To Operate or Not: Prediction of 3-Month Postoperative Mortality in Geriatric Cancer Patients

Breast Cancer Surgery 10-Year Survival Prediction by Machine Learning: A Large Prospective Cohort Study

Machine learning algorithms have proven to be effective for predicting survival after surgery, but their use for predicting 10-year survival after breast cancer surgery has not yet been discussed. This study compares the accuracy of predicting 10-year survival after breast cancer surgery in the following five models: a deep neural network (DNN), K nearest neighbor (KNN), support vector machine (SVM), naive Bayes classifier (NBC) and Cox regression (COX), and to optimize the weighting of significant predictors. The subjects recruited for this study were breast cancer patients who had received breast cancer surgery (ICD-9 cm 174-174.9) at one of three southern Taiwan medical centers during the 3-year period from June 2007, to June 2010. The registry data for the patients were randomly allocated to three datasets, one for training (n = 824), one for testing (n = 177), and one for validation (n = 177). Prediction performance comparisons revealed that all performance indices for the DNN model were significantly (p < 0.001) higher than in the other forecasting models. Notably, the best predictor of 10-year survival after breast cancer surgery was the preoperative Physical Component Summary score on the SF-36. The next best predictors were the preoperative Mental Component Summary score on the SF-36, postoperative recurrence, and tumor stage. The deep-learning DNN model is the most clinically useful method to predict and to identify risk factors for 10-year survival after breast cancer surgery. Future research should explore designs for two-level or multi-level models that provide information on the contextual effects of the risk factors on breast cancer survival.

Association of frailty and chemotherapy-related adverse outcomes in geriatric patients with cancer: a pilot observational study in Taiwan

Background: With the rapid growth of the elderly population and the increasing incidence of cancer, an increasing number of geriatric patients are receiving cancer treatment, making the selection of appropriate treatment an important issue. Increasing studies have confirmed that frailty can predict adverse outcomes in geriatric patients with cancer after treatment, but local data from Taiwan are lacking. Therefore, this study aimed to investigate the correlation between frailty and chemotherapy-related adverse outcomes in geriatric patients with cancer.

Material and Methods: A total of 234 geriatric patients aged ≥65 years with cancer receiving chemotherapy were enrolled during the study period of September 2016 to November 2018. The collected data included: patients’ basic demographics and Comprehensive Geriatric Assessment (CGA) before treatment, chemotherapy-related adverse outcomes, unexpected hospitalizations, and emergency department visits within 3 months of treatment. We investigated the association between frailty and chemotherapy-related adverse outcomes in geriatric patients with cancer using the chi-square test and logistic regression analysis.

Results: The prevalence of frailty in geriatric patients with cancer was 58.1%. Age, marital status, main caregiver, cancer type, and Eastern Cooperative Oncology Group performance status, and physical fitness were factors associated with frailty. Frail geriatric patients with cancer were at higher risk of chemotherapy-related adverse outcomes, such as grades 3–4 thrombocytopenia (odds ratio [OR] = 11.13, p = 0.021) and grades 3–4 hyponatremia (OR = 12.03, p = 0.017), than non-frail patients, and they were at increased risk of unexpected hospitalizations (OR = 2.15, p = 0.025) and emergency department visits (OR = 1.99, p = 0.039).

Conclusions: Frailty is a common problem in geriatric patients with cancer and significantly impacts chemotherapy-related adverse outcomes. Our findings suggest that geriatric patients with cancer should undergo frail assessment prior to chemotherapy as a reference to guide future treatment decisions.

Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery

BACKGROUND

The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology.

METHODS

The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology.

RESULTS

A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction.

CONCLUSIONS

In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.

High World Heath Organization Performance Status Is Associated With Short- and Long-term Outcomes After Colorectal Cancer Surgery: A Nationwide Population-Based Study

BACKGROUND

The value of performance status is widely used in medical oncology, but the association with surgical outcomes in colorectal cancer has not been described.

OBJECTIVE

The aim of this study was to investigate the association between World Heath Organization performance status and 90-day mortality, 30-day mortality, complications, and overall survival after elective colorectal cancer surgery.

DESIGN

The study was conducted as a nationwide population-based cohort study with prospectively collected data.

SETTING

Data from 2014 through 2016 were provided by the Danish nationwide colorectal cancer database (Danish Colorectal Cancer Group).

PATIENTS

All patients aged ≥18, who had elective surgery for colorectal cancer were included.

