Patterns of inpatient surgeries for the top four cancers in the United States, National Hospital Discharge Survey, 1988-95

Colorectal cancer resection rates in patients with inflammatory bowel disease: a population-based study

Background and objective

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). This study aimed to analyse the trends in rates of resection for IBD-related CRC in the USA.

Methods

We used the Nationwide Inpatient Sample from 1995 to 2012. Temporal trends in age-adjusted rates of resection for CRC in the setting of IBD were analysed using multivariate Joinpoint regression models. The primary outcome was surgical resection of CRC in the setting of IBD.

Results

We included 3 597 168 IBD discharges in the present study, of which 275 479 underwent CRC resection between 1995 and 2012. The annual CRC resection rates among IBD population decreased significantly from 1995 to 2012. This decrease was significant in all age groups with an annual decrease of 393 (P < 0.001), 359 (P < 0.001), 293 (P < 0.001) and 159 (P < 0.001) per 100 000 IBD discharges between 1995 and 2012 for age groups 18-39, 40-49, 50-74 and >75 years, respectively. The annual IBD-CRC resection rate per 100 000 IBD discharges for proximal CRC decreased by 149 (P < 0.001), 130 (P < 0.001), 95 (P < 0.001) and 50 (P < 0.001), respectively, and the annual distal CRC resections per 100 000 IBD discharges decreased by 104 (P < 0.001), 123 (P < 0.001), 123 (P < 0.001) and 82 (P < 0.001), respectively, for age groups 18-39, 40-49, 50-74 and >75 years, between 1995 and 2012. On multivariate Poisson regression analysis, after adjustment for age and sex, CRC resections decreased by 3.9% each year from 1995 to 2012.

Conclusions

CRC resection rates among IBD patients have continued to decrease annually from 1995 to 2012. There is a population-level decrease in resection of both proximal and distal CRC reflecting a decreasing incidence of IBD-related CRC incidence in the USA.

Development of a mouse model of abdominal cutaneous flaps for breast reconstruction

Autologous tissue transfer, in addition to replacing tissue that was lost during injury or surgery, offers women an excellent option to improve cosmetic appearance and self-confidence following mastectomy due to breast cancer. However, flap necrosis is a complication in obese patients undergoing this procedure. We created a mouse model to study the flap-related complications that leads to decreased flap survival in autologous breast reconstruction.

Proximal and distal colorectal cancer resection rates in the United States since widespread screening by colonoscopy

BACKGROUND & AIMS

Screening decreases colorectal cancer (CRC) incidence and mortality. Colonoscopy has become the most common CRC screening test in the United States, but the degree to which it protects against CRC of the proximal colon is unclear. We examined US trends in rates of resection for proximal vs distal CRC, which reflect CRC incidence, in the context of national CRC screening data, before and since Medicare's 2001 decision to pay for screening colonoscopy.

METHODS

We used the Nationwide Inpatient Sample, the largest US all-payer inpatient database, to estimate age-adjusted rates of resection for distal and proximal CRC, from 1993 to 2009, in adults. Temporal trends were analyzed using Joinpoint regression analysis.

RESULTS

The rate of resection for distal CRC decreased from 38.7 per 100,000 persons (95% confidence interval [CI], 35.4-42.0) to 23.2 per 100,000 persons (95% CI, 20.9-25.5) from 1993 to 2009, with annual decreases of 1.2% (95% CI, 0.1%-2.3%) from 1993 to 1999, followed by larger annual decreases of 3.8% (95% CI, 3.3%-4.3%) from 1999 to 2009 (P < .001). In contrast, the rate of resection for proximal CRC decreased from 30.0 per 100,000 persons (95% CI, 27.4-32.5) to 22.7 per 100,000 persons (95% CI, 20.6-24.7) from 1993 to 2009, but significant annual decreases of 3.1% (95% CI, 2.3%-4.0%) occurred only after 2002 (P < .001). Rates of resection for CRC decreased for adults ages 50 years and older, but increased for younger adults.

CONCLUSIONS

These findings support the hypothesis that population-level decreases in rates of resection for distal CRC are associated with screening, in general, and that implementation of screening colonoscopy, specifically, might be an important factor that contributes to population-level decreases in rates of resection for proximal CRC.

