An innovative approach to comprehensive communication skills training for residents: A resident-led communication curriculum

Innovations to enhance residency training in interpersonal and communication skills are needed and a resident-led strategy has not been well-described. In this study, we explored a resident-led comprehensive communication skills curriculum for internal medicine residents. Residents and faculty prepared the curriculum as part of an Accreditation Council for Graduate Medical Education (ACGME) Back to Bedside Project and with "The language of caring guide for physicians." Employing active learning techniques, three residents led 43 internal medicine residents in seven 1 h sessions from 2019 to 2020. Using a 35-question survey, we assessed pre and post self-reported competence in: mindful practice, collaboration and teamwork, effective openings and closing, communicating with empathy, effective explanations, engaging patients and families as partners, and hard conversations. A Wilcoxon signed rank test was employed to explore differences in median scores after matching each person's pretest and posttest score. The median score for aggregate communication and the scores for all seven competencies assessed improved from pre to post (p < 0.05). This indicates that residents reported higher incidences of performing patient-centered communication skills after the curriculum compared to before. Using a five-point Likert scale, 100% of participants agreed the program improved their communication skills and improved confidence in bedside patient-centered communications. A resident-led comprehensive communication skills curriculum for internal medicine residents was implemented showing improvement in skills over the course of the curriculum. The curriculum was well-accepted by post-survey evaluation and was feasible with motivated resident-leaders, use of an existing guide to communication, and reserved didactic time to implement the program.

Community Exercise Program Participation and Mental Well-Being in the U.S. Texas-Mexico Border Region

Hispanics are disproportionately affected by low rates of physical activity and high rates of chronic diseases. Hispanics generally and Mexican Americans specifically are underrepresented in research on physical activity and its impact on mental well-being. Some community-based interventions have been effective in increasing physical activity among Hispanics. This study examined data from a sample of low-income Hispanic participants in free community exercise classes to characterize the association between self-reported frequency of exercise class attendance, intensity of physical activity, and participant well-being. As part of two cross-sectional samples recruited from a stratified random sample of community exercise classes, 302 participants completed a questionnaire consisting of a modified version of the Godin-Shephard Leisure-Time Exercise Questionnaire (LTEQ) and the Mental Health Continuum Short Form (MHC-SF). Adjusted logistic regression analyses indicated that those who achieve mild, moderate, and strenuous self-reported physical activity have 130% higher odds (p = 0.0422) of positive mental well-being after adjustment for age, frequency of attendance, and self-reported health. This study provides evidence that the intensity of physical activity is associated with flourishing mental well-being among Hispanic adults. The association between physical activity and mental well-being is more pronounced when considering participants engaged in mild levels of physical activity. The study further provides insight into the planning and development of community-based physical activity programming tailored to low-income populations.

Intersection of Mental Health and Dysphonia: A Scoping Review

OBJECTIVE

Previous research has indicated that voice disorders frequently co-occur with mental health disorders, which may influence voice treatment seeking behavior and effectiveness. Our goal is to characterize the existing literature on the relationship between voice disorders and mental health and to investigate nuances related to mental health and voice disorder diagnosis.

DATA SOURCES

Ovid MEDLINE, ProQuest PsycINFO, and Web of Science.

REVIEW METHODS

Using the PRISMA protocol, a scoping review was performed. Databases searched included: Ovid MEDLINE, ProQuest PsycINFO, and Web of Science. Our inclusion criteria were all adults seen in an outpatient setting for voice and mental health disorders, excluding those with a prior history of head and neck surgery, cancers, radiation, or developmental anomalies, and certain mental health disorders. Results were screened by two independent screeners for inclusion. Data were then extracted and analyzed to present key findings and characteristics.

RESULTS

A total of 156 articles, with publication dates ranging from 1938 to 2021, were included in the analysis, with females and teachers being the most described population groups. The most frequently studied laryngeal disorders were dysphonia (n = 107, 68.6%), globus (n = 33, 21.2%), and dysphonia with globus (n = 16, 10.2%). The two most common mental health disorders found in the included studies were anxiety disorders (n = 123, 78.8%) and mood disorders (n = 111, 71.2%). The Voice Handicap Index was the most used tool to gather data on voice disorders (n = 36, 23.1%), while the Hospital Anxiety and Depression Scale was the most used tool to gather data on mental health disorders (n = 20, 12.8%). The populations studied within the included articles were predominately female and worked in educational occupations. Race and ethnicity was only reported for 10.2% of included articles (n = 16) and the most commonly studied race was White/Caucasian (n = 13, 8.3%).

CONCLUSION

Our scoping review of the current literature on mental health and voice disorders reveals an intersection between the conditions. The current literature represents change over time in terms of terminology that recognizes the patient's individualized experience of mental health and laryngeal conditions. However, there is still a great deal of homogeneity in the studied patient populations in terms of race and gender, with patterns and gaps that require further investigation.

Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum

OBJECTIVES

Curriculum for clinical reasoning in the preclinical years is sparse and the COVID-19 pandemic heightened the need for virtual curriculums.

METHODS

We developed, implemented and evaluated a virtual curriculum for preclinical students scaffolding key diagnostic reasoning concepts: dual process theory, diagnostic error, problem representation and illness scripts. Fifty-five second-year medical students participated in four 45-min virtual sessions led by one facilitator.

