Anal Cancers in Previously Screened Versus Unscreened Patients: Tumor Stage and Treatment Outcomes

BACKGROUND

Targeted screening programs for patients at high risk for anal squamous-cell carcinoma have been proposed; however, the evidence in support of screening remains unclear.

OBJECTIVE

This study aimed to determine whether screening high-risk patients (predominantly those living with HIV) detected squamous-cell carcinoma at an earlier stage compared to the routine practice of not screening.

DESIGN

This is a cohort study.

SETTINGS

This study was conducted at a quaternary care center in Canada.

PATIENTS

Included patients were at least 18 years old with a pathologic diagnosis of invasive anal squamous-cell carcinoma between 2002 and 2022.

INTERVENTIONS

Patients diagnosed through a high-risk screening program were compared to those who did not undergo screening.

MAIN OUTCOME MEASURES

The primary outcome was clinical stage at presentation, categorized as T1N0M0 vs other. Secondary outcomes included treatments received, treatment failure, and overall survival.

RESULTS

A total of 612 patients with anal squamous-cell carcinoma were included, with 26 of those patients diagnosed through a screening program. Patients with screen-detected cancers had greater odds of presenting with T1N0M0 tumors compared to unscreened patients (18 [69.2%] vs 84 [14.3%]; adjusted OR 9.95; 95% CI, 3.95-25.08). A propensity score-matched sensitivity analysis found similar results (OR 11.13; 95% CI, 4.67-26.52). Screened patients had greater odds of treatment with wide local excision alone, as opposed to any combination of chemotherapy, radiation therapy, and surgery (3 [12.5%] vs 18 [3.2%]; OR 4.38; 95% CI, 1.20-16.04). There were no statistically significant differences in treatment failure or overall survival between groups.

LIMITATIONS

The small number of screened patients limits the power of the analysis.

CONCLUSIONS

Screening for anal squamous-cell carcinoma among high-risk populations detects cancers at an earlier stage. Patients with screen-detected cancers also had a greater likelihood of being candidates for wide local excision alone, which may have spared them the morbidity associated with chemoradiotherapy or abdominoperineal resection. See Video Abstract.

CNCERES DE ANO EN PACIENTES PREVIAMENTE DETECTADOS POR CRIBADO VERSUS NO DETECTADOS ESTADIO DEL TUMOR Y RESULTADOS DEL TRATAMIENTO

ANTECEDENTES:Se han propuesto programas de cribado dirigidos a pacientes con alto riesgo de carcinoma anal de células escamosas; sin embargo, la evidencia a favor de la detección sigue sin estar clara.OBJETIVO:Este estudio tuvo como objetivo determinar si el cribado de pacientes de alto riesgo (predominantemente aquellos que viven con el VIH) detectó el carcinoma de células escamosas en una etapa más temprana en comparación con la práctica habitual de no cribado.DISEÑO:Este es un estudio de cohortes.CONFIGURACIÓN:Este estudio se realizó en un centro de atención cuaternaria en Canadá.PACIENTES:Los pacientes incluidos tenían al menos 18 años con un diagnóstico patológico de carcinoma de células escamosas anal invasivo entre 2002 y 2022.INTERVENCIONES:Los pacientes diagnosticados mediante un programa de cribado de alto riesgo se compararon con aquellos que no se sometieron a cribado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el estadio clínico en la presentación, categorizado como T1N0M0 versus otro. Los resultados secundarios incluyeron los tratamientos recibidos, el fracaso del tratamiento y la supervivencia general.RESULTADOS:Se incluyeron un total de 612 pacientes con carcinoma anal de células escamosas, con 26 de esos pacientes diagnosticados a través de un programa de cribado. Los pacientes con cánceres detectados mediante cribado tenían mayores probabilidades de presentar tumores T1N0M0 en comparación con los pacientes no cribados (18 [69.2%] frente a 84 [14.3%]; razón de probabilidad ajustada 9.95; intervalo de confianza del 95 % 3.95 -25.08). Un análisis de sensibilidad emparejado por puntaje de propensión encontró resultados similares (odds ratio 11.13; intervalo de confianza del 95% 4.67 -26.52; p < 0.001). Los pacientes examinados tenían mayores probabilidades de recibir tratamiento con escisión local amplia sola, en comparación con cualquier combinación de quimioterapia, radiación y cirugía (3 [12.5%] frente a 18 [3.2%]; razón de probabilidad 4.38; intervalo de confianza del 95 % 1.20 -16.04). No hubo diferencias estadísticamente significativas en el fracaso del tratamiento o la supervivencia global entre los grupos.LIMITACIONES:El pequeño número de pacientes evaluados limita el poder del análisis.CONCLUSIONES:La detección del carcinoma anal de células escamosas entre las poblaciones de alto riesgo detecta los cánceres en una etapa más temprana. Los pacientes con cánceres detectados mediante cribado también tenían una mayor probabilidad de ser candidatos para una escisión local amplia sola, lo que puede haberles evitado la morbilidad asociada con la quimiorradioterapia o la resección abdominoperineal. (Traducción --Dr. Aurian Garcia Gonzalez ).

