Anasooya Abraham

Increasing Rates of Contralateral Prophylactic Mastectomy Among Patients With Ductal Carcinoma In Situ

PURPOSE Some women with unilateral ductal carcinoma in situ (DCIS) undergo contralateral prophylactic mastectomy (CPM) to prevent cancer in the opposite breast. The use and trends of CPM for DCIS in the United States have not previously been reported. METHODS We used the Surveillance, Epidemiology, and End Results database to analyze the initial treatment (within 6 months) of patients with unilateral DCIS diagnosed from 1998 through 2005. We determined the CPM rate as a proportion of all surgically treated patients and as a proportion of all patients who underwent mastectomy. We compared demographic and tumor variables in women with unilateral DCIS who underwent surgical treatment. RESULTS We identified 51,030 patients with DCIS; 2,072 patients chose CPM. The CPM rate was 4.1% for all surgically treated patients and 13.5% for patients undergoing mastectomy. Among all surgically treated patients (including breast-conserving surgery), the CPM rate increased by 148% from 1998 (2.1%) to 2005 (5.2%). Among patients who underwent mastectomy to treat DCIS (excluding patients undergoing breast-conserving surgery), the CPM rate increased by 188% from 1998 (6.4%) to 2005 (18.4%). Young patient age, white race, recent year of diagnosis, and the presence of lobular carcinoma in situ were significantly associated with higher CPM rates among all surgically treated patients and all patients undergoing mastectomy. Large tumor size and higher grade were significantly associated with increased CPM rates among all surgically treated patients but lower CPM rates among patients undergoing mastectomy. CONCLUSION The use of CPM for DCIS in the United States markedly increased from 1998 through 2005.

A Critical Analysis of the Surgical Management of Early-Stage Gallbladder Cancer in the United States

BackgroundRadical resection is recommended for selected patients with gallbladder (GB) cancer. We sought to determine whether radical resection improves survival for patients with early-stage cancer and to evaluate surgeon compliance with current treatment recommendations.Patients and methodsPatients with stage 0, I, or II GB cancer who underwent surgical resection were identified from the Surveillance, Epidemiology, and End Results (SEER) tumor registry from 1988 through 2004. Patients were classified by surgical procedure performed (simple vs. radical resection) and adjuvant treatment given (radiation therapy [RT] vs. no RT). Unadjusted and adjusted overall survival (OS) and cancer-specific survival (CSS) were compared.ResultsOf the 4,631 patients who underwent surgery for early-stage GB cancer from 1988 through 2004, 4,188 (90.4%) underwent cholecystectomy alone and 443 (9.6%) underwent radical surgery including hepatic resection. The proportion of patients having radical surgery for T1b, T2, and T3 cancers was 4.5%, 5.6%, and 16.3%, respectively. For patients with T1b/T2 cancer, radical resection was associated with significant improvement in adjusted CSS (p = 0.01) and OS (p = 0.03). For patients with T3 cancers, we noted no improvement in CSS or OS. Survival for patients with node-positive disease (stage 2b) was universally poor and not improved by radical resection. For all patients who underwent radical resection, node negativity, female sex, age <70, low grade, and RT predicted improved CSS and OS.ConclusionsDespite a significant survival advantage for patients with T1b/T2 GB cancer who undergo radical resection, this treatment is significantly underutilized. Ensuring delivery of recommended surgical treatment is vital to improving outcomes for patients with this disease.

Lymph node evaluation is associated with improved survival after surgery for early stage gallbladder cancer

BACKGROUND Guidelines for the current National Comprehensive Cancer Network recommend radical cholecystectomy, including hepatic resection and portal lymph node (LN) dissection, for patients with early stage gallbladder (GB) cancer. We sought to determine the survival benefit conferred by adequate LN evaluation. METHODS We used the surveillance, epidemiology and end results (SEER) neoplasm registry to identify patients who had an operation for GB cancer between 1988 and 2004. Patients were classified by stage of disease, operative procedure performed (cholecystectomy alone or radical resection), number of LNs evaluated (0, 1, >1), and receipt of radiation (RT). We included patients with T1B, T2, and T3 neoplasms who were LN positive or negative. Patients with T4 neoplasms and those with metastatic disease were excluded. Multivariate analysis included adjustment for age, race, sex, neoplasm grade, stage, operation performed, receipt of RT, and neoplasm registry. RESULTS We identified 4,614 patients who underwent operative treatment for stage 1-2B GB (including T1B-T3 and LN positive or negative) cancer between 1988 and 2004. Of 4,614 patients, 9.6% (442) had radical resection, whereas 90.4% (4,172) had cholecystectomy alone. Among patients undergoing radical resection, 56% had LNs evaluated as compared with 28% of patients after cholecystectomy. For patients with T1B and T2 neoplasms who underwent radical resection, pathologic evaluation of at least 1 LN was associated with a significant improvement in median overall survival (OS) compared with those who had no LN evaluated (123 months vs 22 months; P < .0001). Radical resection with no LN evaluation provided similar OS compared with cholecystectomy alone (22 months vs 23 months; P = NS). For patients with T3 neoplasms, radical resection, including pathologic evaluation of at least 1 LN, was also associated with improved OS compared with radical resection with no LN evaluation (12 months vs 7 months; P = .0014). Again, individuals who had radical resection without LN evaluation had similar OS compared with those who had cholecystectomy alone (7 months vs 6 months; P = NS). Individuals who had radical resection with LN evaluation were more likely to receive RT than those who had radical resection without LN evaluation (33.1% vs 19.1%; P = .002). In multivariate analysis (including adjustment for RT), however, LN evaluation was still associated with a decrease in mortality compared with no LN evaluated (HR = 0.611; 95% CI = 0.484, 0.770). The pathologic evaluation of additional LN (>1) did not provide any additional benefit compared with the evaluation of a single node (HR = 0.795; 95% CI = 0.571, 1.107). Radical resection alone (without LN evaluation) did not provide any benefit over cholecystectomy alone (HR = 1.098; 95% CI = 0.971, 1.241). CONCLUSION LN evaluation is a critical component of radical resection for GB cancer. In the absence of LN evaluation, radical resection provides no benefit over cholecystectomy alone.