RESULTS

The curriculum led to increased perceived understanding and increased confidence in diagnostic reasoning concepts and skills.

CONCLUSIONS

The virtual curriculum was effective in introducing diagnostic reasoning and was well-received by second-year medical students.

Diurnal variability of cortisol in the Pennsylvania adult smoking study: Exploration of association with nicotine intake

Cortisol in saliva, urine and plasma follows a diurnal rhythm typically characterized as a morning peak and a decline throughout the waking day. While often measured under controlled conditions, inter-individual differences in cortisol diurnal rhythms in free living populations are not well characterized. Cortisol levels may vary substantially between individuals and the level of variation may differ depending on the time of day. Further, associations with individual characteristics such as nicotine dependence on cortisol rhythms have not been adequately determined. We developed a Liquid Chromatography-Tandem Mass Spectrometry method to measure cortisol in saliva of 180 smokers from the Pennsylvania Adult Smoking Study. Diurnal patters of cortisol were determined by obtaining five timed samples throughout the day for a total of 900 determinations. Adherence to the protocol was estimated by asking participants to record the time of sample collection. Longitudinal linear mixed effects models were developed to measure the predictors of mean levels. Phenotypic groups were constructed based on the minimum and maximum cortisol levels. Mixed method modelling was conducted to determine the effects of phenotype and study adherence as well as reported measures of stress, nicotine dependence and cigarette smoking frequency. Nicotine metabolites were measured to accurately quantify dose of smoking intake. Results showed that there was moderate compliance to the timed protocol. Descriptive and analytic findings showed that some smokers had atypical cortisol patterns, and that the cortisol profiles based on experience of maximum and minimum cortisol levels can predict how cortisol varies throughout the day. There was no association with reported stress, cigarettes per day, and nicotine metabolites. There was no association with the Fagerstrom Test for Nicotine Dependence. The Hooked on Nicotine Checklist (HONC) score was associated with decreased cortisol levels. Overall these results show new approaches and expectations to population-based studies of cortisol.

Physician's Knowledge and Practices Surrounding Low-Dose Aspirin for Preeclampsia Risk Reduction

OBJECTIVE

 Preeclampsia is a leading cause of pregnancy-related deaths. Up to 60% of maternal deaths associated with preeclampsia may be prevented. Clinical trials have shown that low-dose aspirin reduces preeclampsia up to 30% among women at increased risk. Since 2014, multiple professional societies and the U.S. Preventive Services Task Force have released guidelines on the use of low-dose aspirin to reduce the risk of preeclampsia. We aimed to evaluate physician's knowledge and practices surrounding low-dose aspirin for preeclampsia risk reduction.

STUDY DESIGN

 We distributed an anonymous electronic survey to licensed physicians in the Rio Grande Valley of Texas who provide prenatal care, including general obstetrician-gynecologists, maternal fetal medicine subspecialists, and family medicine physicians. The survey consisted of 20 items assessing demographics, provider practices, and knowledge on the use of low-dose aspirin for preeclampsia risk reduction.

RESULTS

 We received 48 surveys with a response rate of 55%. More than 90% of physicians reported recommending low-dose aspirin for preeclampsia risk reduction, of which 98% correctly identified the dose. Of the physicians recommending aspirin, 83% initiate dosing between 12 and 16 weeks, but only 52% continue it until the day of delivery. Nearly 80% of respondents identified that one high-risk factor for preeclampsia is an indication for prophylaxis, but only 56% identified that two or more moderate risk factors should prompt aspirin recommendation.

CONCLUSION

 Despite clear professional guidelines, physicians demonstrated gaps in knowledge and differences in practices. Enhancing screening tools to assess patient's risk of developing preeclampsia and tailored medical education on moderate risk factors are needed to identify patients who may benefit from this intervention. Increasing the use of aspirin in patients at risk is critical given the benefits of low-dose aspirin in the reduction of poor maternal and neonatal outcomes related to preeclampsia.

KEY POINTS

· Low-dose aspirin reduces preeclampsia in patients up to 30%.. · Physicians have gaps in knowledge despite guidelines.. · Following guidelines reduces poor outcomes associated with preeclampsia..

Factors associated with meeting physical activity guidelines during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic impacted individual physical activity levels. Less is known regarding how factors such as sociodemographic and built environment were associated with physical activity engagement during the pandemic. Understanding these factors is critical to informing future infectious disease mitigation policies that promote, rather than hinder physical activity. The purpose of this study was to assess predictors of physical activity levels during the beginning of the pandemic (April-June 2020), including Stay-at-Home length and orders, neighborhood safety, and sociodemographic characteristics.

METHODS

Data included 517 participants who responded to an anonymous online survey. Physical activity was assessed with a modified Godin Leisure-time exercise questionnaire. We used logistic regression models to estimate unadjusted and adjusted odds ratios (aOR) and their 95% confidence intervals (CI) for the associations between independent variables (e.g., demographic variables, neighborhood safety, COVID Stay-at-Home order and length of time) and physical activity levels that did not meet (i.e., < 600 metabolic equivalents of task [MET]-minutes/week) or met guidelines (i.e., ≥ 600 MET-minutes/week). We used R-Studio open-source edition to clean and code data and SAS V9.4 for analyses.