Clinical tools to assess functional capacity before elective non-cardiac surgery: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the evidence on clinical tools to assess functional capacity prior to elective non-cardiac surgery.

INTRODUCTION

Functional capacity is a strong prognostic indicator before surgery, which can be used to identify patients at elevated risk of postoperative complications, yet, there is no consensus on which clinical tools should be used to assess functional capacity in patients prior to non-cardiac surgery.

INCLUSION CRITERIA

This review will consider any randomized or non-randomized studies that evaluate the performance of a functional capacity assessment tool in adults (≥18 years) prior to non-cardiac surgery. For studies to be included, the tool must be used clinically for risk stratification. We will exclude studies on lung and liver transplant surgery, as well as ambulatory procedures performed under local anesthesia.

METHODS

The review will be conducted in line with the JBI methodology for scoping reviews. A peer-reviewed search strategy will be used to query relevant databases (ie, MEDLINE, Embase, EBM Reviews). Additional sources of evidence will include databases of non-peer-reviewed literature and the reference lists of included studies. Two independent reviewers will identify eligible studies in 2 stages: stage 1, based on titles and abstracts; and stage 2, based on full texts. Information on study details, measurement properties, pragmatic qualities, and/or clinical utility metrics will be charted in duplicate onto standardized data collection forms. The results will be presented using descriptive summaries, frequency tables, and visual plots that highlight the extent of evidence and remaining gaps in the validation process of each tool.

REVIEW REGISTRATION

Open Science Framework https://osf.io/6nfht.

The impact of unexpected intensive care unit admission after cancer surgery on long-term symptom burden among older adults: a population-based longitudinal analysis

BACKGROUND

Older adults are at high-risk for a post-operative intensive care unit (ICU) admission, yet little is known about the impact of these admissions on quality of life. The objective of this study was to evaluate the impact of an unexpected post-operative ICU admission on the burden of cancer symptoms among older adults who underwent high-intensity cancer surgery and survived to hospital discharge.

METHODS

We performed a population-based cohort study of older adults (age ≥ 70) who underwent high-intensity cancer surgery and survived to hospital discharge in Ontario, Canada (2007-2017). Using the Edmonton Symptom Assessment System (ESAS), a standardized tool that quantifies patient-reported physical, mental, and emotional symptoms, we described the burden of cancer symptoms during the year after surgery. Total symptom scores ≥ 40 indicated a moderate-to-severe symptom burden. Modified log-Poisson analysis was used to estimate the impact of an unexpected post-operative ICU admission (admission not related to routine monitoring) on the likelihood of experiencing a moderate-to-severe symptom burden during the year after surgery, accounting for potential confounders. We then used multivariable generalized linear mixed models to model symptom trajectories among patients with two or more ESAS assessments. A 10-point difference in total symptom scores was considered clinically significant.