Does enrollment in cancer trials improve survival

BACKGROUND Stakeholders derive many benefits from cancer clinical trials, including guidance for future oncologic treatment decisions. However, whether enrollment in cancer trials also improves patient survival independently of trial outcomes remains underinvestigated. We hypothesized that cancer trial enrollment is not associated with patient survival outcomes. STUDY DESIGN Using the 2002 to 2008 California Cancer Registry, we identified 555,469 patients with stage I to IV solid organ tumors. Baseline characteristics were compared by trial participation status. Logistic regression determined predictors of trial enrollment. Multivariate Cox proportional hazards regression examined the impact of trial participation on overall and cancer-specific mortality with adjustment for covariates. RESULTS Only 0.33% of our cohort was enrolled in clinical trials. Trial participants were likely to be younger than 65 (odds ratio [OR] 2.13; 95% CI 1.90 to 2.38), Hispanic rather than non-Hispanic white (OR 0.78; 95% CI 0.67 to 0.90), and have breast cancer (OR 3.14; 95% CI 2.62 to 3.77). Multivariate survival analyses demonstrated that enrollment in cancer trials predicted a lower hazard of death. However, when stratified by disease site, this survival benefit was observed only in lung, colon, and breast cancers. Sensitivity and interaction analyses confirmed these relationships. CONCLUSIONS In this first population-based study examining trial effect in solid organ cancers, enrollment into cancer trials predicted lower overall and cancer-specific mortality among common cancer sites. Although these findings may demonstrate a survival benefit due to trial enrollment, they likely also reflect the favorable attributes of trial enrollees. Once corroborated, stakeholders must consider broader cancer trial designs representative of the cancer burden treated in the real world.

Contralateral prophylactic mastectomy for patients with unilateral breast cancer

Patients with unilateral breast cancer are at increased risk of developing a second cancer in the contralateral breast. Some women choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast. Several studies have demonstrated that CPM significantly decreases the occurrence of contralateral breast cancer. However, the effectiveness of CPM at reducing breast cancer mortality is not as clear. Moreover, CPM is not risk free and patients may need to undergo additional surgical procedures, especially if reconstruction is performed. Nevertheless, most patients are satisfied with their decision to undergo CPM. Alternatives to CPM include close surveillance with clinical breast examination, mammography and possibly breast magnetic resonance imaging. Endocrine therapy with tamoxifen or aromatase inhibitors significantly reduces the risk of contralateral breast cancer and may be more acceptable than CPM for some patients. The decision to undergo CPM is complex and many factors likely contribute to its use. Future prospective studies are critically needed to evaluate the decision-making processes leading to CPM.

Adjuvant chemotherapy for stage III colon cancer in the oldest old: Results beyond clinical guidelines

Randomized trials demonstrating the benefits of chemotherapy in patients with American Joint Committee on Cancer stage III colon cancer underrepresent persons aged ≥ 75 years. The generalizability of these studies to a growing elderly population remains unknown.

Bile Acids Increase Independently From Hypocaloric Restriction After Bariatric Surgery.

