Cancer surgeons' attitudes and practices about discussing the chance of operative “cure”

Development and Validation of a Machine-Learning Model to Predict Early Recurrence of Intrahepatic Cholangiocarcinoma

BACKGROUND

The high incidence of early recurrence after hepatectomy for intrahepatic cholangiocarcinoma (ICC) has a detrimental effect on overall survival (OS). Machine-learning models may improve the accuracy of outcome prediction for malignancies.

METHODS

Patients who underwent curative-intent hepatectomy for ICC were identified using an international database. Three machine-learning models were trained to predict early recurrence (< 12 months after hepatectomy) using 14 clinicopathologic characteristics. The area under the receiver operating curve (AUC) was used to assess their discrimination ability.

RESULTS

In this study, 536 patients were randomly assigned to training (n = 376, 70.1%) and testing (n = 160, 29.9%) cohorts. Overall, 270 (50.4%) patients experienced early recurrence (training: n = 150 [50.3%] vs testing: n = 81 [50.6%]), with a median tumor burden score (TBS) of 5.6 (training: 5.8 [interquartile range {IQR}, 4.1-8.1] vs testing: 5.5 [IQR, 3.7-7.9]) and metastatic/undetermined nodes (N1/NX) in the majority of the patients (training: n = 282 [75.0%] vs testing n = 118 [73.8%]). Among the three different machine-learning algorithms, random forest (RF) demonstrated the highest discrimination in the training/testing cohorts (RF [AUC, 0.904/0.779] vs support vector machine [AUC, 0.671/0.746] vs logistic regression [AUC, 0.668/0.745]). The five most influential variables in the final model were TBS, perineural invasion, microvascular invasion, CA 19-9 lower than 200 U/mL, and N1/NX disease. The RF model successfully stratified OS relative to the risk of early recurrence.

CONCLUSIONS

Machine-learning prediction of early recurrence after ICC resection may inform tailored counseling, treatment, and recommendations. An easy-to-use calculator based on the RF model was developed and made available online.

Physician-Centered Outcomes for Skin Cancer Treatment: A Single-Day Modified Delphi Process to Assess the Importance of Themes in Skin Cancer Management

BACKGROUND

Success in skin cancer treatment is determined through outcome measurement. Patients and physicians may prioritize different outcomes of care, and identification of such may enhance patient-centered care.

OBJECTIVE

To identify gaps between patient and physician attitudes toward skin cancer outcomes.

MATERIALS AND METHODS

A single-day, 21-patient, modified, in-person Delphi process to solicit and rate the importance of skin cancer-related outcomes was conducted. Twelve masked dermatologic surgeons rated patient-generated outcomes in a 2-round modified Delphi process. Each item was rated on a 1 to 9 scale (1, least important; 9, most important) using the Qualtrics web platform (Qualtrics, Provo, UT). Results of the physician ratings were compared with the patient ratings.

RESULTS

A list of 53 skin cancer treatment-related themes and outcomes was generated. Eight items were ranked by physicians as "very high" (>80% importance), 5 as "high" (>70% importance), 19 as intermediate, and 21 as low. The physician and patient panels' ratings were concordant for 56% of items, whereas 7 outcome items showed a 2-category discordance.

CONCLUSION

Physicians and patients were concordant regarding skin cancer treatment on multiple spheres. Areas of discordance include patient fear of unknown future risk, recurrence, or empowering patients to make treatment choices, and may be areas of continued improvement for delivery of patient-centered care.

Palliative Care Utilization among Patients Admitted for Gastrointestinal and Thoracic Cancers

BACKGROUND

Although a growing body of literature recommends the early initiation of palliative care (PC), the use of PC remains variable.

OBJECTIVE

The current study sought to describe the use of PC and to identify factors associated with the use of inpatient PC.

DESIGN

Retrospective, cross-sectional analysis of data from the National Inpatient Sample.

SETTING AND SUBJECTS

Patients admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer from 2012 to 2013.

MEASUREMENTS

In-hospital length of stay (LOS), morbidity, mortality, and total charges.

RESULTS

A total of 282,899 patients were identified who met inclusion criteria of whom, 24,100 (8.5%) patients received a PC consultation during their inpatient admission. Patients who received PC were more likely to have a longer LOS (LOS >14 days: 5.4% vs. 9.4%) and were more likely to develop a postoperative complication (28.3% vs. 45.9%, both p < 0.001). Inpatient mortality was significantly higher among patients who had received PC than those who did not (5.4% vs. 44.1%, p < 0.001). On multivariable analysis, patient age (age ≥75 years: Odds Ratio [OR] = 2.54, 95% CI: 2.33-2.78), comorbidity (CCI >6: OR = 2.60, 95% CI: 2.48-2.74), and admission to larger hospitals (reference small: OR = 1.20, 95% CI: 1.14-1.25) were associated with greater odds of receiving PC (all p < 0.05). Patients who underwent a major operation during their inpatient admission demonstrated 79% lower odds of receiving PC (OR = 0.21, 95% CI: 0.20-0.22, p < 0.001).

CONCLUSIONS

Among patients admitted for cancer, PC services were used in 8.5% of patients during their inpatient admission with surgical patients being 79% less likely to receive a PC consultation. Further research is required to delineate the barriers to the use of PC so as to promote the use of PC among high-risk patients.

Palliative care physicians' experiences of end-of-life communication: A focus group study

The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.