RESULTS

Among 16,560 patients (mean age 76.5 years; 43.4% female), 1,503 (9.1%) had an unexpected ICU admission. After accounting for baseline characteristics, patients with an unexcepted ICU admission were more likely to experience a moderate-to-severe symptom burden relative to those without an unexpected ICU admission (RR 1.64, 95% CI 1.31-2.05). Specifically, among patients with an unexcepted ICU admission the average probability of experiencing moderate-to-severe symptoms ranged from 6.9% (95 CI 5.8-8.3%) during the first month after surgery to 3.2% (95% CI 0.9-11.7%) at the end of the year. Among the 11,229 (67.8%) patients with multiple ESAS assessments, adjusted differences in total scores between patients with and without an unexpected ICU admission ranged from 2.0 to 5.7-points throughout the year (p < 0.001).

CONCLUSION

While unexpected ICU admissions are associated with a small increase in the likelihood of experiencing a moderate-to-severe symptom burden, most patients do not experience a high overall symptom burden during the year after surgery. These findings support the role of aggressive therapy among older adults after major surgery.

Geriatric assessment and treatment decision-making in surgical oncology

PURPOSE OF REVIEW

Present an approach for surgical decision-making in cancer that incorporates geriatric assessment by building upon the common categories of tumor, technical, and patient factors to enable dual assessment of disease and geriatric factors.

RECENT FINDINGS

Conventional preoperative assessment is insufficient for older adults missing important modifiable deficits, and inaccurately estimating treatment intolerance, complications, functional impairment and disability, and death. Including geriatric-focused assessment into routine perioperative care facilitates improved communications between clinicians and patients and among interdisciplinary teams. In addition, it facilitates the detection of geriatric-specific deficits that are amenable to treatment. We propose a framework for embedding geriatric assessment into surgical oncology practice to allow more accurate risk stratification, identify and manage geriatric deficits, support decision-making, and plan proactively for both cancer-directed and non-cancer-directed therapies. This patient-centered approach can reduce adverse outcomes such as functional decline, delirium, prolonged hospitalization, discharge to long-term care, immediate postoperative complications, and death.

SUMMARY

Geriatric assessment and management has substantial benefits over conventional preoperative assessment alone. This article highlights these advantages and outlines a feasible strategy to incorporate both disease-based and geriatric-specific assessment and treatment when caring for older surgical patients with cancer.

Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis

BACKGROUND

Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults.

PATIENTS AND METHODS

We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery.

RESULTS

Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy.

CONCLUSIONS

Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.

Frailty assessment tools for use by surgeons when evaluating older adults prior to surgery: a scoping review protocol

INTRODUCTION

Despite growing evidence, uncertainty persists about which frailty assessment tools are best suited for routine perioperative care. We aim to understand which frailty assessment tools perform well and are feasible to implement.

METHODS AND ANALYSIS

Using a registered protocol following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA), we will conduct a scoping review informed by the Joanna Briggs Institute Guide for Scoping Reviews and reported using PRISMA extension for Scoping Reviews recommendations. We will develop a comprehensive search strategy with information specialists using the Peer Review of Electronic Search Strategies checklist, and implement this across relevant databases from 2005 to 13 October 2021 and updated prior to final review publication. We will include all studies evaluating a frailty assessment tool preoperatively in patients 65 years or older undergoing intracavitary, non-cardiac surgery. We will exclude tools not assessed in clinical practice, or using laboratory or radiologic values alone. After pilot testing, two reviewers will independently assess information sources for eligibility first by titles and abstracts, then by full-text review. Two reviewers will independently chart data from included full texts using a piloted standardised electronic data charting. In this scoping review process, we will (1) index frailty assessment tools evaluated in the preoperative clinical setting; (2) describe the level of investigation supporting each tool; (3) describe useability of each tool and (4) describe direct comparisons between tools. The results will inform ready application of frailty assessment tools in routine clinical practice by surgeons and other perioperative clinicians.

