CC) care delivery and outcomes. The relative importance of these factors in explaining racial and insurance disparities is less clear, however. This study aimed to determine the association and interaction of race and insurance with CC treatment disparities. Retrospective cohort review of a prospective hospital-based database. In this cross-sectional study, patients diagnosed with stage I to III CC in the United States were identified from the National Cancer Database (NCDB; 2006 to 2016). Multivariable regression with generalized estimating equations (GEEs) were performed to evaluate the association of insurance and race/ethnicity with odds of receipt of surgery (stage I to III) and adjuvant chemotherapy (stage III), with an additional 2-way interaction term to evaluate for effect modification. Confounders included sex, age, median income, rurality, comorbidity, and nodes and margin status for the model for chemotherapy. Of 353,998 patients included, 73.8% (n = 261,349) were non-Hispanic White (NHW) and 11.7% (n = 41,511) were non-Hispanic Black (NHB). NHB patients were less likely to undergo resection [odds ratio (OR) 0.66, 95% confidence interval [CI] 0.61 to 0.72, p < 0.001] or to receive adjuvant chemotherapy [OR 0.83, 95% CI 0.78 to 0.87, p < 0.001] compared to NHW patients. NHB patients with private or Medicare insurance were less likely to undergo resection [OR 0.76, 95% CI 0.63 to 0.91, p = 0.004 (private insurance); OR 0.59, 95% CI 0.53 to 0.66, p < 0.001 (Medicare)] and to receive adjuvant chemotherapy [0.77, 95% CI 0.68 to 0.87, p < 0.001 (private insurance); OR 0.86, 95% CI 0.80 to 0.91, p < 0.001 (Medicare)] compared to similarly insured NHW patients. Although Hispanic patients with private and Medicare insurance were also less likely to undergo surgical resection, this was not the case with adjuvant chemotherapy. This study is mainly limited by the retrospective nature and by the variables provided in the dataset; granular details such as continuity or disruption of insurance coverage or specific chemotherapy agents or dosing cannot be assessed within NCDB. This study suggests that racial disparities in receipt of treatment for CC persist even among patients with similar health insurance coverage and that different disparities exist for different racial/ethnic groups. Changes in health policy must therefore recognize that provision of insurance alone may not eliminate cancer treatment racial disparities.

Impact of Biological Sex on Survival Outcomes in Low-Grade Glioma

Low-grade glioma (LGG) is a heterogeneous group of brain tumors for which accurate determination of prognosis and optimal therapeutics remains challenging. Recent evidence suggests a correlation between female biological sex and favorable survival in patients with high-grade glioma. However, in patients with LGG, the impact of biological sex and other socioeconomic and treatment factors on survival is not well understood. In the present study, we aim to elucidate the relationship between biological sex and survival outcomes in LGG. We hypothesize that female sex is associated with favorable survival outcomes.Using the National Cancer Database (NCDB), a retrospective analysis of patients with LGG diagnosed between 2004 and 2016 in the United States was performed. Demographic, tumor, and treatment data were abstracted; patients with missing information were excluded. Survival outcomes and factors associated with survival were assessed with the Kaplan-Meier and Cox proportional hazard methods.22,822 evaluable patients were identified in the NCDB. The median age was 48 years (range: 18 to 90). 44.2% of patients were female. 89% of patients were white, 5.9% were black, and 4.9% were of other or unknown race. 67% of patients had surgery, 49% of patients had radiation, and 42% had chemotherapy. The median follow-up time for the cohort was 38.8 months. Median overall survival (OS) for the cohort was 79 months. On Kaplan-Meier analysis, females had statistically significantly favorable survival outcomes: Ten-year overall survival was 44.1% for females and 38.5% for males (P < 0.001). Median OS was 7.3 years (95% confidence interval [CI] 6.9-7.8) for females and 6.1 years (95% CI 5.8-6.3) for males. On univariate analysis, age, sex, insurance status, Charlson-Deyo score, receipt of surgery, receipt of chemotherapy, and receipt of radiation were associated with survival; race was not associated with survival. On multivariable Cox regression analysis, after adjusting for patient factors (age, sex, Charlson-Deyo score, and insurance status) and treatment factors (surgery, chemotherapy, and radiation), female sex was significantly associated with decreased risk of death (hazard ratio [HR] 0.92, 95% CI 0.88-0.96, P < 0.01). Other factors associated with decreased risk of death were receipt of radiation (HR 0.67, 95% CI 0.63-0.70, P < 0.01), receipt of surgery (HR 0.58, 95% CI 0.55-0.61, P < 0.01), and receipt of chemotherapy (HR 0.94, 95% CI 0.90-0.99, P = 0.018). Factors associated with increased risk of death were higher Charlson-Deyo score (HR 1.2, 95% CI 1.18-1.25, P < 0.01) and Medicaid/uninsured/unknown insurance status (HR 1.2, 95% CI 1.11-1.26, P < 0.01).In this large national cohort, female biological sex was associated with improved survival outcomes in LGG. Biological sex should be viewed as an important prognostic factor in LGG, and further study of the underlying mechanisms and clinical implications of this finding are warranted.S.S. Kilic: None. K. Yang: None. S. Kilic: None. A. Halima: None. J.H. Suh: Consultant; Philips, Novocure. Met to discuss current indications for TTF; Novocure. Met during 1 day retreat to discuss future of radiation oncology; Philips. Scientific advisory board; Neutron Therapeutics. T.A. Chan: None. J.S. Yu: None. S.T. Chao: Honoraria; Varian Medical Systems, Zeiss, AbbVie. Consultant; AbbVie. D. Peereboom: None. Y. Rauf: None. G. Stevens: None. D.Y. Park: None. M. Ahluwalia: Research Grant; AstraZeneca, Bristol Meyers Squibb, Bayer, Incyte, Pharmacyclics, Novocure, Mimivax, Merck. Consultant; Bayer, Novocure, Kiyatec, Insightec, GlaxoSmithKline, Nuvation, Cellularity, Apollomics. Stock; Doctible, Mimivax, Cytodyn. M.C. Tom: Research Grant; Blue Earth Diagnostics. E.S. Murphy: None.