RESULTS

Most participants were 18-45 years old (58%), female (79%), Hispanic (58%), and college/post-graduates (76%). Most (70%) reported meeting physical activity guidelines. In multivariate-adjusted analyses stratified by income, in the highest income bracket (≥ $70,000) pet ownership was associated with higher odds of meeting physical activity guidelines (aOR = 2.37, 95% CI: 1.23, 4.55), but this association did not persist for other income groups. We also found lower  perceived neighborhood safety was associated with significantly lower odds of meeting physical activity guidelines (aOR = 0.15, 95% CI:0.04-0.61), but only among individuals in the lowest income bracket (< $40,000). Within this lowest income bracket, we also found that a lower level of education was associated with reduced odds of meeting physical activity guidelines.

DISCUSSION

We found that perceived neighborhood safety, education and pet ownership were associated with meeting physical activity guidelines during the early months of the COVID-19 pandemic, but associations differed by income. These findings can inform targeted approaches to promoting physical activity during subsequent waves of COVID-19 or future pandemics.

Factors Contributing to SARS-CoV-2 Vaccine Hesitancy of Hispanic Population in Rio Grande Valley

Hispanic communities have been disproportionately affected by economic disparities. These inequalities have put Hispanics at an increased risk for preventable health conditions. In addition, the CDC reports Hispanics to have 1.5× COVID-19 infection rates and low vaccination rates. This study aims to identify the driving factors for COVID-19 vaccine hesitancy of Hispanic survey participants in the Rio Grande Valley. Our analysis used machine learning methods to identify significant associations between medical, economic, and social factors impacting the uptake and willingness to receive the COVID-19 vaccine. A combination of three classification methods (i.e., logistic regression, decision trees, and support vector machines) was used to classify observations based on the value of the targeted responses received and extract a robust subset of factors. Our analysis revealed different medical, economic, and social associations that correlate to other target population groups (i.e., males and females). According to the analysis performed on males, the Matthews correlation coefficient (MCC) value was 0.972. An MCC score of 0.805 was achieved by analyzing females, while the analysis of males and females achieved 0.797. Specifically, several medical, economic factors, and sociodemographic characteristics are more prevalent in vaccine-hesitant groups, such as asthma, hypertension, mental health problems, financial strain due to COVID-19, gender, lack of health insurance plans, and limited test availability.

Patterns of Colorectal Cancer in Texas Counties From 2000 to 2017

PURPOSE

Residents living in Texas counties along the United States-Mexico border make up a unique demographic. These counties consist of a large proportion of Hispanic-Latinx people who experience a high rate of health uninsurance and underinsurance, low household income averages, and, as a whole, exhibiting relatively poor health outcomes compared to the US general population. Limited information exists regarding the effects of these characteristics on the incidence of colorectal cancer (CRC).

METHODS

Using data from the Texas Department of State Health Service, we calculated that the overall age-adjusted incidence rate (AAIR) of CRC was lower and decreased at a slower rate over time in Texas border counties compared with nonborder counties in Texas.

RESULTS

The AAIR of CRC was lower and decreased at a slower rate over time in Texas border counties compared with nonborder counties in Texas. Conversely to other groups analyzed, the AAIR of CRC in individuals age 50-64 years in border counties increased.

CONCLUSION

These findings are likely a reflection of less utilization of cancer screening in border counties than in nonborder counties. The increase in AAIR of CRC among individuals age 50-64 years in border counties warrants further investigation.

Colorectal cancer incidence in Texas border versus non-border counties

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Background: There are 32 counties and 2.8 million people in the Texas border region. The population is 88.4% Hispanic with estimates that 47% lack health insurance - not including non-US citizens, who are more likely to lack health insurance than US citizens. In 2014, 7 of the 20 US counties with the lowest CRC screening rates were in Texas, 6 of which were Texas border counties. It is unknown how the incidence of CRC in Texas border counties has changed over time compared to non-border counties. In this study, we investigate changes in the incidence of CRC in Texas border counties between 2000 and 2017. Methods: Data were obtained from the Texas Department of State Health Service’s Texas Cancer Registry. Cases of patients aged 18 or older between 2000 and 2017 were included in our analysis. Cases were excluded if they contained incomplete information regarding age, sex, year of diagnosis, site of diagnosis or poverty level. Simple descriptive statistics were calculated for all covariates. Chi-square tests of independence were created to examine the association between each categorical variable and border county status. Age-adjusted incidence rates (AAIR) were created for the state overall and by border status. SAS v9.4 was used for all data analysis. Results: In border counties from 2000 to 2017, the overall AAIR decreased from 65.9 (per 100,000) to 56.7. In those 50-64 years old and 65 years and older residing in border counties, the AAIR increased from 63.3 to 78.1 and decreased from 244 to 176.1, respectively. In non-border counties from 2000 to 2017, the overall AAIR decreased from 85.2 (per 100,000) to 57.3. In those 50-64 years old and 65 years and older residing in non-border counties, the AAIR decreased from 94.9 to 78.0 and from 303 to 168.5, respectively. Conclusions: The overall AAIR of CRC was lower in Texas border counties compared to non-border counties, which is likely a consequence of lower screening rates in border counties. The overall AAIR decreased at a slower rate in Texas border counties compared to non-border counties, which may represent lower rates of utilization of CRC screening over time in border counties. The increase in the AAIR among those 50-64 years old in Texas border counties warrants further investigation.