ETHICS AND DISSEMINATION

Ethic approval is not required for this secondary data analysis. This scoping review will be published in a peer-review journal. Results will be used to inform an ongoing implementation study focused on geriatric surgery to overcome the current lack of uptake of older adult-oriented care recommendations and ensure broad impact of research findings.

Functional Improvement Trajectories After Surgery (FIT After Surgery) study: protocol for a multicentre prospective cohort study to evaluate significant new disability after major surgery in older adults

INTRODUCTION

Older adults prioritise surviving surgery, but also preservation of their functional status and quality of life. Current approaches to measure postoperative recovery, which focus on death, complications and length of hospitalisation, may miss key relevant domains. We propose that postoperative disability is an important patient-centred outcome to measure intermediate-to-long recovery after major surgery in older adults.

METHODS AND ANALYSIS

The Functional Improvement Trajectories After Surgery (FIT After Surgery) study is a multicentre cohort study of 2000 older adults (≥65 years) having major non-cardiac surgery. Its objectives are to characterise the incidence, trajectories, risk factors and impact of new significant disability after non-cardiac surgery. Disability is assessed using WHO Disability Assessment Schedule (WHODAS) 2.0 instrument and participants' level-of-care needs. Disability assessments occur before surgery, and at 1, 3, 6, 9 and 12 months after surgery. The primary outcome is significantly worse WHODAS score or death at 6 months after surgery. Secondary outcomes are (1) significantly worse WHODAS score or death at 1 year after surgery, (2) increased care needs or death at 6 months after surgery and (3) increased care needs or death at 1 year after surgery. We will use multivariable logistic regression models to determine the association of preoperative characteristics and surgery type with outcomes, joint modelling to characterise longitudinal time trends in WHODAS scores over 12 months after surgery, and longitudinal latent class mixture models to identify clusters following similar trajectories of disability.

ETHICS AND DISSEMINATION

The FIT After Surgery study has received research ethics board approval at all sites. Recruitment began in December 2019 but was placed on hold in March 2020 because of the COVID-19 pandemic. Recruitment was gradually restarted in October 2020, with 1-year follow-up expected to finish in 2023. Publication of the primary results is anticipated to occur in 2024.

Self-management interventions for issues identified in a geriatric assessment: A systematic review

BACKGROUND

With the development of electronic geriatric assessment (GA), recommendations for self-management can be provided to patients without the presence of health care providers. Our research question was to identify what self-management interventions can be used by patients to address issues identified in GA and to determine their effect on patient-centered outcomes such as quality of life, health, mood, cognition, and functional status.

METHODS

Searches were conducted on July 13, 2021, by a health sciences librarian in Medline, Embase, CINAHL, PsycInfo, and the Cochrane Library. A combination of database-specific subject headings and text word searches was used such as self-management, a key word for each of the geriatric assessment domains and older adults. Two independent reviewers reviewed abstracts and full texts for inclusion and abstracted data. Narrative synthesis was used to summarize findings.

RESULTS

Among 28,520 abstracts reviewed, 34 randomized controlled trials were included. The most frequently studied geriatric domains were mood (n = 13 studies), mobility/falls (n = 12), quality of life (n = 11), and functional status (n = 7). The majority of studies demonstrated positive effects on mobility/falls (9 of 12), pain (3 of 5), comorbidity (4 of 4), and medication management (4 of 4). Most studies were of low to moderate quality. All geriatric domains were targeted in at least one study.

CONCLUSIONS

Low- to moderate-quality studies show a variety of effective self-efficacy-targeted interventions exist for older adults to improve several important geriatric domains and related outcomes. However, long-term effects, validation, and scalability of these interventions remain largely unknown.

All-Cause and Cancer-Specific Death of Older Adults Following Surgery for Cancer

Importance

Cancer care has inherent complexities in older adults, including balancing risks of cancer and noncancer death. A poor understanding of cause-specific outcomes may lead to overtreatment and undertreatment.

