Polygenic Risk Prediction in Diverticulitis

OBJECTIVE

To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making.

BACKGROUND

PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making.

METHODS

We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool.

RESULTS

Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42-2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04-2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (-63.3), outpatient management (-54.9), and patient preference (-39.6). PRS was predicted to have high utility (+71).

CONCLUSIONS

A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making.

Surgeon Strategies to Patient-Centered Decision-making in Cancer Care: Validation and Applications of a Conceptual Model

We sought to construct and validate a model of cancer surgeon approaches to patient-centered decision-making (PCDM) and compare applications of that model relative to surgical specialties. Ten PCDM strategies were assessed using a cross-sectional survey administered online to 295 board-certified cancer surgeons. Structural equation modeling was used to empirically validate and compare approaches to PCDM. Within the full sample, 7 strategies comprised a latent construct labeled, "physical & emotional accessibility," associated with surgeon approaches to PCDM (β = 0.37, p < .05). Three individual strategies were included: "expectations (Q4)" (β = 0.52, p < .05), "decision preferences (Q5) (β = 0.47, p < .05), and "access medical information (Q3)" (β = 0.75). Surgical specialties for subgroup analysis were classified as general/other (67.6%) or hepato-pancreato-biliary and upper gastrointestinal (HPB/UGI) (34.2%). For general/other surgeons, 7 individual strategies composed the model of surgeon approaches to PCDM, with "time (Q6) (β = 0.70, p < .001) and "therapeutic relationship building (Q9)" (β = 0.69, p < .001) being the strongest predictors. The HPB/UGI model included 2 latent constructs labeled "physical accessibility" (β = 0.72, p < .05) and "creating a decision-making dialogue" (β = 0.62) as well as the individual strategy, "effective communication (Q8)" (β = 0.51, p < .05). Although models of surgeon PCDM varied, there were 4 overlapping strategies, including effective communication. Tailoring models of PCDM may improve surgeon uptake and thus, overall patient satisfaction with their cancer care.

Comparing Surgeon Approaches to Patient-Centered Cancer Care Using Vignette Methodology

BACKGROUND

We sought to characterize surgeon perceptions of patient attachment-related behaviors relative to patient-centered approaches during treatment decision-making within the clinical encounter.

METHODS

An online survey including clinical vignettes was sent to board-certified surgeons to assess their approach to patient-centered treatment decision-making. Within these vignettes, patient behaviors associated with attachment styles (secure vs 3 insecure subtypes: avoidant, anxious, and fearful) were fixed and patient factors (age, race, occupation, and gender) were randomized. Analysis included repeated measures mixed-effects linear regression.

RESULTS

Among the 208 respondents, the majority were male (65.4%) and White/Caucasian (84.5%) with an average age of 51.6 years (SD = 9.9). Most surgeons had been in practice for more than 10 years (66.8%) and treated adult patients (77.4%). Surgical specializations included breast (27.2%), HPB (35.0%), and broad-based/general (21.8%). Patient race, age, and gender did not impact surgeons' patient-centered approach to treatment decision-making (all ps > 0.05). However, when the "patient" had a white collar occupation and were securely attached, surgeons reported a greater likeliness to spend equal time presenting all treatment options (p = 0.02 and p < 0.001, respectively) and believe the patient wanted an active role in decision-making (p = 0.01 and p < 0.001, respectively). Surgeons reported being least likely to agree with a patient's treatment decision (p < 0.001) and an increased likelihood of being directive (p = 0.002) when patients exhibited behaviors associated with avoidant attachment.

CONCLUSION

Attachment-related behaviors were associated with differences in surgeon approaches to patient-centered decision-making. Attachment styles may offer a framework for providers to understand patient behaviors and needs, thereby providing insight on how to tailor their approach and provide optimal patient-centered care.

Is There a Bias Against Obese Patients in the Treatment of Breast Cancer?

BACKGROUND

Patient and tumor characteristics often coincide with obesity, potentially affecting treatment decision-making in obese breast cancer patients. Independent of all of these factors, however, it is unclear whether obesity itself impacts the decision to offer patients undergoing mastectomy breast reconstruction, postmastectomy radiation therapy (PMRT), or neoadjuvant chemotherapy. We sought to determine whether implicit bias against obese breast cancer patients undergoing mastectomy plays a role in their treatment.

METHODS

Medical records of breast cancer patients undergoing mastectomy from January 2010 to April 2018 from a single institution were retrospectively reviewed, separated into obese (BMI ≥30) and nonobese (BMI <30) categories, and compared using nonparametric statistical analyses.