Disparity in outcomes of melanoma adjuvant immunotherapy by demographic profile

Background

Randomized comparisons have demonstrated survival benefit of adjuvant immunotherapy in node-positive melanoma patients but have limited power to determine if this benefit persists across various demographic factors.

Materials & methods

We assessed the impact of demographic factors on the survival benefit of adjuvant immunotherapy in a database of 38,189 node-positive melanoma patients using the Kaplan-Meier method and Cox proportional hazards models.

Results

All assessed demographic factors other than race significantly impacted survival of node-positive melanoma patients in univariate analysis. In multivariable analysis, only the age group interacted with immunotherapy.

Conclusion

Analysis of this large database of unselected node-positive melanoma patients demonstrated a positive survival benefit of immunotherapy across all demographic factors assessed and the impact was greater for patients 65 years of age and older.

Abstract C086: Racial disparities in clinical characteristics and outcomes of patients with pancreatic neoplasms: An eleven-year analysis of the National Cancer Database (NCDB)

Background: Pancreatic neoplasms consist of exocrine, endocrine and benign tumors. Exocrine pancreatic cancer is the fourth leading cause of cancer-related death in the US. Racial disparities in incidence, diagnosis, treatment, and outcomes have been evaluated in different types of tumors, but the data on pancreatic neoplasms are lacking. Our aim is to evaluate the racial disparities in clinical characteristics and survival of patients with pancreatic neoplasms.

Methods: Using the National Cancer Database (NCDB), we identified 340,780 patients diagnosed with a pancreatic neoplasm between 2004 and 2015. Simple descriptive statistics were created for all covariates. Chi-square analysis was used to examine the distribution of demographic and clinicopathologic variables among different races. Survival analysis was done on patients with either death dates or follow-up dates, totaling 305,576 patients. Kaplan Meier survival analysis was used for unadjusted results, and Cox proportional hazards model was used for multivariable analysis. Races were grouped into White, Black, Hispanic, and others. The objective of the study is to assess racial disparities in clinical presentation, and to evaluate whether this influences the outcomes in patients with pancreatic neoplasms.

Results: The median age at diagnosis was 69 (range 18-90) years and 50.6% were males. Carcinoma was the most common histology (81.3%), followed by other histology (9.6%), benign (5.4%) and neuroendocrine (3.7%) tumors. The percent of White, Black, Hispanic, and other race was 74.5, 11.3, 5.0, and 9.1%. Whites presented at more advanced ages compared to Blacks, Hispanics, and others (78.3, 68.6, 69.3, 76.3% were ≥60 years at diagnosis; p&lt;0.0001). Blacks and Hispanics presented more frequently with advanced stage (III and IV) of the disease compared to Whites (54.7, 52.8, 50.9%; p&lt;0.0001). Uninsured patients had a higher risk of death compared to those with insurance, HR=1.11 [95% CI 1.09-1.14]. Patients with lower annual income had a higher hazard of death (one example: &lt;$38,000 vs &gt;$63,000 HR=1.20 [95% CI 1.19-1.22]). Unadjusted analysis showed Blacks had a marginally higher hazard of death than Whites, HR=1.02 [95% CI 1.01-1.03]. However, after adjustment for age, sex, histology, grade, comorbidity score, income, education, and year of diagnosis, Blacks and Hispanics had a slightly better overall survival than Whites, HR=0.96 [95% CI 0.94-0.97] and 0.85 [95% CI 0.84-0.87]. Among patients with treatment information, time to first treatment was significantly longer among Blacks and Hispanics compared to Whites (4.4 and 3.2 days longer on average, p&lt;0.0001).

Conclusion: Our study provides evidence that various disparities exist across different races in pancreatic neoplasms. However, they did not lead to inferior outcomes in minorities. Our findings should be examined in other cohorts where more data about treatment are available.

Citation Format: Hussein Assi, Michael Machiorlatti, Sara Vesely, Vipul Pareek, Hassan Hatoum, Sarbajit Mukherjee. Racial disparities in clinical characteristics and outcomes of patients with pancreatic neoplasms: An eleven-year analysis of the National Cancer Database (NCDB) [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C086.

Predictors of Outcome in Patients With Fibrolamellar Carcinoma: Analysis of the National Cancer Database

BACKGROUND

Fibrolamellar carcinoma (FLC) is a very rare liver tumor. We aimed to retrospectively analyze the clinicopathological factors and treatment modalities affecting overall survival (OS) in FLC. The objective of the study was to identify predictors of survival in FLC.

PATIENTS AND METHODS

Using the National Cancer Database, we identified 496 patients diagnosed with FLC between 2004 and 2015. Clinicopathological, treatment, and survival data were collected.

RESULTS

Hepatic resection was performed on 254 (51.2%) patients, liver-directed therapy on 13 (2.6%) patients, and liver transplantation on 15 (3.0%) patients. Median OS by stage were 142.1, 87.2, 32.3, and 14.1 months for stages 1, 2, 3, and 4, respectively. Metastatectomy was not associated with superior median OS (23.4 vs. 10.5 months, p=0.163). Age ≤40, low Charlson-Deyo comorbidity score, early stage and hepatic resection were independently associated with longer OS.