Incidence and Impact of Lymphopenia Associated With Total Neoadjuvant Therapy for Low-Lying Rectal Tumors

To assess incidence of lymphopenia and its association with outcomes in patients treated with total neoadjuvant therapy (TNT) for low-lying rectal tumors.Patients with Stage II-III, low rectal adenocarcinomas treated from 2015-2018 with TNT were retrospectively reviewed. All patients were candidates for an APR surgical resection, but were treated with intent to omit surgery if they had a clinical complete response. All patients received definitive radiation (median dose 54 Gy, range 50-56 Gy, at 1.8-2 Gy/fx) with concurrent capecitabine, with additional chemotherapy (CT) delivered either prior to or following chemoradiation (CRT). Institutional results on patient outcomes have previously been reported with a clinical complete response rate of 75%; with only 19% of those ultimately requiring surgery for local recurrence. Absolute lymphocyte counts (ALC) were collected prior to initiating CRT and at 3-month intervals following CRT and graded based on severity of lymphopenia (absolute lymphocyte count < 1000/mm3) using CTCAE v5.0. A Cox proportional hazards model was used to identify if degree of lymphopenia was associated with receipt of surgery (as surgery was only performed for either incomplete response or local recurrence).A total of 28 patients with low rectal cancers were treated with TNT during this period, with ALC analyzed for the 26 who had detailed lymphocyte data available. 7 patients were treated with CT followed by CRT, receiving a median of 8 (range 4-8) cycles of CT, and 18 patients were treated with CRT followed by CT, receiving a median of 6 cycles (range 1-9). One patient refused CT after CRT. Prior to initiating CRT, the median ALC was 1,665/mm3 (range, 710-3,060/mm3), with lymphopenia present in only 4 patients (1 neoadjuvant CT and 3 adjuvant CT). The median ALC nadir during CRT was 450/mm3 (range, 230-900/mm3), with all 26 patients experiencing lymphopenia during the course of CRT: 4% Grade 1, 35% Grade 2, 61% Grade 3, and 0% Grade 4. Rates of lymphopenia at 3-, 6-, and 12-months post CRT were 73%, 81%, and 42%, respectively. On Cox regression analysis, increased pre-CRT and 12-month post-CRT lymphocyte counts were associated with a decreased risk of need for surgery (P < 0.05) and remained significant when accounting for the sequencing of CT, while lymphocyte count nadir during CRT and 3-/6-month post-CRT levels were not (P > 0.05).Despite the frequency of lymphopenia during CRT, the degree of lymphopenia during and up to 6 months after CRT did not appear to predict future surgery. However, increased pre-CRT and 12-month post-CRT ALC were associated with decrease need of surgery. CRT produces both oxidative stress and immune response stimulation to kill cancer cells. Patients with higher pre-CRT and 12-month post-CRT ALC may represent a population with more robust immune systems, producing more favorable tumor responses. Additional studies are warranted.

Prevalence, variability, and predictors of sinus surgery in pediatric patients with cystic fibrosis.

