Effect of academic status on outcomes of surgery for rectal cancer

Health Disparities among Patients with Cancer Who Received Molecular Testing for Biomarker-Directed Therapy

Health disparities present a barrier to successful oncology treatment. The potential for precision oncology to reduce health disparities has not previously been analyzed. We performed a retrospective analysis of 12,627 patients from six major cancer centers whose tumors underwent molecular testing at Caris Life Sciences between 2010 and 2020. Kaplan-Meier and Cox regression were used to describe and analyze overall survival. The molecular and demographic features of the cohort were analyzed by χ2 and ANOVA tests. Black patients composed 25% of the cohort and White patients 63%. Among this molecularly-tested cohort, there were minimal outcome differences based on race, geographic location, or poverty level. When analyzing the interaction of age, race, and sex, racial-based disparities were noted primarily for young non-White women in the study cohort but were more pronounced for men and women of all ages in the broader patient population within the Surveillance, Epidemiology, and End Results database. Mutations in five genes-APC, EGFR, STK11, TP53, and KRAS-were found to affect overall survival among our cohort, and their prevalence varied by race in specific tumor types. Real-world outcomes data in mutation-defined cohorts also provided additional context to previously reported therapeutic response trends. Our study shows that patients who undergo molecular testing display reduced racial health disparities compared with the general population, whereas persistent racial disparities are influenced by age and sex. Genomic-driven racial disparities should be examined at a tumor lineage-specific level. Increased access to molecular testing for all eligible patients may play a role in improving health equity. Significance: This study is the largest of its kind to analyze health disparities and genomic features among a diverse multiinstitutional cohort of patients who underwent molecular testing. Continuing to increase awareness of and access to molecular testing approaches may help to reduce cancer health disparities and improve outcomes for all patients.

Minimally Invasive Lower Anterior Resections - Better than Open But Not All the Same

Background/Objective: Optimal approach for lower anterior resection has been closely debated. The relatively new addition of the robotic approach adds a layer of complexity to this topic. The majority of the literature has compared the possible approaches between two techniques; however, only a few studies have comprehensively compared all 3 approaches at the same time, especially in a non-academic center.Study Design: This is a retrospective cohort study of a prospectively maintained database of data from a large group of private-practice colorectal surgeons in a large metropolitan area. Specifically, rectal resections using open, laparoscopic, and robotic approaches were queried. A total of 130 patients underwent open, laparoscopic, or robotic oncological lower anterior resection from 2016 to January 2020.Results: Statistical significance of length of stay was noted between the three approaches with the mean length of stay for open being 8.08 days, laparoscopic being 7.04 days, and robotic being 4.96 days (P < .005). No statistical significance was noted for estimated blood loss, operating time, or postoperative complications including anastomotic leak, ileus, pneumonia, pulmonary embolism, surgical site infection, and urinary tract infection. When directly comparing any minimally invasive surgery approach to open, estimated blood loss was decreased in addition to the shortened length of stay (P < .05).Conclusions: This study demonstrates that MIS LAR has significant benefit over the open approach. However, finding that robotic surgery had was superior to laparoscopic LAR which was surprising and important. This experience in the private world raises the question as to whether robotic LAR should be considered the standard of care.

Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review

Background

Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS.

Methods

A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration.

Results

A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS.

Conclusion

Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.

Adoption of single agent anticancer therapy for advanced hepatocellular carcinoma and impact of facility type, insurance status, and income on survival: Analysis of the national cancer database 2004-2014

Background

This study analyzes the pattern of use of single agent anticancer therapy (SAACT) in the treatment and survival of advanced hepatocellular carcinoma (aHCC) before and after sorafenib was FDA approved in 2007.

Methods

Adult patients diagnosed with HCC and treated with only ACT from 2004 – 2014 were identified in NCDB database. Patients were analyzed during three time frames: 2004–2006 (pre‐sorafenib (PS)), 2007–2010 (early sorafenib (ES)) and 2011–2014 (late sorafenib (LS)). Cox proportional hazards models and Kaplan‐Meier method were used for analyses.