CONCLUSION

Our study reports current trends in FLC management, and identifies independent predictors of OS.

Abstract P6-11-04: Trends and variations in female breast cancer along the Texas-Mexico border trends and variations in breast cancer along the Texas-Mexico border

Background: Breast cancer is the leading cause of cancer death in Hispanic women. Compared to non-Hispanic Whites, Hispanic women are more likely to be diagnosed at later stages, with larger tumors and more likely to die from their cancer. The health disparities seen in the Hispanic population have been partially attributed to inadequate health insurance coverage and greater shortage of physicians, resulting in limited access to quality health care, lower cancer screening rates, and delays in treatment. The counties along Texas-Mexico border region, which occupy 1,254-miles of shared border and consist predominantly of a Hispanic population, share the worst health disparity statistics in the U.S. In this study, we investigate incidence and survival of breast cancer and explore whether these findings corroborate the trends seen in state and national surveillance reports.

Methods: We used publicly available female breast cancer cases in Texas between 1995-2015 made available from the Texas Cancer Registry. Chi-square tests examined the association between each categorical variable and border county status. Crude and age-adjusted incidence rates overall, invasive, and noninvasive were created for the state overall and by border status. To assess survival, unadjusted and adjusted median OS (95% CI) was calculated for overall and invasive/non-invasive female breast cancer by border status using Kaplan Meier survival analysis. Cox proportional hazards multi-variables models were also used to identify risk-factors that are associated with the difference in cancer survival rates overall and by border status.

Results: Adjusting for age, a decrease in the incidence ratio (IR) of overall and invasive female breast cancer is observed from 2000 to 2004 in border versus non-border counties followed by relative stability in the IR from 2005 to 2010. Without adjustment, relative to nonborder counties, border counties have a 7-month reduction in median overall survival (OS) for invasive cancer and 13-month reduction in median OS overall. After adjustment for age group, race, poverty level, grade and stage, Cox proportional hazard analysis revealed a lower hazard of death favoring border counties, 14% and 12%, respectively, for both invasive and noninvasive breast cancer (Table 1). Further stratification by neighborhood poverty level reveals no difference in the hazard of death amongst those within counties with poverty from 0-9.99%. However, for those belonging in lower poverty tracts, 10-19.9% and 20-100%, there is a 10% reduction in the hazard of death for both overall and invasive cancers that is statistically significant (Table 2).

Conclusion: Prior studies have demonstrated later diagnosis and worse outcomes in Hispanic women with breast cancer. Disparities notwithstanding, our results indicate that women of all races in a low poverty level (&gt;10%) and those living in the border counties have a significantly lower hazard of death. Further studies will examine the unexpected positive outcomes to identify potentially protective factors.

Table 1Cancer TypeUnadjustedAdjustedHRp-valueHRp-valueOverall1.08&lt; 0.00010.86&lt;0.0001Invasive1.0450.00040.86&lt; 0.0001Noninvasive1.080.09200.880.0158*adjusted for age group, race, poverty group, grade, stage, and year of diagnosis.

Table 2Cancer TypePoverty Level0-4.9%5-9.9%10-19.9%20-100%HRp-valueHRp-valueHRp-valueHRp-valueOverall1.110.27961.040.48610.900.00090.90&lt;.0001Invasive Cancer 1.110.32551.040.51960.900.0020.90&lt;.0001

Citation Format: Fernando Cristobal Diaz, Elva Nora Osuna-Salazar, Candace Robledo, Michael Machiorlatti, Nabeel Sarhill, Henry Kwang. Trends and variations in female breast cancer along the Texas-Mexico border trends and variations in breast cancer along the Texas-Mexico border [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-04.

Surgery Versus Surveillance for Well-Differentiated, Nonfunctional Pancreatic Neuroendocrine Tumors: An 11-Year Analysis of the National Cancer Database

BACKGROUND

Pancreatic neuroendocrine tumors (panNETs) are a rare group of tumors that make up 2%-3% of pancreatic tumors. Recommended treatment for panNETs generally consists of resection for symptomatic or large asymptomatic tumors; however, optimal management for localized disease is still controversial, with conflicting recommendations in established guidelines. Our study aim is to compare surgical intervention versus active surveillance in nonmetastatic panNETs by size of primary tumor.

MATERIALS AND METHODS

Using the National Cancer Database, we identified 2,004 patients diagnosed with localized well-differentiated, nonfunctional panNETs (NF-panNETs) between 2004 and 2015. Patients' clinicopathologic characteristics, treatment modalities, and overall survival (OS) were analyzed using frequency statistics, chi-square, and Kaplan-Meier curves. The objective of the study is to assess the outcome of surgical resection versus nonoperative management in patients with panNETs with different tumor sizes.

RESULTS

Tumor sizes were divided into three categories: <1 cm, 1-2 cm, and >2 cm. The number of patients with tumor size <1 cm, 1-2 cm, and >2 cm was 220 (11%), 794 (39.6%), and 990 (49.4%), respectively. Overall, 1,781 underwent surgical resection, whereas 223 patients did not. Median follow-up was 25.9 months. After adjusting for covariates, surgical resection was associated with improved OS in patients with tumor size 1-2 cm (hazard ratio [HR] = 0.37) and >2c m (HR = 0.30) but not <1 cm (HR = 2.81). Independent prognostic factors were age at diagnosis, Charlson-Deyo comorbidity score, stage, tumor location, and surgical resection. Higher tumor grade was not associated with worse OS.