MAIN OUTCOME MEASURES

Multiple logistic regressions were performed to investigate 90-day mortality, 30-day mortality, and complications. One-year mortality was determined by Cox regression, and overall survival was illustrated by Kaplan-Meier curves.

RESULTS

A total of 10,279 patients had elective colorectal cancer surgery during the study period (6892 colonic and 3387 rectal). Thirty-four percent of the patients with colorectal cancer had a World Heath Organization performance status ≥1. The odds ratios of postoperative 90-day mortality in colon cancer for performance status 1, 2, and 3/4 compared with performance status 0 were 2.50 (95% CI, 1.67-3.73), 5.00 (95% CI, 3.19-7.86), and 17.34 (95% CI, 10.18-29.55). The odds ratios of postoperative 90-day mortality in rectal cancer for performance status 1, 2, and 3/4 were 3.90 (95% CI, 2.23-6.85), 9.25 (95% CI, 4.75-18.02), and 10.56 (95% CI, 4.07-27.41). Performance status was also associated with 30-day mortality, overall survival, and medical complications.

LIMITATIONS

Only 1 year of follow-up was possible for all patients, and cancer-specific survival was not available.

CONCLUSION

One of three patients has a performance status >0 and is associated with an increased risk of death, complications, and overall survival for both colonic and rectal cancers. See Video Abstract at http://links.lww.com/DCR/B540.

EL ALTO NIVEL DE DESEMPEO DE LA ORGANIZACIN MUNDIAL DE LA SALUD SE ASOCIA CON RESULTADOS A CORTO Y LARGO PLAZO DESPUS DE LA CIRUGA DEL CNCER COLORRECTAL UN ESTUDIO POBLACIONAL A NIVEL NACIONAL

ANTECEDENTES:El valor del estado funcional se usa ampliamente en oncología médica, pero no se ha descrito la asociación con los resultados quirúrgicos en el cáncer colorrectal.OBJETIVO:El objetivo fue investigar la asociación entre el estado funcional de la Organización Mundial de la Salud y la mortalidad a 90 días, la mortalidad a 30 días, las complicaciones y la supervivencia general después de la cirugía electiva del cáncer colorrectal.DISEÑO:El estudio se realizó como un estudio de cohorte poblacional a nivel nacional con datos recolectados prospectivamente.ENTORNO CLINICO:Los datos fueron proporcionados por la base de datos de cáncer colorrectal a nivel nacional danés (DCCG.dk) en un período de estudio de 2014-2016.PACIENTES:Se incluyeron todos los pacientes de ≥18 años que se sometieron a cirugía electiva por cáncer colorrectal.PRINCIPALES MEDIDAS DE VALORACION:Para investigar la mortalidad a los 90 días, la mortalidad a los 30 días y las complicaciones se realizaron regresiones logísticas múltiples. La mortalidad a un año se determinó mediante regresión de Cox y la supervivencia general se ilustra mediante curvas de Kaplan-Meier.RESULTADOS:Un total de 10 279 pacientes se sometieron a cirugía electiva de cáncer colorrectal en el período de estudio (6892 colónico y 3387 rectal). Treinta y cuatro por ciento de los pacientes con cáncer colorrectal tenían un estado funcional de la Organización Mundial de la Salud ≥1. Los ratios de probabilidades (odds ratios) de mortalidad postoperatoria a los 90 días en cáncer de colon para el estado funcional 1, 2 y 3/4 en comparación con el estado funcional 0 fueron 2,50 (IC del 95%: 1,67-3,73), 5,00 (IC del 95%: 3,19-7,86) y 17,34 (IC del 95%: 10,18-29,55), respectivamente. Los ratios de probabilidades de mortalidad postoperatoria de 90 días en cáncer de recto para el estado funcional 1, 2 y 3/4 fueron 3,90 (IC del 95%: 2,23-6,85), 9,25 (IC del 95%: 4,75-18,02) y 10,56 (IC del 95%: 2,23-6,85) % CI: 4,07-27,41). El estado funcional también se asoció con la mortalidad a los 30 días, la supervivencia general y las complicaciones médicas.LIMITACIONES:Solo fue posible un año de seguimiento para todos los pacientes y la supervivencia específica del cáncer no estaba disponible.CONCLUSIÓN:Uno de cada tres pacientes tiene un estado funcional> 0 y se asocia con un mayor riesgo de muerte, complicaciones y supervivencia general para los cánceres de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B540.

Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

Background: The present study was designed to investigate the relationship between two malnutrition assessment scales, perioperative nutrition screen (PONS) and Nutritional Risk Screening 2002 (NRS2002), with postoperative complications in elderly patients after noncardiac surgery.

Methods: This was a secondary analysis of a prospective cohort study. Elderly patients (65–90 years) undergoing noncardiac surgery were enrolled in Peking University First Hospital. Malnutrition was screened by PONS and NRS2002 at the day before surgery. Multivariable analysis was employed to analyze the relationship between PONS and NRS2002 and postoperative 30-day complications. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive value of PONS and NRS2002 in predicting postoperative complications.

Results: A total of 915 patients with mean age of 71.6 ± 5.2 years were consecutively enrolled from September 21, 2017, to April 10, 2019. The incidence of malnutrition was 27.3% (250/915) by PONS ≥ 1 and 53.6% (490/915) by NRS2002 ≥ 3. The overall incidence of complications within postoperative 30 days was 45.8% (419/915). After confounders were adjusted, malnutrition by PONS ≥ 1 (OR 2.308, 95% CI 1.676–3.178, P < 0.001), but not NRS2002 ≥ 3 (OR 1.313, 95% CI 0.973–1.771, P = 0.075), was related with an increased risk of postoperative complications. ROC curve analysis showed that the performances of PONS [area under the ROC curve (AUC) 0.595, 95% CI 0.558–0.633] showed very weak improvement in predicting postoperative complications than NRS2002 score (AUC 0.577, 95% CI 0.540–0.614).

Conclusion: The present study found that malnutrition diagnosed by PONS was related with an increased risk of postoperative complications. The performances of PONS and NRS2002 were poor in predicting overall postoperative complications.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR-OOC-17012734.

The Impact of Comorbidity on Survival in Patients With Head and Neck Squamous Cell Carcinoma: A Nationwide Case-Control Study Spanning 35 Years

Background

Comorbidity is presumed to impact survival of head and neck squamous cell cancer (HNSCC) patients. However, the prevalence and prognostic impact of comorbidity in these patients is not yet well established. The aim of this study is to outline the comorbidity burden of HNSCC patients and investigate the relation to overall survival and cancer-specific mortality.

Methods

The comorbidity burden of patients registered with HNSCC in the Danish Cancer Registry between 1980 and 2014 was evaluated based on the Charlson Comorbidity Index (CCI). Patients' risks of comorbid conditions compared to age- and gender-matched controls were estimated by odds ratios (OR). The impact of comorbidity on overall survival and cancer-specific mortality was evaluated by Cox regression and Kaplan-Meier survival analysis.

Results

A total of 25,388 HNSCC patients were included (72.5% male; mean age 63.2 years at diagnosis; median follow-up 3.0 years). CCI at diagnosis was significantly higher in patients compared to controls (p < 0.001). The most common comorbid conditions among the patients were additional non-metastatic malignancy (10.9%) and cerebrovascular disease (7.7%). Compared to controls, patients had higher odds of metastatic malignancy (OR: 4.65; 95% CI: 4.21-5.15; p < 0.001), mild liver disease (OR: 6.95; 95% CI: 6.42-7.53; p < 0.001), and moderate-severe liver disease (OR: 7.28; 95% CI: 6.14-8.65; p < 0.001). The multivariate Cox analysis revealed increasing hazard ratios with increasing CCI and in coherence the Kaplan-Meier curves showed poorer overall survival and increased cancer-specific mortality in patients with higher CCI.

Conclusion

HNSCC patients' comorbidity burden was significantly greater compared to the general population and increased comorbidity was correlated with increased cancer-related mortality.

Resectability and Ablatability Criteria for the Treatment of Liver Only Colorectal Metastases: Multidisciplinary Consensus Document from the COLLISION Trial Group