Objectives: To measure changes in the composition of serum bile acids (BA) and the expression of Takeda G-protein-coupled receptor 5 (TGR5) acutely after bariatric surgery or caloric restriction. Summary Background Data: Metabolic improvement after bariatric surgery occurs before substantial weight loss. BA are important metabolic regulators acting through the farnesoid X receptor and TGR5 receptor. The acute effects of surgery on BA and the TGR5 receptor in subcutaneous white adipose tissue (WAT) are unknown. Methods: A total of 27 obese patients with type 2 diabetes mellitus were randomized to Roux-en-Y gastric bypass (RYGB) or to hypocaloric diet (HC diet) restriction (NCT 1882036). A cohort of obese patients with and without type 2 diabetes mellitus undergoing vertical sleeve gastrectomy was also recruited (n = 12) as a comparison. Results: After vertical sleeve gastrectomy, the level of BA increased [total: 1.17 ± 1.56 &mgr;mol/L to 4.42 ± 3.92 &mgr;mol/L (P = 0.005); conjugated BA levels increased from 0.99 ± 1.42 &mgr;mol/L to 3.59 ± 3.70 &mgr;mol/L (P = 0.01) and unconjugated BA levels increased from 0.18 ± 0.24 &mgr;mol/L to 0.83 ± 0.70 &mgr;mol/L (P = 0.009)]. With RYGB, there was a trend toward increased BA [total: 1.37 ± 0.97 &mgr;mol/L to 3.26 ± 3.01 &mgr;mol/L (P = 0.07); conjugated: 1.06 ± 0.81 &mgr;mol/L to 2.99 ± 3.02 &mgr;mol/L (P = 0.06)]. After HC diet, the level of unconjugated BA decreased [0.92 ± 0.55 &mgr;mol/L to 0.32 ± 0.43 &mgr;mol/L (P = 0.05)]. The level of WAT TGR5 gene expression decreased after surgery, but not in HC diet. Protein levels did not change. Conclusions: The levels of serum BA increase after bariatric surgery independently from caloric restriction, whereas the level of WAT TGR5 protein is unaffected.

Does patient rurality predict quality colon cancer care? a population based study

BACKGROUND: More than 50 million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening. OBJECTIVE: Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care. DESIGN: We constructed a retrospective cohort of 123,129 patients with stage 0 to IV colon cancer. Rural residence was established based on the patient medical service study area designated by the registry. SETTINGS: The study was conducted using the 1996–2008 California Cancer Registry. PATIENTS: All of the patients diagnosed between 1996 and 2008 with tumors located in the colon were eligible for inclusion in this study. MAIN OUTCOME MEASURES: Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I to III disease, and receipt of chemotherapy for stage III disease. Proportional-hazards regression was used to examine the impact of rurality on cancer-specific survival. RESULTS: Of all of the patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I to III disease, and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer-specific survival. LIMITATIONS: We could not account for socioeconomic status directly, although we used insurance status as a surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities, or complications. CONCLUSIONS: A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures, and survival. Future endeavors should help improve care to this vulnerable population (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A143).

Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma

IntroductionThe extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival.MethodsUsing 2001–2008 California Cancer Registry, we identified 2,229 patients who underwent gastrectomy with adequate nodal evaluation (≥15 lymph nodes) for American Joint Committee on Cancer stage I–IV M0 gastric adenocarcinoma. Cox proportional hazard analyses were used to evaluate the impact of surgery alone on survival.ResultsNearly 70% of our cohort had T1/2 tumors and 29% had N0 disease. Forty-nine percent of the cohort underwent surgery alone. These patients were more likely to be older, Medicare-insured, with T1 and N0 disease. On unadjusted analyses, persons who underwent surgery alone for stage I or N0 disease experienced 1- and 3-year overall and cancer-specific survival comparable to those who received adjuvant therapy. On multivariate analyses for stage I or N0 disease, surgery alone predicted superior survival outcomes than when combined with adjuvant therapies.ConclusionSurgery alone with adequate nodal evaluation may have a role in low-risk gastric cancer. To corroborate these findings, surgery with adequate lymphadenectomy alone (as treatment arm) deserves consideration in the design of gastric cancer trials to provide effective yet resource-conserving, rather than maximally tolerated, treatments.

Cancer Surgery Among American Indians

IMPORTANCE American Indians (AIs) have the poorest cancer survival rates of any U.S. ethnic group. Late diagnosis, poor access to specialty care, and delays in therapy likely contribute to excess mortality. Surgery plays a central role in therapy for solid organ cancer. OBJECTIVE To determine whether operative outcomes also contribute to poor long-term survival among AI patients with cancer. DESIGN Population-based retrospective cohort study comparing patient- and hospital-level factors and short-term operative outcomes for AI and non-Hispanic white patients. Survey-weighted multivariate analyses assessed the effect of AI ethnicity on hospital location, in-hospital mortality, and prolonged length of stay. SETTING A 20% stratified sample of all US community hospitals. PATIENTS Patients undergoing oncologic resection for 1 of 20 malignant neoplasms in the Nationwide Inpatient Sample from January 1, 1998, through December 31, 2009. MAIN OUTCOME MEASURE In-hospital mortality, length of stay, and hospital location (rural vs urban). RESULTS Of 740,878 patients who met our inclusion criteria, 3048 were AIs. The AI patients were younger, more likely to undergo cancer surgery at rural hospitals, and more likely to be admitted for nonelective procedures and had more comorbidities than non-Hispanic white patients of similar ages (all, P < .05). The AI patients had comparable inpatient mortality and length of stay. CONCLUSIONS AND RELEVANCE This investigation is the largest study of surgical outcomes among AIs to date and the first to focus on cancer surgery. This relatively young cohort does not experience poor outcomes after oncologic resection. Future research should uncover other factors in the continuum of cancer care that may contribute to the poor long-term survival of AI patients with cancer, including delivery of perioperative therapies.