Chronic rhinosinusitis is common among individuals with cystic fibrosis (CF) and has an impact on quality of life. Sinus surgery is a treatment option, but minimal literature exists regarding prevalence and indications. Using the linked CF Foundation Patient Registry (CFFPR) - Pediatric Health Information Systems (PHIS) database, we investigated variability in receipt of surgery, predictors of surgery, and time to first surgery. We included individuals less than 18 receiving care between 2006 and 2015 at a CF Foundation care program that is also a PHIS-participating-hospital. We used logistic regression to examine predictors of receipt of surgery and a Kaplan-Meier curve to examine time to first surgery among those born 2005-2007. There were 11,545 children and adolescents and 2156 (18.7%) received at least one surgery. Variation in number of surgeries was observed across hospitals (median: 63 [IQR, 33-110]). There was an inconsistent pattern between receipt of surgery and markers of disease severity; those receiving surgery having increased odds of treatment use and pulmonary exacerbations and decreased odds of lower lung function and body mass index. Among the cohort of young children, 159 (14%) had at least one surgery with a median age at first surgery of 5.6 (IQR, 3.9-7.0). The use of sinus surgery is frequent, but variable, among children and adolescents. Clinical factors are associated with receipt of surgery, but further understanding is needed on other factors that impact variability in use. Our study indicates the need for additional evaluation of the management of CF-related CRS and indications for surgery.

Asian American ethnic subgroup disparities in time to surgical treatment for breast cancer in the California Cancer Registry.

101 Background: Health risks and outcomes among Asian American patients are not adequately understood when Asians are treated as a homogenous ethnic group. This work is the first to explore trends in time to surgical treatment for breast cancer amongst Asian American ethnic subgroups. Methods: We used data from the population-based California Cancer Registry to identify a cohort of females diagnosed with invasive breast cancer between 2012-2017 in California. Time to surgical treatment was defined as the time elapsed between definitive diagnosis of breast cancer and receipt of surgery. Covariates included individual patient sociodemographic, health history, and tumor characteristics. Multivariable logistic regression was used to determine the odds of receiving surgery within 30 and 90 days of breast cancer diagnosis and multivariable Cox proportional hazards regression was used to analyze the likelihood of shorter time to surgery. A Bonferroni corrected alpha level was used to account for multiple racial/ethnic group comparisons. Results: Of 106,441 breast cancer patients, 57% were non-Hispanic white (NHW), 21% were Hispanic, 14% were Asian (4% Filipino; 3% Chinese; 1% each of Asian Indian or Pakistani (AIP), Vietnamese, Japanese, and Korean; 3% other Asian), and 6% were non-Hispanic black (NHB). Compared to NHWs, Hispanics (OR = 0.86, 99.5% CI = 0.82-0.92) and NHBs (OR = 0.82, 99.5% CI = 0.76-0.90) were less likely to receive surgery within 30 days of breast cancer diagnosis, while Chinese (OR = 1.30, 99.5% CI = 1.17-1.45) and AIPs (OR = 1.24, 99.5% CI = 1.04-1.48) were more likely to receive surgery within 30 days. These trends persisted for Hispanic (OR = 0.87, 99.5% CI = 0.79-0.96), NHB (OR = 0.73, 99.5% CI = 0.63-0.85), and Chinese patients (OR = 1.33, 99.5% CI = 1.04-1.71) when analyzing the likelihood of receiving surgery within 90 days of diagnosis. Compared to NHWs, Hispanics (OR = 0.94, 99.5% CI = 0.92-0.97), NHBs (OR = 0.88, 99.5% CI = 0.85-0.91), and Vietnamese (OR = 0.90, 99.5% CI = 0.83-0.98) were less likely to experience shorter time to surgical treatment, while Chinese (OR = 1.15, 99.5% CI = 1.09-1.21) and AIPs (OR = 1.09, 99.5% CI = 1.01-1.18) were more likely to have shorter time to surgery. Conclusions: In this population-based study of the California Cancer Registry, trends in time to surgical treatment for breast cancer were not consistent for patients belonging to different Asian ethnic subgroups. While Chinese and AIP patients tended to receive surgery sooner than NHW patients, Vietnamese patients face a disparity in receiving timely surgical treatment relative to NHW patients. Further research is needed to fully understand and appropriately target disparities in breast cancer treatment for patients of different Asian American ethnic subgroups.

Surgical Services for Breast Cancer Patients in Australia, is There a Gap for Aboriginal and/or Torres Strait Islander Women?

Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women. This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians. The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes. Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.