CONCLUSION

Our findings suggest that active surveillance is potentially a safe approach for NF-panNETs <1 cm. Larger tumors likely need active intervention. Intermediate-grade tumors did not result in worse survival outcome compared with low-grade tumors. Future studies might consider prospective randomized clinical trials to validate our findings.

IMPLICATIONS FOR PRACTICE

The present study seeks to address the discrepancy in treatment recommendations in the management of nonfunctional pancreatic neuroendocrine tumors (NF-panNETs) by evaluating whether surgical resection is associated with improved overall survival in different tumor size groups as well as elucidating independent prognostic factors in patients with NF-panNETs. Data from the National Cancer Database were reviewed. This study's findings suggest that active surveillance is potentially a safe approach for NF-panNETs <1 cm. Larger tumors likely need active intervention. Independent prognostic factors include age at diagnosis, Charlson-Deyo comorbidity score, stage, tumor location, and surgical resection. These findings will help guide medical and surgical oncologists when formulating treatment plans for patients with small NF-panNETs.

Socioeconomic differences in nicotine exposure and dependence in adult daily smokers

Background

Socioeconomic status (SES) is a major determinant of tobacco use but little is known whether SES affects nicotine exposure and the degree of nicotine dependence.

Methods

The Pennsylvania Adult Smoking Study is a cross-sectional study of smoke exposure and nicotine dependence among adults conducted in central Pennsylvania between June 2012 and April 2014. The study included several measures of SES, including assessments of education and household income, as well as occupation, home ownership, health insurance, household density and savings accounts. Measurements included saliva for the nicotine metabolites cotinine (COT), 3-‘hydroxycotinine (3HC) and total metabolites (COT +3HC). Puffing behavior was determined using portable smoking topography devices.

Results

The income levels of lighter smokers (< 20 cigarettes per day) was $10,000 more than heavier smokers. Higher Fagerström Test for Nicotine Dependence scores were associated with lower income and job status, scores ranged from 5.4 in unemployed, 4.4 in blue-collar, and 3.8 in white-collar workers. In principal components analysis used to derive SES indicators, household income, number in household, and type of dwelling were the major SES correlates of the primary component. Job category was the major correlate of the second component. Lower SES predicted significantly higher adjusted total nicotine metabolite levels in the unemployed group. Job category was significantly associated with total daily puffs, with the highest level in the unemployed, followed by blue-collar workers, after adjustment for income.

Conclusions

Among smokers, there was a relationship between lower SES and increased nicotine dependence, cigarettes per day and nicotine exposure, which varied by job type.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6694-4) contains supplementary material, which is available to authorized users.

Clinical characteristics and predictors of outcomes in patients with fibrolamellar carcinoma: An eleven-year analysis of the National Cancer Database (NCDB)

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Background: Fibrolamellar carcinoma (FLC) is a very rare liver tumor, comprising only 1% of all primary liver tumors in the United Sates. There is no standard of care for unresectable disease. Current practices are based on small retrospective studies and case series. We aim to analyze the clinicopathologic factors and treatment modalities affecting overall survival (OS) in FLC. Methods: Using the National Cancer Data Base (NCDB), we identified 496 patients diagnosed with FLC between 2004 and 2015. Simple descriptive statistics were created for all covariates. Survival data was available on 461 patients. Kaplan Meier Survival analysis was used for unadjusted results, and Cox proportional hazards model was used for multivariable analysis. The objective of the study is to identify predictors of survival in FLC. Results: The median age at diagnosis was 32 (range 18-90) years. Fifty-six percent were males. Stage distribution included 114 (31.2%), 43 (11.8%), 89 (24.3%) and 120 (32.8%) patients for stages I, II, III and IV, respectively. Median follow-up was 24 months. Surgery of the primary site was performed on 282 (56.9%) of patients, 146 (51.2%) of which had regional lymph node dissection. Seventy (47.9%) patients had pN+ disease. Among patients with available serum alpha fetoprotein (AFP) data, 146 (42.5%) had abnormal AFP levels (> 20 ng/mL). Median OS by stage were 78.5, 87.2, 18.6, and 10.6 months for stages I, II, III, and IV, respectively. Multivariate analysis showed that age (HR 1.01, p < 0.0001), pN+ (HR 2.31, p = 0.0003), and abnormal AFP (HR 1.69, p = 0.0003) were negative predictors of survival. Among metastatic patients, 57 (11.4%) had metastatectomy. Metastatectomy improved overall survival in stage IV FLC, HR 0.51 (95% CI 0.29-0.89). Conclusions: Independent predictors of decreased OS in patients with FLC include age, pN+ and abnormal AFP. Metastatectomy improved OS. FLC is a rare disease entity that warrants further investigations to better delineate optimal treatment approaches.