The guidelines for metastatic colorectal cancer crudely state that the best local treatment should be selected from a ‘toolbox’ of techniques according to patient- and treatment-related factors. We created an interdisciplinary, consensus-based algorithm with specific resectability and ablatability criteria for the treatment of colorectal liver metastases (CRLM). To pursue consensus, members of the multidisciplinary COLLISION and COLDFIRE trial expert panel employed the RAND appropriateness method (RAM). Statements regarding patient, disease, tumor and treatment characteristics were categorized as appropriate, equipoise or inappropriate. Patients with ECOG≤2, ASA≤3 and Charlson comorbidity index ≤8 should be considered fit for curative-intent local therapy. When easily resectable and/or ablatable (stage IVa), (neo)adjuvant systemic therapy is not indicated. When requiring major hepatectomy (stage IVb), neo-adjuvant systemic therapy is appropriate for early metachronous disease and to reduce procedural risk. To downstage patients (stage IVc), downsizing induction systemic therapy and/or future remnant augmentation is advised. Disease can only be deemed permanently unsuitable for local therapy if downstaging failed (stage IVd). Liver resection remains the gold standard. Thermal ablation is reserved for unresectable CRLM, deep-seated resectable CRLM and can be considered when patients are in poor health. Irreversible electroporation and stereotactic body radiotherapy can be considered for unresectable perihilar and perivascular CRLM 0-5cm. This consensus document provides per-patient and per-tumor resectability and ablatability criteria for the treatment of CRLM. These criteria are intended to aid tumor board discussions, improve consistency when designing prospective trials and advance intersociety communications. Areas where consensus is lacking warrant future comparative studies.

Hepatic resection for hepatocellular carcinoma in the octogenarian: is it justified?

Liver resection is a standard treatment for hepatocellular carcinoma (HCC). The purpose of this study was to investigate the clinicopathological characteristics and long-term outcomes of octogenarians with HCC treated with liver resection. Records of patients who underwent liver resection for HCC were reviewed, and patients older and younger than 80 years were compared. There were 77 patients 80 years of age or older and 3,309 younger than 80 years. Hepatitis C virus infection was the most common etiology among the octogenarians (43.1%), followed by non-viral causes (37.5%). The older group had more co-morbidity but less hepatitis B virus infection and cirrhosis. More than 70% of the non-viral older group had diabetes mellitus, as compared to only 21.6% in the viral older group. The older group had rates of perioperative morbidity, mortality, disease-free survival, and overall survival comparable to the younger group (all p>0.1). Multivariate analysis revealed that α-fetoprotein ≥400 ng/mL, tumor size ≥10 cm, and vascular invasion were independent prognostic factors for overall survival in the older patients. These findings demonstrate that liver resection is a justified treatment for HCC in octogenarians, and it can achieve surgical outcomes comparable to those in younger populations.

An examination of surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer

Objective: The purpose of this study was to examine surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer.Methods: This study retrospectively reviewed the records of patients ≥65 years old who received a gastrectomy for gastric adenocarcinoma. Demographic, clinical, and pathological data were extracted from the medical records. Patients were divided into two groups: those 65-79 years of age and those ≥80 years of age. Data and survival outcomes were compared between the groups.Results: Sixty-four patients were included, 32 males and 32 females. The mean age in the 65-79 years old group was 73.4 ± 4.5 years, and in the ≥80 years group was 85.2 ± 3.4 years (p < .001). Three patients in the older group had chronic kidney disease, as compared to none in the 65-79 years group (p = .04); all other demographic, clinical, tumor, and surgical characteristics were similar between the groups, except for surgical time (all, p > .05). Patients ≥80 years had a higher incidence of pulmonary complications (24% vs 4.7%, p = .03), but there was no significant difference in in-hospital mortality. The ≥80 years group had a higher overall survival, but the difference between the groups was not statistically significant (42.9% and 34.9%, p = .224).Conclusions: Curative intent resection, gastrectomy with D1+/D2 lymph node dissection is a viable option for elders ≥80 years old with gastric carcinoma.

PANCREATICODUODENECTOMY WITH VENOUS RESECTION: AN ANALYSIS OF 30-DAY MORBIDITY AND MORTALITY

BACKGROUND

Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined.

OBJECTIVE

To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital.

METHODS

A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality.

RESULTS

The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores.

CONCLUSION

PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

Effect of S-1 on survival outcomes in 838 patients with advanced pancreatic cancer: A 7-year multicenter observational cohort study in Taiwan

Objective

Studies have rarely explored the efficacy of S‐1 in treating advanced pancreatic cancer outside Japan. This study compared the survival outcomes of patients with advanced pancreatic cancer treated with S‐1 with the survival outcomes of those without S‐1 treatment before and after S‐1 reimbursement was introduced in Taiwan in June of 2014.

Method

We retrospectively analyzed 838 patients with locally advanced or metastatic pancreatic cancer who underwent palliative chemotherapy from 2010 to 2016 at 4 institutes in Taiwan. For survival analysis, patients were categorized into two groups according to whether they received S‐1 treatment as palliative chemotherapy after diagnosis: (a) S‐1‐treated (n = 335) and (b) non‐S‐1‐treated (n = 503) groups.

