Bridget N. Fahy

Utilization of palliative care consultation service by surgical services.

BACKGROUNDnPalliative medicine was recognized as a unique medical specialty in 2006. Since that time, the number of hospital-based palliative care services has increased dramatically. It is unclear how palliative care consultation services (PCCS) are utilized by surgical services. The purpose of this study was to examine utilization of PCCS by surgical services compared to medical services at the University of New Mexico.nnnMETHODSnA database of palliative care consultations performed at University of New Mexico Hospital between 2009 and 2013 was queried to identify consultations requested by surgical vs. medical services. Demographic, clinical, and outcome variables were compared.nnnRESULTSnA total of 521 consultations were analyzed: 441 (85%) consultations from medical and 80 (15%) consultations from surgical services. Surgical patients were older than medical patients and more likely to be in an intensive care unit (ICU) at the time of consultation. There was no difference between referring services in indication for palliative care consultation or time from hospital admission to consultation. Surgical patients were more likely to die in the hospital compared to medical patients. Among patients discharged from the hospital alive, there was no difference between the groups in discharge disposition. More patients in both groups had a change from full code to do-not-resuscitate (DNR) status following palliative care consultation.nnnCONCLUSIONSnReferrals for palliative care consultations are much less common from surgical than medical services. Characteristics of surgical patients suggest that palliative care consultations are reserved for older patients, critically ill patients, and those more likely to be at end-of-life. Our findings suggest the possible need for increased palliative care consultations among less critically ill patients and/or those with an improved prospect of recovery.

Follow-up After Curative Resection of Colorectal Cancer

Of the 13.7 million cancer survivors living in the United States as of January 2012, 1.2 million, or 9xa0%, were colorectal cancer (CRC) survivors. Determining an optimal surveillance for CRC survivors is necessary because of the significant burden follow-up poses to patients, physicians, and the health care system. Currently, there is no consensus regarding optimal follow-up in CRC patients. Current literature and published guidelines related to CRC follow-up were reviewed to examine the evidence for the surveillance strategies and specific tools demonstrated to improve outcome after curative CRC resection. An intensive surveillance strategy results in increased identification of recurrences amenable to curative resection but does not result in reduced overall or CRC-specific mortality. Patients most likely to benefit from surveillance include younger patients, those with earlier tumors, locoregional recurrences, longer time to recurrence, lower carcinoembryonic antigen (CEA) levels before reoperation, and those with isolated recurrence. Complete resection of recurrence is the only factor consistently associated with improved survival. CEA, colonoscopy, and liver-focused imaging surveillance appear to have the greatest impact on mortality after curative CRC resection. A CRC surveillance strategy is recommended that includes tumor risk stratification, that provides a focus on identifying recurrences amenable to complete resection, and that utilizes those modalities demonstrated to be most effective at improving outcome after CRC resection.

Pediatric melanoma in New Mexico American Indians, Hispanics, and non-Hispanic whites, 1981–2009

BACKGROUNDnPediatric melanoma rates are increasing nationally. Our purpose was to determine the incidence of melanoma in New Mexicos (NMs) American Indian, Hispanic, and non-Hispanic white children.nnnMETHODSnA retrospective review (1981 to 2009) of the NM Tumor Registry was conducted. Melanomas diagnosed in children <19 years of age were identified. Average annual age-adjusted incidence rates per million were calculated.nnnRESULTSnSixty-four cases were identified. Rates per million were 7.4 for non-Hispanic whites, 2.1 for Hispanics, and 3.3 for American Indians. Fifty-nine percent were women. Fifty-five (86%) cases were localized, 6 (9%) were regional, and 1 (3%) case was metastatic. Majority of cases (49/64; 77%) occurred in children >14 years of age. American Indians presented with thicker melanomas as compared to whites and Hispanics.nnnCONCLUSIONSnIncidence rates for pediatric melanoma in NM are highest for non-Hispanic whites. Distant metastasis is uncommon. Melanoma in children is rare, but practitioners must be aware of its occurrence for prompt diagnosis and treatment.

Desmoplastic Small Round Blue Cell Tumor: A Review of Treatment and Potential Therapeutic Genomic Alterations

Desmoplastic small round blue cell tumors (DSRCTs) originate from a cell with multilineage potential. A molecular hallmark of DSRCT is the EWS-WT1 reciprocal translocation. Ewing sarcoma and DSRCT are treated similarly due to similar oncogene activation pathways, and DSRCT has been represented in very limited numbers in sarcoma studies. Despite aggressive therapy, median survival ranges from 17 to 25 months, and 5-year survival rates remain around 15%, with higher survival reported among those undergoing removal of at least 90% of tumor in the absence of extraperitoneal metastasis. Almost 100% of these tumors contain t(11;22) (p13;q12) translocation, and it is likely that EWS-WT1 functions as a transcription factor possibly through WT1 targets. While there is no standard protocol for this aggressive disease, treatment usually includes the neoadjuvant HD P6 regimen (high-dose cyclophosphamide, doxorubicin, and vincristine (HD-CAV) alternating with ifosfamide and etoposide (IE) chemotherapy combined with aggressively attempted R0 resection). We aimed to review the molecular characteristics of DSRCTs to explore therapeutic opportunities for this extremely rare and aggressive cancer type.