Objective

To examine all-cause and cancer-specific death throughout 5 years for older adults after cancer resection.

Design, Setting, and Participants

This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). All adults 70 years or older who underwent resection for a new diagnosis of cancer between January 1, 2007, and December 31, 2017, were included. Patients were followed up until death or censored at date of last contact of December 31, 2018.

Exposures

Cancer resection.

Main Outcome and Measures

Using a competing risks approach, the cumulative incidence of cancer and noncancer death was estimated and stratified by important prognostic factors. Multivariable subdistribution hazard models were fit to explore prognostic factors.

Results

Of 82 037 older adults who underwent surgery (all older than 70 years; 52 119 [63.5%] female), 16 900 of 34 044 deaths (49.6%) were cancer related at a median (interquartile range) follow-up of 46 (23-80) months. At 5 years, estimated cumulative incidence of cancer death (20.7%; 95% CI, 20.4%-21.0%) exceeded noncancer death (16.5%; 95% CI, 16.2%-16.8%) among all patients. However, noncancer deaths exceeded cancer deaths starting at 3 years after surgery in breast, prostate, and melanoma skin cancers, patients older than 85 years, and those with frailty. Cancer type, advancing age, and frailty were independently associated with cause-specific death.

Conclusions and Relevance

At the population level, the relative burden of cancer deaths exceeds noncancer deaths for older adults selected for surgery. No subgroup had a higher burden of noncancer death early after surgery, even in more vulnerable patients. This cause-specific overall prognosis information should be used for patient counseling, to assess patterns of over- or undertreatment in older adults with cancer at the system level, and to guide targets for system-level improvements to refine selection criteria and perioperative care pathways for older adults with cancer.

Apical lymphadenectomy during low ligation of the IMA during rectosigmoid resection for cancer

Background

Low ligation of the inferior mesenteric artery with preservation of the left colic artery may decrease the risk of colorectal anastomotic ischemia compared to high ligation at its origin. Low ligation leaves apical nodes in situ and is therefore paired with apical lymphadenectomy. We sought to compare relevant oncologic outcomes between high ligation and low ligation plus apical lymphadenectomy in rectosigmoid resection for colorectal cancer.

Methods

We conducted a retrospective cohort study. Patients receiving a rectosigmoid resection for cancer between January 2012 and July 2018 were included. Patients with metastatic disease and those who underwent low ligation without apical lymphadenectomy were excluded. Our primary outcome was nodal yield/metastasis. Secondary outcomes included perioperative complications, local recurrence, and overall survival.

Results

Eighty-four patients underwent high ligation and 89 low ligation plus apical lymphadenectomy (median follow-up 20 months). In the low-ligation group, a median of 2 (interquartile range = 1–3) apical nodes was resected; 4.1% were malignant, increasing pathologic stage in 25% of these patients. There were no differences in nodal yield, complications, anastomotic leak, local recurrence, or overall survival.

Conclusion

No differences were identified between high ligation and low ligation plus apical lymphadenectomy with respect to relevant clinical outcomes. Prospective trial data are needed to robustly establish the oncologic benefit and safety of the low ligation plus apical lymphadenectomy technique.

Association of frailty with long-term homecare utilization in older adults following cancer surgery: Retrospective population-based cohort study

INTRODUCTION

Frailty is an important prognostic factor, and the association with postoperative dependence is important outcome to older adults. We examined the association of frailty with long-term homecare utilization for older adults following cancer surgery.

METHODS

In this population-based cohort study, we determined frailty status in all older adults (≥70 years old) undergoing cancer resection (2007-2017). Outcomes were receipt of homecare and intensity of homecare (days per month) over 5 years. We estimated the adjusted association of frailty with outcomes, and assessed interaction with age.