Results

The median overall survival was longer in the S‐1‐treated group than in the non‐S‐1‐treated group (10.7 vs 6.0 mo, P < 0.001). Subgroup survival analyses showed that the S‐1‐treated group had more favorable outcomes than the non‐S‐1‐treated group in terms of stage III (19.6 vs 10.1 mo, P < 0.001) and stage IV (8.5 vs 5.3 mo, P < 0.001) disease. The disease control rates were 43.6% and 32.8% (P < 0.001) in patients treated with and without S‐1 in the first‐line setting, respectively. In multivariate analysis, exposure to S‐1 treatment was an independent prognosticator for survival.

Conclusion

Our results support the clinical use of S‐1 as the treatment of choice for patients with locally advanced or metastatic pancreatic cancer, particularly in resource‐limited situations.

Complications of Percutaneous Bone Tumor Cryoablation: A 10-year Experience

Background Percutaneous cryoablation has been shown to be effective in the management of painful bone tumors. However, knowledge of the complication rate and risk factors for complication is currently lacking. Purpose To report the complication rate and associated risk factors for bone tumor cryoablation. Materials and Methods This retrospective study reviewed complications in 239 consecutive patients (131 men and 108 women; median age, 64 years; age range, 6-86 years) who underwent cryoablation of 320 primary or metastatic bone tumors between January 2008 and November 2017. Common Terminology Criteria for Adverse Events was used to categorize complications as major (grade 3-4) or minor (grade 1-2). Multivariable analysis was performed for variables with P values less than .20, including age, tumor location, adjacent critical structures, number of cryoprobes, and Eastern Cooperative Oncology Group performance status (ECOG-PS). Results Among the 320 tumors, the total complication rate was 9.1% (29 of 320; 95% confidence interval [CI]: 6%, 12.2%). The major complication rate was 2.5% (eight of 320; 95% CI: 0.8%, 4.2%), with secondary fracture the most frequent complication (1.2% [four of 320]; mean delay, 71 days); cryoablation site infection, tumor seeding, bleeding, and severe hypotension were each observed in 0.3% (one of 320) of procedures. Minor complications included postprocedural pain (2.2% [seven of 320]), peripheral neuropathy (0.9% [three of 320]), and temporary paresthesia (0.9% [three of 320]). For all complications, associated risk factors included ECOG-PS greater than 2 (odds ratio [OR], 3.1 [95% CI: 3, 7.6]; P = .01), long-bone cryoablation (OR, 17.8 [95% CI: 2.3, 136.3]; P = .01), and use of more than three cryoprobes (OR, 2.5 [95% CI: 1.0, 6.0]; P = .04); for major complications, associated risk factors included age greater than 70 years (OR, 7.1 [95% CI: 1.6, 31.7]; P = .01) and use of more than three cryoprobes (OR, 23.6 [95% CI: 2.8, 199.0]; P = .01). Conclusion Bone tumor cryoablation is safe, with a 2.5% rate of major complications, most commonly secondary fracture (1.2%). Major complications are associated with age greater than 70 years and use of more than three cryoprobes. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Jennings in this issue.

Venous Thromboembolism in Asian Patients with Pancreatic Cancer Following Palliative Chemotherapy: Low Incidence but a Negative Prognosticator for Those with Early Onset

Background: Few studies have reported the epidemiology and clinical outcome of venous thromboembolism (VTE) in Asian patients with pancreatic cancer. This study investigated the incidence, risk factors, and clinical outcome of VTE in patients with pancreatic cancer following palliative chemotherapy. Methods: The medical records of 838 patients with newly diagnosed locally advanced or metastatic pancreatic cancer who underwent palliative chemotherapy between 2010 and 2016 at four institutes in Taiwan were retrospectively reviewed. The clinical characteristics of all patients were analyzed to identify independent predictors of VTE and their effects on survival outcome. Results: During the median follow-up period of 7.7 months (range, 0.6–55.6), VTE occurred in 67 (8.0%) of the 838 patients. Leukocyte count > 11,000/μL and presence of liver metastases were the independent predictors of VTE. Patients with VTE did not show significantly poorer survival outcomes than those without VTE. However, early-onset VTE that occurred within 1.5 months after chemotherapy initiation was an independent negative prognosticator for overall survival. Conclusion: VTE incidence was found to be lower in Asian patients with pancreatic cancer than in their Western counterparts. Early-onset VTE, but not late-onset VTE, is a negative prognosticator for survival outcomes.