Follow-Up After Curative Cancer Surgery: Understanding Costs and Benefits

According to the American Cancer Society, well over 1 million new cancer patients are added each year to the 13.7 million alive today. Consequently, the field of cancer survivorship has become the focus of an increasing amount of attention for both patients and their cancer care providers. In 2005, the Institute of Medicine published a report on cancer survivorship and identified surveillance for cancer spread, recurrence, or second cancers as essential components of survivorship care. As primary providers of cancer treatment, it is imperative that surgeons be active participants in designing and executing survivorship care. To meet this requirement, surgeons must utilize an evidence-based approach to determine how best to follow their patients after curative cancer surgery. Presumed benefits of follow-up following curative cancer surgery include the following: (i) earlier detection of recurrences that result in increased likelihood of curative intervention, (ii) identification of second primary malignancies, and (iii) patient reassurance. Are any or all of these assumptions true? The answer is: it depends. Factors that impact the potential benefit of follow-up include the location of the primary tumor, stage at initial presentation, availability of effective therapies, and patient desire and fitness for cancer therapy. Additionally, one must consider which test(s) are most likely to identify cancer recurrences amenable to treatment or second primary malignancies and the optimal timing of such testing. In addition to the presumed benefits of follow-up after curative cancer surgery, there are both financial and non-financial costs to be considered. Chief among the non-economic costs of surveillance is the emotional cost of surveillance, which was the focus of a recent editorial by Dr. John Smyth in The ASCO Post. As Dr. Smyth points out, cancer surveillance is a ‘‘balance between what we need to know as physicians and what is best for the individual patient.’’ Dr. Brennan also cautioned in an editorial in Annals of Surgical Oncology that the ‘‘need for (patient) reassurance has to be balanced against the anxiety provoked by extensive follow-up testing, such as CT or MRI, which provoke severe distress disorders in the most sanguine of patients.’’ The financial cost of cancer follow-up is another important consideration as clinicians, patients, government, and third-party payors carefully consider the cost effectiveness of various healthcare expenditures. A recent article by Mariotto et al. estimated the cost of cancer care in the USA from 2010 to 2020 and found that costs for all cancer care across the different phases of care (e.g. diagnosis through last year of life) were projected to increase from

Estimation of risk in cancer patients undergoing palliative procedures by the American College of Surgeons risk calculator.

US124.57 billion in 2010 to

Estimation of Risk in Cancer Patients Undergoing Palliative Procedures by the American College of Surgeons Risk Calculator

US186.69 billion in 2020. Some of the largest projected increases in cancer costs were seen in melanoma (95 %), pancreas (67 %), breast (41 %), and colorectal (25 %) cancer. Given that these are tumors primarily managed by surgical resection, it is incumbent upon surgeons to be good stewards of the financial resources needed to treat and follow these patients following curative cancer surgery. Optimal surveillance after curative cancer surgery should ideally be based upon knowledge of the risk of cancer recurrence for a given patient, understanding of surveillance techniques most likely to identify recurrence amenable to treatment, and an appreciation of which patients are most likely to benefit from additional cancer therapies. As illustrated above, any follow-up program must also consider both the emotional and financial cost of a given surveillance strategy. Unfortunately, the data needed to inform decisions regarding optimal surveillance following curative resection are not uniformly available. Society of Surgical Oncology 2013

Racial/ethnic variation in incidence rates for anal cancer in New Mexico.

93 Background: Surgical palliation is defined as the use of a procedure in patients with incurable disease to relieve symptoms. The American College of Surgeons Risk Calculator (ACSRC) was created based on data from the National Surgical Quality Improvement Program to predict the risk of surgical complications on a patient specific level. Whether the ACSRC can accurately predict the risk of postoperative complications following palliative procedures in cancer patients is unknown. The purpose of this study was to determine if the ACSRC accurately predicted postoperative complication rates in this setting.nnnMETHODSnOur surgical oncology database of patients treated from 2011 to 2013 was queried. Thirty-two patients who underwent palliative procedures were identified. Data extracted included: demographics, comorbidities, site and stage of cancer, type of procedure and post-operative complication rate and type. Risk assessment was performed for each patient using the ACSRC. Actual frequency of complications and length of stay (LOS) were compared to ACSRC predicted rate of complications and LOS.nnnRESULTSnSee Table.nnnCONCLUSIONSnThe ACSRC is a powerful tool for aid in surgical decision-making; however, in the case of palliative procedures, it overestimated the risk of postoperative complications and underestimated the LOS. Overestimation of postoperative complications could result in fewer patients being offered potentially beneficial palliative procedures. [Table: see text].