Results

The NCDB contained 31,107 patients with HCC diagnosed from 2004–2014 and treated with ACT alone. Patients were generally men (78.0%), >50 years of age (92.5%). A significant increase in the rate of adaption of SAACT was observed over time: 6.2% PS, 15.2% ES, and 22.2% LS (p < 0.0001). During this later period, the highest proportion of SAACT is among academic and integrated network facilities (23.3%) as compared to community facilities (17.0%, p < 0.0001). The median overall survival of patients with aHCC treated only with SAACT improved significantly over time from 8.0 months (m) (95% CI: 7.4–8.8) to 10.7 m (10.4–11.2) to 15.6 m (15.2–16.0, p < 0.001). Multivariate analysis indicates worse outcomes for patients treated at community cancer programs (HR 1.28, (5% CI: 1.23–1.32), patients without insurance (HR 1.11, 1.06–1.16) and estimated household income of <$63,000 (HR 1.09, 1.05–1.13).

Conclusion

aHCC patients treated only with ACT have experienced an overall improvement in survival, but significant differences exist between facility type, insurance status, and income.

Comparing outcomes for non-metastatic rectal cancer in academic vs. community centers: A propensity-matched analysis of the National Cancer Database

BACKGROUND

Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions.

METHODS

The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression.

RESULTS

After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen.

CONCLUSIONS

No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.

Operative outcome of laparoscopic colorectal cancer surgery in a regional hospital in a developing country: A propensity score-matched comparative analysis

OBJECTIVE

Laparoscopic surgery is an alternative procedure for colorectal cancers. However, high-level supporting evidence has been derived from high-volume centers in developed countries. During the early phase of applying the laparoscopic approach, we evaluated the procedure's short-term outcomes in our regional middle-volume hospital in a developing country.

METHODS

We retrospectively analyzed data for a cohort of 223 colorectal cancer patients who underwent elective surgery from October 2017 to September 2019. We compared 165 patients undergoing open surgery (OS group) with 58 undergoing laparoscopic surgery (LS group) using a propensity score-matched analysis.

RESULTS

After matching, each group contained 58 patients for evaluating outcomes. The LS group had more harvested mesenteric lymph nodes (5.0 nodes, 95% confidence interval (CI): 1.8-8.1; p-value: <0.01) with comparable blood loss (p-value: 0.54) and margin status (p-value: 0.66). However, LS was more time-consuming (68.8 min longer; 95% CI: 53.0-84.7; p-value: <0.01). Morbidity and mortality rates were equivalent (odds ratio (OR): 1.3, 95% CI: 0.25-2.73, p-value: 0.74, and OR: 2, 95% CI: 0.18-22.1, p-value: 0.57, respectively). The LS group experienced fewer days to begin normal eating (-0.5 days, 95% CI: -0.9 to -0.1, p-value: 0.04) and shorter hospital stay (-1.5 days, 95% CI: -2.7 to -0.4, p-value: <0.01). The conversion rate was 3.5%.

CONCLUSION

The laparoscopic approach was applicable even in a regional middle-volume hospital in a developing country. However, longer surgical time was a drawback.

Academic Affiliation and Surgical Volume Predict Survival in Head and Neck Cancer Patients Receiving Surgery

OBJECTIVE

To determine whether the academic affiliation or surgical volume affects the overall survival (OS) of human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC) patients receiving surgery.

METHODS

A retrospective study of 39 North Carolina Medical Centers was conducted. Treatment centers were classified as academic hospitals, community cancer centers, or community hospitals and were divided into thirds by volume. The primary outcome was 5-year OS. Hazard ratios (HR) were determined using Cox proportional hazard models, adjusting for demographics, tumor site, stage, insurance status, tobacco use, alcohol use, stage, chemotherapy, and radiation therapy. Patients were also stratified by stage (early stage and advanced stage).

RESULTS

Patients treated at community cancer centers had significantly better 5-year OS (HR 0.68, 95% confidence interval [CI] = 0.48-0.98), and patients treated at academic hospitals trended toward better 5-year OS (HR 0.72, 95% CI = 0.50-1.04) compared to patients treated at community hospitals. The effect for academic affiliation on survival was more pronounced for patients with advanced stage cancer at diagnosis (HR 0.60, 95% CI = 0.37-0.95). There were no significant survival differences among early stage patients by treatment center type. Top-third (HR = 0.64, 95% CI = 0.42-0.96) centers by surgical volume had significantly better 5-year OS, and middle-third (HR = 0.71, 95% CI = 0.51-1.03) centers by volume trended toward better 5-year OS when compared to the bottom-third centers by volume.

CONCLUSION

Patients treated at academic hospitals, community cancer centers, and hospitals in the top third by case volume have favorable survival for HPV-negative HNSCC. The effect for academic hospitals is most pronounced among advanced stage patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E479-E488, 2021.

Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database

BACKGROUND

As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer.

STUDY DESIGN

The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers.

RESULTS

35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937).

CONCLUSION

MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.