Voiding dysfunction after pelvic colorectal surgery

Bladder dysfunction following colorectal surgery may be related to extirpative procedures in the region of the pelvic autonomic plexus. The most common etiology is from autonomic disruption during abdominoperineal or low anterior resections. Contemporary technical modifications have allowed surgeons to achieve oncologic control while preserving the autonomic nerves that innervate the bladder and sexual organs. Although these modifications have resulted in a significant decrease in the incidence of postoperative bladder dysfunction, bladder dysfunction continues to be a source of significant morbidity after surgery. In this patient population, symptoms are not reliable for accurate diagnosis. The use of urodynamics provides objective measurements of bladder and outlet function and are paramount in providing an accurate diagnosis and in recommending treatments. Follow-up and treatment are highly individualized based on urodynamic findings, patient expectations, patient abilities, and family support. This article provides an overview of pertinent neuroanatomy, diagnosis, urodynamic interpretation, and treatment related to bladder dysfunction following pelvic colorectal surgery.

Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery

BACKGROUND

Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume.

METHODS

Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression.

RESULTS

Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload.

CONCLUSION

The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.

Trends in Lung Surgery

BACKGROUND

Reports on the temporal evolution in lung resection are limited. To elucidate temporal changes in the demographics of lung resections, we analyzed nationally representative data that were collected for the National Hospital Discharge Survey from 1988 to 2002.

METHODS

Data collected between 1988 and 2002 were analyzed. Patients with International Classification of Diseases, ninth revision, clinical modification, procedure codes for lung resection were included in the sample. Three 5-year time periods were created (1988 to 1992, 1993 to 1997, and 1998 to 2002) to simplify the temporal analysis. Changes in the prevalence of procedures, age, gender, race, length of care, mortality, disposition status, and distribution by hospital size were evaluated. Trends in procedure-related complications were analyzed.

RESULTS

Between 1988 and 2002, a total of 512,758 lung resections were performed. Comparing the earliest to the most recent time period, we found increases in the average age (61.1 years [range, 1 to 89 years] vs 63.2 years [range, 1 to 91 years], respectively), in the proportion of patients who were female (40.1% vs 49.6%, respectively), and in the proportion of Medicare/Medicaid patients (43.8% vs 49%/4.7% vs 6.7%, respectively). Decreases in the average length of stay (12.9 days [range, 1 to 358 days] vs 9.1 days [range, 1 to 175 days], respectively) and in the proportion of patients discharged to their primary residence (86% vs 79.5%, respectively) were seen. The proportion of patients who had undergone lobectomies compared to other types of lung resection increased. Mortality rates were 5% vs 5.4%, respectively, while the frequency of complications decreased.

CONCLUSION

We identified temporal changes in lung resection surgery that may help in the construction of health-care policies to address the changing needs of and financial burdens on the health-care system.

The Use of Erythropoietin in Patients Undergoing Radical Prostatectomy: Effects on Hematocrit, Transfusion Rates and Quality of Life

OBJECTIVE

It was the aim of this study to prospectively study the effects on hematocrit levels, transfusion rates and quality of life (QOL) indices in men preoperatively supplemented with recombinant erythropoietin (rEPO) undergoing radical prostatectomy for clinically localized prostate cancer.

METHODS

Thirty men undergoing radical prostatectomy were randomized either to receive rEPO (n=25) or to serve as controls (n=25). Outcome measurements obtained preoperatively, as well as 10 days and 6 weeks postoperatively included serum hematocrit levels, transfusion rates and QOL indices (using SF-12 validated questionnaires).

RESULTS

The rEPO group had a significant increase in preoperative hematocrit (median increase=4 points; p=0.002). Although there were no significant differences in hematocrit at 10 days, the rEPO had a significantly higher hematocrit value at 6 weeks (p=0.0086). No differences were observed in transfusions rates between groups (4% in each group). SF-12 mental and SF-12 physical scores were not different between the two groups at any time point.

CONCLUSION

Preoperative administration of rEPO significantly increases preoperative and postoperative hematocrit levels. However, no differences were observed with regard to transfusion rates or postoperative QOL indices despite these higher hematocrit values.

Trends in prostate cancer incidence, hospital utilization and surgical procedures, Canada, 1981-2000

BACKGROUND

Numbers of new prostate cancer cases in Canada continue to increase because of increasing prostate cancer incidence, population growth, aging of the population, and earlier detection methods such as PSA (prostate-specific antigen) testing. Concern has been expressed that PSA-related increases in incidence will make unaffordable demands on Canadian hospital resources. Our objective is to relate increases in prostate cancer incidence to trends in hospitalizations and in- patient treatment.

METHODS

Hospitalizations with prostate cancer as primary diagnosis were obtained from the Hospital Morbidity Database, estimates of prostate cancer day surgery from the Discharge Abstract Database, newly diagnosed cases from the Canadian Cancer Registry, and prostate cancer deaths from the Vital Statistics Mortality Databases--all for the years 1981-2000.