Factors related to patient propensity to receive adjuvant chemotherapy and outcomes in stage III gastric cancer cases after D2 surgery

BACKGROUND

Radical gastrectomy and extended lymph node (D2) dissection followed by adjuvant chemotherapy is the optimal treatment for patients with stage III gastric cancer in Asian population. The clinical factors associated with patient propensity to receive adjuvant chemotherapy and outcomes were analyzed.

METHODS

In total, 509 patients with stage III gastric cancer who had undergone D2 surgery between 2007 and 2017 at a single medical center in Taiwan were analyzed. The patients' preoperative clinical characteristics relevant to adjuvant chemotherapy adherence were analyzed using multivariate regression. Significant variables were analyzed using recursive partitioning analysis (RPA) for identifying specific patient groups with the lowest and highest probabilities of adjuvant chemotherapy adherence.

RESULTS

After surgery, 361 (70.9%) patients in the cohort had received adjuvant chemotherapy. All patients were categorized into five probability groups with adherence to adjuvant chemotherapy according to age, Eastern Cooperative Oncology Group (ECOG) performance status grade, and American Society of Anesthesiologists (ASA) class, which were discovered to be independent factors in the RPA-based probability prediction. In general, adjuvant chemotherapy improved survival across broad categories of stage III gastric cancer patients (overall survival hazard ratio: 0.53-0.75 and disease-free survival hazard ratio: 0.47-0.76).

CONCLUSIONS

Our study identified that age, ECOG grade, and ASA class were independent clinical factors associated with patient propensity to receive adjuvant chemotherapy in stage III gastric cancer. Knowledge of the clinical factors of patients may help clinicians identify and encourage specific patients to receive the adjuvant chemotherapy.

Impact of body mass index on long-term survival outcome in Asian populations with solid cancer who underwent curative-intent surgery: A six-year multicenter observational cohort study

Purpose: Being elevated body mass index (BMI) has been considered a poor prognostic factor in patients with cancer. However, studies about the impact of elevated BMI on the survival outcome after cancer surgery have conflicting results. This study aimed to evaluate the impact of BMI on long-term postoperative survival outcome in a large cohort of Asian population with solid cancers. Methods: A total of 33,551 patients who underwent curative-intent surgery for solid cancers between January 2007 and December 2012 at four hospitals in Taiwan were included. BMI was analyzed using univariate and multivariate regression analyses to determine its association with survival outcome. Results: With a median follow-up of 43.8 (range, 1-91) months, the rate of all-cause mortality was 21.7% (n=7264 patients), while that of cancer-related mortality was 13.4% (n=4499 patients). BMI was a significant prognostic factor in multivariate analysis for overall survival (OS) and cancer-specific survival (CSS). The adjusted hazard ratio (HR) per kg/m² was 0.922 (95% confidence interval [CI], 0.916-0.929; P<0.001) and 0.932 (95% CI, 0.924-0.940; P<0.001) for OS and CSS, respectively. Patients with BMI <17 kg/m² had the highest postoperative mortality risk, with a hazard ratio of 3.8-fold higher for OS and 5.0-fold higher for CSS than those with BMI >35 kg/m². Conclusions: This study showed that BMI was positively associated with survival outcome in patients with cancer who underwent radical surgery. BMI was an independent prognostic factor and can be used to risk stratify patients in Asians with solid cancers.

The pattern of comorbidities in cancer patients in Lagos, South-Western Nigeria

Purpose

Comorbidities have been indicated to influence cancer care and outcome, with strong associations between the presence of comorbidities and patient survival. The objective of this study is to determine the magnitude and pattern of comorbidities in Nigerian cancer populations, and demonstrate the use of comorbidity indices in predicting mortality/survival rates of cancer patients.

Methods

Using a retrospective study design, data were extracted from hospital reports of patients presenting for oncology care between January 2015 and December 2016 at two tertiary health facilities in Lagos, Nigeria. Patient comorbidities were ranked and weighted using the Charlson comorbidity index (CCI).

Results

The mean age for the 848 cancer patients identified was 53.9 ± 13.6 years, with 657 (77.5%) females and 191 (22.5%) males. Breast (50.1%), cervical (11.1%) and colorectal (6.3%) cancers occurred most frequently. Comorbidities were present in 228 (26.9%) patients, with the most common being hypertension (20.4%), diabetes (6.7%) and peptic ulcer disease (2.1%). Hypertension-augmented CCI scores were 0 (15.6%), 1–3 (62.1%), 4–6 (21.7%) and ≥7 (0.6%). The mean CCI scores of patients ≤50 years (0.8 ± 0.9) and ≥51 years (3.3 ± 1.2) were significantly different (p < 0.05). Patients with lower mean CCI scores were more likely to receive chemotherapy (2.2 ± 1.6 versus 2.5 ± 1.9; p < 0.05) and/or surgery (2.1 ± 1.5 versus 2.4 ± 1.7; p < 0.05).