RESULTS

Of 82,037 patients, 6443 (7.8%) had frailty. Receipt and intensity of homecare was greater with frailty, but followed similar trajectories over 5 years between groups. Homecare receipt peaked in the first postoperative month (51.4% frailty, 43.1% no frailty), and plateaued by 1 year until 5 years (28.5% frailty, 12.8% no frailty). After 1 year, those with frailty required 4 more homecare days per month than without frailty (14 vs 10 days/month). After adjustment, frailty was associated with increased homecare receipt (hazard ratio 1.40; 95%CI 1.35-1.45), and increasing intensity each year (year 1 incidence rate ratio [IRR] 1.22, 95%CI 1.18-1.27 to year 5 IRR 1.47, 95%CI 1.35-1.59). The magnitude of the association of frailty with homecare receipt decreased with age (p_interaction <0.001).

CONCLUSION

While the trajectory of homecare receipt and intensity is similar between those with and without frailty, frailty is associated with increased receipt of homecare and increased intensity of homecare after cancer surgery across all age groups.

Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients

Objective

To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort.

Background

Growing evidence suggests poorer outcomes for Black patients undergoing surgery.

Methods

A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality.

Results

After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001).

Conclusion and Relevance

This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.

Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment

Importance

Functional outcomes are central to cancer care decision-making by older adults.

Objective

To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure.

Design, Setting, and Participants

This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018.

Main Outcomes and Measures

The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used.

Results

A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time.

Conclusions and Relevance

This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.

Immediate and Long-Term Health Care Support Needs of Older Adults Undergoing Cancer Surgery: A Population-Based Analysis of Postoperative Homecare Utilization

BACKGROUND

Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA.

METHODS

This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used.

RESULTS

Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%).

CONCLUSION

Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.

Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma

Unlike intraperitoneal colorectal injuries, the standard of care for extraperitoneal rectal trauma includes a diverting colostomy due to relative inaccessibility of these injuries for primary repair. New technologies to enhance access to the extraperitoneal rectum have gained increasing use in benign and malignant rectal disease. We present two cases of low-velocity penetrating extraperitoneal rectal trauma. In both cases, a transanal minimally invasive surgery (TAMIS) approach was used to access, and primarily repair, full-thickness rectal lacerations. These patients were successfully managed without a colostomy and without complication. TAMIS enables access to distal rectal injuries, facilitating primary repair and bringing the management of extraperitoneal rectal injuries in line with intraperitoneal injuries, with the potential to avoid fecal diversion.

Benefits of minimally-invasive surgery for sigmoid and rectal cancer in older adults compared with younger adults: Do older adults have the most to gain?

INTRODUCTION

Randomized trials demonstrated oncologic safety and short-term benefits of laparoscopy. We investigated if the benefit of laparoscopy on short-term outcomes is greater for older adults compared with younger adults.

METHODS

We identified all older (≥70 years old) and younger (<70) adults with primary sigmoid and rectal cancer treated with resection between 2002 and 2018 from an institutional database. We compared 30-day postoperative outcomes using multivariable logistic regression with an interaction term between age group and surgical approach. Primary outcomes were death, major (Clavien-Dindo III-IV) and minor (Clavien-Dindo I-II) complications, and wound complications.

RESULTS

We included 792 patients, 293 (37%) older and 499 (63%) younger. Use of laparoscopy was similar between age groups: 120/293 (41%) older, 204/499 (41%) younger (p = .98). All patients had 30-day follow-up. Compared with open resection, minimally-invasive resection was associated with a greater reduction in deaths in older adults than in younger adults (absolute difference in older adults 7.0% less versus 2.1% less in younger adults; adjusted odds ratio [aOR] older 3.01, 95% confidence interval [CI] 1.31-7.33; aOR younger 0.31, 95% CI 0.05-1.24; interaction p = .01). Similarly, minimally-invasive resection was associated with a greater reduction in major complications in older adults than in younger adults (absolute difference in older adults 6.4% less versus 2.4% less in younger adults; aOR older 1.91, 95% CI 1.07-3.41; aOR younger 0.70, 95% CI 0.34-1.38; interaction p = .03).