RESULTS

Between 1981-2000, the number of new cases rose from 7,000 to 18,500 with a transient peak, 1991-1994. Hospitalizations rose parallel to the incidence until 1991 but then fell sharply in spite of further increasing incidence. The use of radical prostatectomy (RP) increased steadily, but transurethral prostatectomy and bilateral orchiectomy decreased in the 1990s. Decreases in length of stay and in number of hospitalizations resulted in considerably decreased annual hospital days for all prostate cancer in-patient procedures except RP, which remained level since 1993.

CONCLUSIONS

A net decrease in number of in-patient days occurred, despite the increasing number of new prostate cancer cases and the increasing use of radical prostatectomy. We concluded that increases in hospital utilization due to early detection programs, such as PSA testing, are unlikely to overwhelm in-patient services of Canadian hospitals.

Trends in in-patient Hospital Utilization and Surgical Procedures for Breast, Prostate, Lung and Colorectal Cancers in Canada

OBJECTIVE

To analyse population-based trends of in-patient surgical procedures for breast (female), prostate, lung and colorectal cancers.

METHODS

The Hospital Morbidity Files supplied hospital data and the Canadian Cancer Registry, incidence data. Age-adjusted rates were standardized to the 1991 Canadian population.

RESULTS

All four cancers showed major changes in trends of surgical procedures. For breast cancer, the rate of in-patient breast conservation surgery (BCS) increased from 1981 to the early 1990s while the rate of mastectomy decreased. Because day surgery was not included, the subsequent in-patient BCS rate stayed level. For prostate cancer, the rate of transurethral prostatectomy was initially high but decreased after 1990, while the rate of radical prostatectomy increased rapidly, only minimally affected by the PSA-related peak in incidence. The lung cancer lobectomy rate in men remained at 10/100,000 after 1986, but in women rose from 3/100,000 to 7/100,000, reflecting increasing lung cancer incidence. For colorectal cancer, right hemicolectomies and anterior resections increased, especially in men.

CONCLUSIONS

Surgery trends reflected changes in incidence and treatment preferences. Canadian trends were generally similar to US trends, although the timing of some of the changes differed. Canadians tended to use less invasive procedures such as BCS and anterior resection.

Expectant management: an option for localized prostate cancer

Localized prostate cancer demonstrates tremendous heterogeneity in the natural history of the disease. To this end, although prostate cancer may be present histologically in nearly 30% of all men above the age of 50 y, the lifetime risk of developing clinically significant disease is 18% (one in six). Furthermore, the lifetime risk of dying from prostate cancer is less than 4%. Therefore, in order to avoid unnecessarily treating potentially insignificant prostate cancer, the concept of expectant management has been considered for this disease. In this brief review, we discuss the evolution of expectant management for men with localized prostate cancer.

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.

Treatment options in the management of choroidal metastases

We performed a retrospective study of 40 consecutive patients (50 eyes) treated for choroidal metastases of solid systemic malignancies in order to evaluate treatment results. Patients received either systemic or local therapy or a combination of both. The most common primary tumor was breast carcinoma (62.5%). Systemic chemotherapy alone was used in 13.3% of eyes, local therapy alone in 44.4%, and a combination of both in 42.2% of eyes. Local treatment modalities included brachytherapy, external beam irradiation, and laser photocoagulation. Complete regression of the choroidal metastases was seen in 57.8% of eyes, partial regression in 15.6 and no response in 4.4%; 22.2% were not available for re-evaluation. We have concluded that the treatment modality in patients with metastatic ocular disease should be individually tailored. When ocular metastases are concurrent with widespread metastatic disease, systemic chemotherapy alone or in combination with local therapy is reasonable. In patients manifesting metastases in the eyes alone, local therapy modalities may be safe, allowing conservation of visual functions with minimal systemic morbidity.

Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival

OBJECTIVE

To examine the effects of demographic, geographical and socio-economic factors, and the influence of private health insurance, on patterns of prostate cancer care and 3-year survival in Western Australia (WA).

PATIENTS AND METHODS

The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of men diagnosed with prostate cancer between 1982 and 2001. The likelihood of having a radical prostatectomy (RP) was estimated using logistic regression, and the likelihood of death 3 years after diagnosis was estimated using Cox regression.