Effect of body mass index and albumin level on outcomes of patients receiving anti PD-1/PD-L1 therapy

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Background: Obesity has been previously investigated for its role in cancer and promoting tumor growth, at least partially by inducing a chronic inflammatory state. However, it’s unclear how this would play out in the era of immunotherapy, where inflammation has been linked to treatment response. Albumin, a marker of nutritional status, is also a negative inflammatory marker. Patients with low albumin levels have been known to have a poor prognosis. In this study, we aim to assess the association of body mass index (BMI) and albumin level with outcomes of patients treated with immunotherapy. Methods: We retrospectively evaluated the outcomes of 198 patients, aged 18 years or older, treated with anti PD-1/PD-L1 at the University of Oklahoma Health Sciences Center from 2014 to 2017. Simple descriptive statistics were created for all covariates. Kaplan Meier and Cox Proportional Hazard regression were performed to assess how categorical and continuous variables were related to overall survival (OS) and progression free survival (PFS). A final multi-variable model was created using all variables associated with OS and PFS. Results: The median age was 62 years and the median follow-up time was 272 days. Melanoma was the most common diagnosis (25.7%) followed by lung cancer (23.5%) and ovarian cancer (11.5%). Higher BMI was associated with better outcomes. BMI (≥30 vs < 30) unadjusted was significantly associated with better OS (236 vs 133 days, p = 0.04) and PFS (316 vs 210 days, p = 0.01). As a continuous variable, a higher BMI was significantly associated with a better OS but not PFS with HR 0.96 (95% CI 0.93-0.99, p = 0.04) and HR 0.98 (95% CI 0.95-1.01, p = 0.09) respectively. BMI was not associated with OS or PFS in a multivariate analysis. Albumin level at initiation of treatment was not associated with OS (p = 0.12) or PFS (p = 0.19). Conclusions: In this single institution cohort, BMI had a significant effect on outcomes of patients receiving anti PD-1/PD-L1 agents. This warrants further investigation of BMI as a prognostic factor.

Outcomes and Prognostic Factors of Resected Salivary Gland Malignancies: Examining a Single Institution's 12-year Experience

BACKGROUND

Despite adjuvant radiotherapy, survival outcomes remain poor in patients with salivary gland malignancies who have multiple poor prognostic factors. This study aimed to determine which patients may benefit from treatment intensification.

PATIENTS AND METHODS

Patients who underwent curative resection with or without adjuvant radiotherapy between 2002 and 2014 were identified and a retrospective chart review was performed. Overall survival (OS) and disease-free survival (DFS) were the main outcomes measured.

RESULTS

A total of 95 patients met the inclusion criteria. The median follow-up was 46.8 months. The median age was 60 years. Radiotherapy was given to 78 patients. Multivariate analysis revealed that male sex and perineural invasion significantly reduced overall and disease-free survival. Distant metastases comprised of 67% of recurrences and 33% were locoregional.

CONCLUSION

Adjuvant chemoradiotherapy should be considered for patients with tumors with perineural invasion, especially in males with high-risk histopathology or high-grade, late-stage disease. To our knowledge, this is the first study to assess the impact of pack-year smoking history on survival outcomes.

Outcomes and prognostic factors of localized, resected malignant salivary gland tumors: Examining a single institution’s 12-year experience to discover indications for adjuvant chemotherapy

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Background: Survival outcomes remain poor in salivary gland malignancies (SGMs) with multiple poor prognostic factors despite adjuvant radiotherapy. We examined prognostic factors that portended poor survival in resected SGMs to determine possible indications for adjuvant chemoradiotherapy. Methods:Patients who underwent curative resection with or without adjuvant radiotherapy between 2002 and 2014 were identified and retrospective chart review was performed. Bivariate analysis was performed on continuous variables using Analysis of Variance. Chi-Square analysis and Fishers Exact Tests were performed on categorical variables. To evaluate the overall survival (OS) and disease-free survival (DFS), Kaplan-Meier curves and log-rank tests of homogeneity were used. Results: Overall, 99 patients met inclusion criteria. Median follow-up time was 46.8 months. Univariate analysis revealed male sex, smoking history ≥ 10 pack-years, high grade, stage III-IVB, squamous cell histology, and perineural invasion significantly impacted OS and DFS. High-risk histopathology significantly impacted DFS and trended towards poor OS. Positive resection margins trended towards significantly impacting DFS. Multivariate analysis revealed only male sex and perineural invasion significantly impacted OS and DFS. Conclusions: Survival outcomes remain poor for patients with high-grade, late-stage tumors with perineural invasion. Specifically, perineural invasion is a poor prognostic factor regardless of age, histology, stage, and grade. Males and patients with a smoking history ≥ 10 pack-years have worse survival outcomes with male sex being a more influential prognostic factor. Notably, this is the first study to quantify patient’s smoking history in malignant salivary gland tumors and assess the impact of pack-year smoking history on survival outcomes. Given our observed trend, positive resection margins would likely become significant influencer of DFS with larger sample size and longer follow up. Adjuvant chemoradiotherapy should be evaluated in patients with the above-mentioned characteristics.

Discontinuation of Antimicrobial Prophylaxis (AP) in Children With Spina Bifida: A Case Series Analysis

Background

Spina bifida increases the risk for urinary tract infections (UTI). Antimicrobial prophylaxis (AP) reduces symptomatic UTI’s but selects resistant organisms. Measures to ensure regular and complete emptying of the bladder combined with treatment of constipation reduce the risk for UTI.

Objectives

Demonstrate that close adherence to a catheterization regimen in children with spina bifida (Selective Treatment - ST) reduces the need for antimicrobial prophylaxis.