Conclusion

Comorbidities occur significantly in Nigerian cancer patients and influence the prognosis, treatment outcome and survival rates of these patients. There is a need to routinely evaluate cancer patients for comorbidities with the aim of instituting appropriate multidisciplinary management measures where necessary.

Addition of biomarker panel improves prediction performance of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator for cardiac risk assessment of elderly patients preparing for major non-cardiac surgery: a pilot study

BACKGROUND

Number of elderly patients subjected to extensive surgical procedures in the presence of cardiovascular morbidities is increasing every year. Therefore, there is a need to make preoperative diagnostics more accurate.

AIMS

To evaluate the usefulness of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator as a predictive tool in preoperative assessment of cardiovascular risk in elderly patients.

METHODS

This prospective pilot study included 78 patients who were being prepared for extensive non-cardiac surgeries under general anaesthesia. Their data have been processed on the interactive ACS NSQIP calculator. Blood sampling has been performed 7 days prior to surgery, and serum has been separated. Clinical, novel, and experimental biomarkers [hsCRP, H-FABP, and Survivin (BIRC5)] have been measured in specialized laboratories.

RESULTS

Mean age of included patients was 71.35 ± 6.89 years. In the case of heart complications and mortality prediction, hsCRP and ACS NSQIP showed the highest specificity and sensitivity with AUC, respectively, 0.869 and 0.813 for heart complications and 0.883 and 0.813 for mortality. When combined with individual biomarkers AUC of ACS NSQIP raised, but if we combined all three biomarkers with ACS NSQIP, AUC reached as much as 0.920 for heart complications and 0.939 for mortality.

DISCUSSION

ACS NSQIP proved to reduce inaccuracy in preoperative assessment, but it cannot be used independently, which has already been proved by other authors.

CONCLUSIONS

Our results indicate that ACS NSQIP represents an accurate tool for preoperative assessment of elderly patients, especially if combined with cardiac biomarkers.

Chang Gung Research Database: A multi-institutional database consisting of original medical records

Background

The Chang Gung Research Database (CGRD) is a de-identified database derived from original medical records of Chang Gung Memorial Hospital (CGMH), which comprises seven medical institutes located from the northeast to southern regions of Taiwan. The volume of medical services performed in CGMH is large, and clinical and scientific studies based on the CGRD are reported to be of high quality. However, the CGRD as a useful database for research has not been analyzed before. The objective of the study was to analyze the CGRD with regard to its characteristics and coverage of Taiwan's population.

Methods

We performed a nationwide cohort study using population-based data from the Taiwan National Health Insurance Research Database (NHIRD). All patients who had any medical record of outpatient visits or admission between January 1, 1997, and December 31, 2010, were included, and the sex ratio, age distribution, socioeconomic status, urbanicity, severity of illness, prevalence of specific disease, and coverage of the CGRD were analyzed.

Results

The sex ratio, age distribution, socioeconomic status, and urbanicity of the population of the CGRD are different from those of Taiwan NHIRD and medical centers in Taiwan (all the pairwise p < 0.05). The severity of comorbidities, and prevalence of specific diseases of the population of the CGRD are significantly higher than those of Taiwan NHIRD and medical centers in Taiwan for both outpatient and inpatient samples (all the pairwise p < 0.05). The overall coverage of the CGRD was 21.2% for outpatients and 12.4% for inpatients. The disease-specific coverage of the CGRD was 27–34% for outpatients and 14–21% for inpatients.

Conclusions

The CGRD is a multi-institutional, original medical record-based research database with high overall and disease-specific coverage of Taiwan. The population of the CGRD has significantly higher severity of comorbidities, and prevalence of specific diseases than those of Taiwan NHIRD and medical centers in Taiwan.

Sarcopenia: a new predictor of postoperative complications for elderly gastric cancer patients who underwent radical gastrectomy

BACKGROUND

A geriatric assessment is needed to identify high-risk elderly patients with gastric cancer. However, the current geriatric assessment has been considered to be either time-consuming or subjective. The present study aimed to investigate the predictive effect of sarcopenia on the postoperative complications for elderly patients who underwent radical gastrectomy.