CONCLUSIONS

Minimally-invasive compared with open surgery demonstrated a differential benefit on postoperative death and major complications between younger and older adults.

Outcomes of salvage surgery for anal squamous cell carcinoma: A systematic review and meta-analysis

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Background: Following primary chemoradiotherapy for squamous cell carcinoma of the anal canal (A-SCCa), 10% of patients have persistent cancer, and 30% develop local recurrence after initial complete response. Both persistent and recurrent A-SCCa may be amenable to salvage surgery, which typically involves intense health care resource utilization. Because only small cohorts have been reported, we synthesized the evidence for salvage surgery to gain a comprehensive understanding of outcomes. Methods: We systematically searched MEDLINE, Embase, and Cochrane Library (until October 11, 2018) for studies reporting on persistent or recurrent A-SCCa treated with salvage surgery. Quality assessment was performed using the Institute of Health Economics Quality Appraisal Checklist. Overall survival (OS) and disease-free survival (DFS) were pooled using two approaches: survival curve meta-analysis, and exact binomial likelihood random-effects model for survival probabilities. We used meta-regression, subgroup and sensitivity meta-analyses to explore sources of heterogeneity. Results: We identified 39 observational studies that included 1388 patients. Pooled 5-year OS was 45.5% (95% CI 40.6 to 49.9; 33 studies; 1308 patients), and did not differ in patients resected for recurrent (14 studies, n=259 patients) vs. persistent (n=238 patients) disease. There was no association of OS with study year, tumor size, or resection margin at the aggregate-level. Pooled 5-year DFS was 38.3% (95% CI 31.4-43.9; 14 studies; 554 patients). Pooled 30-day complications were 65.3% (95% CI 50.2-77.9; 17 studies; 720 patients): major complications 27.7% (95% CI 22.3-33.8), reoperations 12.7% (95% CI 8.7-18.2), and mortality 1.7% (95% CI 1.1-2.6%). Pooled perineal complications were 32.7% (95% CI 25.0-41.4). Conclusions: Salvage surgery offers 5-year OS of ≈45% and DFS of ≈40% for recurrent/persistent A-SCCa. Major complications and perineal wound complications are common, but postoperative mortality is rare. Presently, there are no reports of patient-reported outcomes such as quality of life after salvage surgery for A-SCCa. Comparative effectiveness studies comparing surgery to other treatments are warranted.

Defining Non-inferiority Margins for Quality of Surgical Resection for Rectal Cancer: A Delphi Consensus Study

INTRODUCTION

Quality of surgical resection metrics (QSRMs) have been used as surrogates for long-term oncologic outcomes in non-inferiority randomized clinical trials (RCTs) comparing laparoscopic and open surgery for rectal cancer. However, non-inferiority margins (Δ_NI) for QSRMs have not been previously defined.

METHODS

A two-round, web-based Delphi was used to define Δ_NI for four QSRMs: positive circumferential resection margin (CRM), incomplete plane of mesorectal excision (PME), positive distal resection margin (DRM), and a composite of these outcomes. Overall, 130 international experts in rectal cancer (68 surgeons, 20 medical oncologists, 16 radiation oncologists, and 26 pathologists) were invited to participate. Experts were presented with evidence syntheses summarizing the association between QSRMs and long-term outcomes, and pooled quality of surgical resection outcomes for open surgery, and were asked to provide Δ_NI for all outcomes balancing the risks and benefits of minimally invasive surgery.

RESULTS

Seventy-two experts participated: 57 completed the initial questionnaire and 58 completed the revised questionnaire, with 43 participating in both rounds. Consensus was reached for all individual QSRM Δ_NI but not for the composite. The mean (standard deviation) Δ_NI was an absolute difference of 2.33% (1.59%) for the proportion of positive CRMs when comparing surgical interventions for the treatment of rectal cancer: 2.85% (1.83%) for incomplete PME; 1.28% (1.13%) for positive DRMs; and 2.71% (2.28%) for the composite. However, opinions varied widely for the composite outcome.