RESULTS

The proportion of men undergoing RP increased six-fold, from 3.1% to 20.1%, over the 20 years, whilst non-radical surgery (transurethral, open or closed prostatectomy) simultaneously halved to 29%. Men who had RP were typically younger, married and with less comorbidity. Patients with a first admission to a rural hospital were much less likely to have RP (odds ratio 0.15; 95% confidence interval, CI, 0.11-0.21), whereas residence alone in a rural area had less effect (0.54, 0.29-1.03). A first admission to a private hospital increased the likelihood of having RP (2.40, 2.11-2.72), as did having private health insurance (1.77, 1.56-2.00); being more socio-economically disadvantaged reduced RP (0.63, 0.47-0.83). The 3-year mortality rate was greater with a first admission to a rural hospital (relative risk 1.22; 95% CI 1.09-1.36) and in more socio-economically disadvantaged groups (1.34, 1.10-1.64), whereas those admitted to a private hospital (0.77, 0.71-0.84) or with private health insurance (0.82, 0.76-0.89) fared better. Men who had RP had better survival than those who had non-radical surgery (4.85, 3.52-6.68) or no surgery (6.42, 4.65-8.84), although this may be an artefact of a screening effect.

CONCLUSION

The 3-year survival was poorer and the use of RP less frequent in men from socio-economically and geographically disadvantaged backgrounds, particularly those admitted to rural or public hospitals, and those with no private health insurance.

Clinical strategies in the management of biochemical recurrence after radical prostatectomy

Prostate cancer is the most frequently diagnosed cancer and the second leading cause of cancer death in men, following lung cancer. Although radical prostatectomy continues to be a curative treatment for most patients diagnosed with prostate cancer, nearly 25% of patients undergoing radical prostatectomy will have biochemical recurrence as defined by an increase in serum prostate-specific antigen (PSA) level to >0.4 ng/mL after prostatectomy or a rapid doubling of the PSA over a 10-year follow-up period. The clinical challenges, an overview of available data, and a framework for the integration of this information for clinical management of biochemical recurrence postprostatectomy for prostate carcinoma are presented in this article. Therapeutic options, in addition to conservative management and watchful waiting, include radiation therapy and androgen deprivation. These options are discussed herein along with expected outcomes.

Breast volume replacement using the latissimus dorsi miniflap

BACKGROUND

Mastectomy is often recommended to women with early breast cancer who have large tumours or where the breast volume requiring resection to achieve adequate tumour clearance is too great to allow for a satisfactory cosmetic result after breast conservation surgery. The use of a latissimus dorsi muscular flap (latissimus dorsi miniflap (LDMF)) to replace the volume loss after major breast sector resection is an option where the tumour to breast volume ratio is large. The present study describes the technique and evaluates the experience of the LDMF at Royal Adelaide Hospital, Adelaide, Australia.

METHODS

Between August 1997 and April 2002, 18 women aged 37-64 years underwent wide local excision for primary breast cancer with LDMF reconstruction. Tumour characteristics, breast specimen weight and postoperative sequelae were assessed. Quality of life measurements and objective assessments of aesthetic outcome were evaluated.

RESULTS

Tumour diameter ranged from 13 to 80 mm (median 30 mm). Nine patients had multifocal or extensive intraductal component positive tumours. The weight of the resected specimens ranged from 75 to 395 g (median 130 g). There were no major postoperative complications, with a range of inpatient stay of 3-10 days. Seromas were aspirated in 14 patients but did not delay adjuvant treatment. Quality of Life results showed high patient satisfaction in all but one patient. A satisfactory cosmetic result was achieved in all but one patient who subsequently required mastectomy.

CONCLUSION

The LDMF procedure allows breast conservation to be achieved in women with large tumour to breast volume ratios, with satisfactory resection margins and good cosmetic and functional results. In the present experience standard oncological adjuvant treatment is not compromised.

An e-learning caregiving program for prostate cancer patients and family members

e-health interventions have the potential to augment caregiving training for management of chronic disease. Instruction on caregiving functions often key to patients and families' well being is time consuming but not reimbursable in our current health care system. A theoretically defined interactive multimedia program is described which would assess patient and family member's level of preparedness for specific caregiving functions for prostate cancer and provide tailored skill building vignettes on caregiving techniques. Maximizing today's technology, this program is best designed for a hybrid delivery utilizing both web-based resources and a CD-ROM. Feedback from 45 prostate patients and family members from a Midwest cancer center on perceived needs for caregiving training underscores the potential value of a computer supported intervention for some patients and families. Implementation of the software, marketing, and distribution will be guided in part by recent e-health experiences that leave many health professionals appropriately skeptical about the utility of such products.