MATERIALS AND METHODS

We conducted a prospective study of patients who underwent radical gastrectomy from August 2014 to December 2015. Computed tomography-assessed lumbar skeletal muscle, handgrip strength, and gait speed were measured to define sarcopenia.

RESULTS

Sarcopenia was present in 69 of 240 patients (28.8%) and was associated with lower body mass index, lower serum albumin, lower hemoglobin, and higher nutritional risk screening 2002 scores. Postoperative complications significantly increased in the sarcopenic patients (49.3% versus 24.6%, P < 0.001), compared with nonsarcopenic patients. The multivariate analysis demonstrated that sarcopenia (odds ratio: 2.959, 95% CI: 1.629-5.373, P < 0.001) and the Charlson comorbidity index ≥2 (odds ratio: 3.357, 95% CI: 1.144-9.848, P = 0.027) were independent risk factors for postoperative complications.

CONCLUSIONS

Sarcopenia, presented as a new geriatric assessment factor, was a strong and independent risk factor for postoperative complications of elderly patients with gastric cancer.

Survival outcomes of geriatric patients with clinically resectable gastric cancer: to operate or not

BACKGROUND

Approximately, 50% of all gastric cancer patients are aged >70 y. Although curative surgery is the treatment of choice, many geriatric patients die of surgical complications. Therefore, we aimed to evaluate the impact of radical surgery on the survival outcome of geriatric patients with resectable gastric cancers.

METHODS

About 488 patients diagnosed with resectable gastric cancers, aged ≥70 y, between January 2007 and December 2012 at Chang Gung Memorial Hospital (CGMH) Linkou branch were included in this study. Using univariate and multivariate analyses, possible prognostic variables for survival outcome were assessed in 445 patients (91.2%) treated with radical surgery (operation [OP] group) and 43 (8.8%) receiving conservative treatment (non-OP group). The impact of radical surgery on survival outcomes was evaluated according to CGMH scores.

RESULTS

On multivariate analysis, surgical resection with subtotal gastrectomy and CGMH score were the only independent prognostic factors for both overall and cancer-specific survival. The median survival time was 43 mo for the entire cohort. The OP group had significantly better survival outcome than the non-OP group (median survival, 50.3 versus 16.2 mo, P < 0.001). The median survival times for patients with CGMH scores ≤20 were 64.1 and 20.0 mo (P < 0.002) and those for patients with CGMH scores >20 were 13.8 and 10.4 mo (P = 0.18) in the OP and non-OP groups, respectively.

CONCLUSIONS

Surgical resection and CGMH score are independent prognostic factors for overall and cancer-specific survival; the CGMH score might be a prognostic indicator of surgical outcome in geriatric patients with resectable gastric cancers.

Effect of Comorbidity on Postoperative Survival Outcomes in Patients with Solid Cancers: A 6-Year Multicenter Study in Taiwan

Purpose: Patients with comorbidities are more likely to experience treatment-related toxicities and death. Our aim was to examine the effect of comorbidity on postoperative survival outcomes in patients with solid cancers.

Methods: In total, 37,288 patients who underwent potentially curative operations for solid cancers at four affiliated hospitals of the Chang Gung Memorial Hospital, between 2007 and 2012, were stratified according to the Charlson Comorbidity Index (CCI) for postoperative survival analysis. Multivariate Cox regression was used to adjust hazard ratios of survival outcomes among different CCI subgroups.

Results: A significantly greater proportion of patients with comorbidities presented with poorer clinicopathological characteristics compared to those without. After cancer surgery, 26% of patients died after a median follow-up duration of 38.9 months. Overall mortality rates of patients with CCI scores of 0, 1, 2, 3, 4, and 5-8 were 22.9%, 29.5%, 38.2%, 43.2%, 50.2%, and 56.4%, respectively. After adjusting for other clinicopathological factors, patients with increasing CCI scores were associated with significantly reduced overall and noncancer-specific survival rates, while only patients with CCI scores of >2 were associated with higher cancer-specific mortality rates.

Conclusions: Patients with increasing numbers of comorbidities were associated with reduced postoperative survival outcomes. Patients with multiple comorbidities were most vulnerable to both cancer- and noncancer-specific deaths in the first 6 months after cancer surgery. Our results suggest that for both the patient and clinician, it should be taken into consideration about cancer surgery when dealing with multiple comorbidities.