Methods

Case series analysis of pediatric spina bifida clinic patients where routine antimicrobial prophylaxis was replaced by clean-catch catheterization and daily bowel regimen (ST). Retrospective chart review of 67 children (mean entry age: 24 months, median age: 4 months; 32 Males, 35 Females) enrolled between 1986 - 2004. Mean follow-up was 128.6 months (range 3 - 257 months). Asymptomatic and symptomatic UTI incidences were noted on AP and ST protocols. Creatinine clearance at study entry and follow-up was calculated by the age appropriate method. A multivariable regression model with delta Glomerular Filtration Rate (GFR) as the dependent variable, independent sample t-test and Wilcoxon rank sum were performed with SAS v. 9.2.

Results

The mean number of infections while on AP was 8.7 (95% CI 5.72, 11.68) and was 1.0 on ST (95% CI 0.48, 1.43). 5 infections on the AP protocol required intravenous (IV) antibiotics due to resistance to oral therapy, but none on ST. Comparing change in GFR between both protocols (AP vs. ST) found a significant difference in the change of GFR by treatment protocol.

Conclusions

AP did not prevent UTIs and resulted in more resistant organisms requiring IV antibiotics. Discontinuing AP allowed the return of susceptibility to oral antimicrobials and significantly improved GFR in those children who had previously been on AP. Adherence to a catheterization regimen with prompt treatment of symptomatic UTI conserved renal function and prevented selection of resistant organisms.

Variability of the pubic arch architecture and its influence on the minimal levator hiatus area

OBJECTIVE

To investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle.

METHODS

A subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements.

RESULTS

The analysis included 56 women with mean age of 43.0±13.4years. The mean MLH area was 13.1±1.8cm(2) (range 9.0-17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r=0.13). Height and pubic arch length were positively correlated with the MLH area (r=0.26 [P=0.52] and r=0.50 [P<0.001], respectively).

CONCLUSION

The MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman's pelvic bone characteristics into account.

Gross tumour volume variations in primary non-small-cell lung cancer during the course of treatment with stereotactic body radiation therapy

INTRODUCTION

We aim to quantify the variations in the gross tumour volume (GTV) during a course of stereotactic body radiotherapy (SBRT) and determine its impact on dosimetric coverage of the GTV.

METHODS

The GTVs and dose coverage for 14 patients with 16 primary non-small-cell lung tumours treated with SBRT were investigated. Initial GTVs were calculated from treatment planning CT scans. The prescribed doses ranged from 48 to 60 Gy in three to five fractions. Before each treatment, patients underwent a CBCT scan. For each CBCT scan, the GTV and the dose received by the GTV were determined and followed during the course of therapy.

RESULTS

There was considerable variation in the measured GTVs during the course of therapy. Increases of up to 63.3% of volume measured by initial CBCT were detected during the first few fractions, after which GTV tended to decrease. Dose coverage (V95) for any given fraction deviated no more than 5% from optimised coverage obtained in the initial treatment plan. In the long term, all patients with follow-up scans demonstrated tumour shrinkage with no radiographic evidence of tumour recurrence.

CONCLUSION

GTV, as evaluated in this study, demonstrates an initial increase in volume followed by a subsequent decrease. This volume change needs to be considered in the design of treatment plans and assignment of treatment margins.

Acute myeloid leukemia: Comparison of epidemiology and treatment outcomes between insured and uninsured patients

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Background: The overall prognosis for most acute myeloid leukemia (AML) patients remains poor. The majority of adult patients (pts) with AML will ultimately need allogeneic stem cell transplant (allo-SCT). Limited data is available comparing epidemiology and treatment outcomes between uninsured and insured pts with AML. We describe a retrospective analysis of adult pts with AML treated at our institution. Methods: From January 2000 to June 2011 we identified 239 pts with AML, of which 185 met inclusion criteria. Patients were classified as having private insurance, public insurance (Medicaid and Medicare), or no insurance. Primary outcomes were overall survival at follow up (OS), complete remission (CR), and percent of pts receiving allo-SCT. Kaplan-Meier analysis was used to estimate survival rates. Results: Of the 185 pts studied, 146 (81%) were white, 16 (9%) African-American and 11 (6%) were Native American. The median age at diagnosis was 49 years. 75 pts had private insurance at the time of diagnosis, 70 had public insurance, and 33 were uninsured. Of those receiving allo-SCT (n=60; 38 male) 48% had private insurance, 30% public, and 22% were uninsured. Whether a patient underwent allo-SCT did not differ according to insurance source (p=0.2189) nor to status at follow-up (p= 0.6480). The proportion of patients achieving CR was higher among those undergoing allo-SCT (p=0.0002). Median OS was 920 days for those who underwent allo-SCT and 192 days for those who did not (p< 0.0001). Median OS did not differ by insurance type (p = 0.1454). The proportion of patients achieving CR did not differ by insurance type (p=0.2665) (66.7% of those with private, 62.7% of those with public, and 78.8% of those with no insurance). Conclusions: For the population referred to our institution, a tertiary referral center for the state, there were no differences in treatment outcomes or in the percent of pts receiving allo-SCT when pts were stratified according to insurance source. Further analysis of this dataset will identify the impact of pretreatment variables stratified by type of insurance.