CONCLUSIONS

Web-based Delphi processes are a feasible approach to generate Δ_NI to evaluate novel surgical interventions. The generated Δ_NI for QSRMs for rectal cancer can be used for future RCTs and non-inferiority meta-analyses.

A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis

BACKGROUND

A watch-and-wait approach for patients with clinical complete response to neoadjuvant chemoradiation could avoid the morbidity of conventional surgery for rectal cancer. However, the safety of this approach is unclear. We synthesised the evidence for watch-and-wait as a treatment for rectal cancer.

METHODS

We systematically searched MEDLINE, Embase, and the grey literature (up to June 28, 2016) for studies of patients with rectal adenocarcinoma managed by watch-and-wait after complete clinical response to neoadjuvant chemoradiation. We determined the proportion of 2-year local regrowth after watch-and-wait. We assessed non-regrowth recurrence, cancer-specific mortality, disease-free survival, and overall survival from studies comparing patients who had watch-and-wait versus those who had radical surgery after detection of clinical complete response or versus patients with pathological complete response.

FINDINGS

We identified 23 studies including 867 patients with median follow-up of 12-68 months. Pooled 2-year local regrowth was 15·7% (95% CI 11·8-20·1); 95·4% (95% CI 89·6-99·3) of patients with regrowth had salvage therapies. There was no significant difference between patients managed with watch-and-wait after a clinical complete response and patients with pathological complete response identified at resection with respect to non-regrowth recurrence (risk ratio [RR] 1·46, 95% CI 0·70-3·05) or cancer-specific mortality (RR 0·87, 95% CI 0·38-1·99). Although there was no significant difference in overall survival between groups (hazard ratio [HR] 0·73, 95% CI 0·35-1·51), disease-free survival was better in the surgery group (HR 0·47, 95% CI 0·28-0·78). We found no significant difference between patients managed with watch-and-wait and patients with clinical complete response treated with surgery in terms of non-regrowth recurrence (RR 0·58, 95% CI 0·18-1·90), cancer-specific mortality (RR 0·58, 95% CI 0·06-5·84), disease-free survival (HR 0·56, 95% CI 0·20-1·60), or overall survival (HR 3·91, 95% CI 0·57-26·72).

INTERPRETATION

Most patients treated by watch-and-wait avoid radical surgery and of those who have regrowth almost all have salvage therapy. Although we detected no significant differences in non-regrowth cancer recurrence or overall survival in patients treated with watch-and-wait versus surgery, few patients have been studied and more prospective studies are needed to confirm long-term safety.

FUNDING

None.

Trends in port-site metastasis after laparoscopic resection of incidental gallbladder cancer: A systematic review

BACKGROUND

The risk of port-site metastasis after laparoscopic removal of incidental gallbladder cancer was previously estimated to be 14-30%. The present study was designed to determine the incidence of port-site metastasis in incidental gallbladder cancer in the modern era (2000-2014) versus the historic era (1991-1999). We also investigated the site of port-site metastasis.

METHODS

Using PRISMA, a systematic review was conducted to identify papers that addressed the development of port-site metastasis after laparoscopic resection of incidental gallbladder cancer. Studies that described cancer-specific outcomes in ≥5 patients were included. A validated quality appraisal tool was used, and a weighted estimate of the incidence of port-site metastasis was calculated.

RESULTS

Based on data extracted from 27 papers that met inclusion criteria, the incidence of port-site metastasis in incidental gallbladder cancer has decreased from 18.6% prior to 2000 (95% confidence interval 15.3-21.9%, n = 7) to 10.3% since then (95% confidence interval 7.9-12.7%, n = 20) (P < .001). The extraction site is at significantly higher risk than nonextraction sites.

CONCLUSION

The incidence of port-site metastasis in incidental gallbladder cancer has decreased but remains high relative to other primary tumors. Any preoperative finding that raises the suspicion of gallbladder cancer should prompt further investigation and referral to a hepato-pancreato-biliary specialist.