RESULTS

Of 972 patients, 291 (31.2%) were obese. Obese patients were more likely to have node-positive, triple-negative breast cancers (P = .026) and were also more likely to have other comorbidities such as a history of smoking (P = .026), hypertension (P < .001), and diabetes (P < .001). Receipt of immediate reconstruction and contralateral prophylactic mastectomy did not vary between obese and nonobese patients. While obese patients were more likely to undergo neoadjuvant chemotherapy (26.5% vs. 18.1%, P = .004) and PMRT (33.0% vs. 23.4%, P = .003), this did not remain significant when controlling for comorbidities and clinicopathologic confounders.

CONCLUSION

Obese patients present with more aggressive tumors and often have concomitant comorbidities. Independent of these factors, however, differences in the treatment of patients undergoing mastectomy do not seem to be affected by an implicit bias against obese patients.

Rising BMI is Associated with Increased Rate of Clinically Relevant Pancreatic Fistula after Distal Pancreatectomy for Pancreatic Adenocarcinoma

Clinically relevant pancreatic fistula (CR-POPF), after distal pancreatectomy (DP), remains a clinical challenge. Prior studies investigating the relationship between BMI and CR-POPF have yielded conflicting results. We hypothesized that BMI is associated with CR-POPF in patients having DP for pancreatic ductal adenocarcinoma (PDAC). Patients who underwent DP for PDAC at a single institution from 2006 to 2018 were retrospectively reviewed. A CR-POPF was defined as International Study Group of Pancreatic Surgery (ISGPS) grade B or C fistula. Uni- and multivariable logistic regression analysis assessed factors associated with CR-POPF after DP. Seventy-eight patients met the inclusion criteria, 51 per cent were female, 51 per cent were white, and the average age was 59 ± 15 years. The median BMI was 26 (IQR 24–29). Of all, 19 per cent (n = 15) of patients had a CR-POPF. With a mean follow-up of 2.8 ± 2.5 years, the presence of a CR-POPF was not associated with survival ( P = 0.17). On univariable logistic regression, older age was associated with a decreased risk of CR-POPF (odds ratio (OR) = 0.95, P = 0.015). Increasing BMI was associated with an increased risk of CR-POPF (OR = 1.1, P = 0.044). On multivariate analysis, after controlling for multiple factors, BMI (OR = 1.12, P = 0.035) was the only factor associated with the development of a CR-POPF, whereas older age (OR = 0.94, P < 0.001) was slightly protective. Increasing BMI is associated with an increased risk of CR-POPF after DP for PDAC. These findings should be considered during preoperative counseling. Efforts to diminish the risk of CR-POPF should be focused on patients with higher BMI.

Assessing Differences in Cancer Surgeon Approaches to Patient-Centered Decision-Making Using Vignette-Based Methodology

BACKGROUND

The objective of this study is to assess surgeon-patient-centered decision-making (PCDM) strategies relative to surgeon and patient factors.

METHODS

Approaches to PCDM were evaluated using a cross-sectional survey based on clinical vignettes assessing surgeon likeliness (0 = not at all likely, 100 = very likely) to utilize PCDM strategies. Data were analyzed using repeated-measures mixed-effects linear regression. Adjusted estimates are provided as least-squares mean (LSM) values.

RESULTS

The final analytic sample consisted of 208 respondents (58.5% response rate); the majority of respondents were male (67.7%) and Caucasian (82.0%) with an average age of 51.6 years (standard deviation, SD = 9.9 years, range 34.0-78.0 years). Specialties included breast (18.9%), hepatopancreatobiliary (21.4%), and other (59.7%). Surgeons practicing at academic (versus nonacademic) hospitals were less likely to be directive (LSM: 66.2 vs. 70.3, p = 0.004), spend equal time discussing all treatment options (LSM: 77.9 vs. 82.3, p = 0.001), and make explicit treatment recommendations (LSM: 67.7 vs. 71.7, p = 0.005). Surgeons who specialized in breast cancer (versus other specialties), in practice 10+ years (versus < 10 years), and female (versus male) were more likely to spend time discussing all treatment options (LSM: 82.8 vs. 77.3; 81.6 vs. 78.6; and 82.1 vs. 78.0, all p < 0.05). Surgeons perceived patients who had blue-collar (versus white-collar) jobs as less likely to want active participation in decision-making (LSM: 62.9 vs. 65.6, p = 0.02).

CONCLUSION

Surgeon approaches to PCDM varied based on a number of surgeon and patient characteristics. Further studies are needed to understand how surgeon PCDM strategies can be tailored to specific care contexts and patient needs.