Elizabeth B. Habermann

Increasing Use of Contralateral Prophylactic Mastectomy for Breast Cancer Patients: A Trend Toward More Aggressive Surgical Treatment

PURPOSE Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of contralateral prophylactic mastectomy in the United States. PATIENTS AND METHODS We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies. RESULTS We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy. CONCLUSION The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.

Trends in the incidence of invasive and in situ vulvar carcinoma.

OBJECTIVE: To characterize the incidence of vulvar carcinoma in situ and vulvar cancer over time. METHODS: We used the Surveillance Epidemiology and End Results database to assess trends in the incidence of vulvar cancer over a 28-year period (1973 through 2000) and determined whether there had been a change in incidence over time. Information collected included patient characteristics, primary tumor site, tumor grade, and follow-up for vital status. We calculated the incidence rates by decade of age, used χ2 tests to compare demographic characteristics, and tested for trends in incidence over time. RESULTS: A total of 13,176 in situ and invasive vulvar carcinomas were identified; 57% of the women were diagnosed with in situ, 44% with invasive disease. Vulvar carcinoma in situ increased 411% from 1973 to 2000. Invasive vulvar cancer increased 20% during the same period. The incidence rates for in situ and invasive vulvar carcinomas are distributed differently across the age groups. In situ carcinoma incidence increases until the age of 40–49 years and then decreases, whereas invasive vulvar cancer risk increases as a woman ages, increasing more quickly after 50 years of age. CONCLUSION: The incidence of in situ vulvar carcinoma is increasing. The incidence of invasive vulvar cancer is also increasing but at a much lower rate. LEVEL OF EVIDENCE: III

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.

Are Mastectomy Rates Really Increasing in the United States

PURPOSE After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006. PATIENTS AND METHODS Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods. RESULTS We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P < .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P < .0001), after adjusting for patient and tumor factors. CONCLUSION In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.

Survival After Lobectomy Versus Segmentectomy for Stage I Non-Small Cell Lung Cancer: A Population-Based Analysis

BACKGROUND Data comparing survival after lobectomy versus that after segmentectomy for stage I non-small cell lung cancer (NSCLC) are limited to single-institution observational studies and 1 clinical trial. We sought to determine if lobectomy offers a survival advantage over segmentectomy for stage I NSCLC based on population-based data. METHODS Using the Surveillance Epidemiology and End Results (SEER) database (1998 to 2007), we identified patients who underwent either anatomic segmentectomy or lobectomy. Wedge resections were excluded. Analysis was limited to patients with stage I adenocarcinoma or squamous cell carcinoma. After stratifying patients based on tumor size (less than or equal to 2.0 cm, 2.1 to 3.0 cm, and 3.1 to 7.0 cm), we assessed for association between extent of resection and survival using the Kaplan-Meier method. To adjust for potential confounding variables, we used Cox proportional hazards regression models. RESULTS There were 14,473 patients who met our inclusion criteria. Lobectomy conferred superior unadjusted overall (p < 0.0001) and cancer-specific (p = 0.0053) 5-year survival compared with segmentectomy. Even after adjusting for patient factors, tumor characteristics, and geographic location, we noted that patients who underwent lobectomy had superior overall and cancer-specific survival rates, regardless of tumor size. Squamous cell histologic type, male sex, low lymph node counts, and increasing age, tumor size, and grade were all independent negative prognostic factors. CONCLUSIONS Using a population-based data set, we found that lobectomy confers a significant survival advantage compared with segmentectomy. Our results provide additional evidence supporting the role of lobectomy as the standard of care for resection of stage I NSCLC regardless of tumor size.

Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality.

IMPORTANCE Programs that analyze and report rates of surgical complications are an increasing focus of quality improvement efforts. The most comprehensive tool currently used for outcomes monitoring in the United States is the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). OBJECTIVE To compare surgical outcomes experienced by patients treated at hospitals that did vs did not participate in the NSQIP. DESIGN, SETTING, AND PARTICIPANTS Data from the University HealthSystem Consortium from January 2009 to July 2013 were used to identify elective hospitalizations representing a broad spectrum of elective general/vascular operations in the United States. Data on hospital participation in the NSQIP were obtained through review of semiannual reports published by the ACS. Hospitalizations at any hospital that discontinued or initiated participation in the NSQIP during the study period were excluded after the date on which that hospitals status changed. A difference-in-differences approach was used to model the association between hospital-based participation in NSQIP and changes in rates of postoperative outcomes over time. EXPOSURE Hospital participation in the NSQIP. MAIN OUTCOMES AND MEASURES Risk-adjusted rates of any complications, serious complications, and mortality during a hospitalization for elective general/vascular surgery. RESULTS The cohort included 345,357 hospitalizations occurring in 113 different academic hospitals; 172,882 (50.1%) hospitalizations were in NSQIP hospitals. Hospitalized patients were predominantly female (61.5%), with a mean age of 55.7 years. The types of procedures performed most commonly in the analyzed hospitalizations were hernia repairs (15.7%), bariatric (10.5%), mastectomy (9.7%), and cholecystectomy (9.0%). After accounting for patient risk, procedure type, underlying hospital performance, and temporal trends, the difference-in-differences model demonstrated no statistically significant differences over time between NSQIP and non-NSQIP hospitals in terms of likelihood of complications (adjusted odds ratio, 1.00; 95% CI, 0.97-1.03), serious complications (adjusted odds ratio, 0.98; 95% CI, 0.94-1.03), or mortality (adjusted odds ratio, 1.04; 95% CI, 0.94-1.14). CONCLUSIONS AND RELEVANCE No association was found between hospital-based participation in the NSQIP and improvements in postoperative outcomes over time within a large cohort of patients undergoing elective general/vascular operations at academic hospitals in the United States. These findings suggest that a surgical outcomes reporting system does not provide a clear mechanism for quality improvement.

Operative outcomes beyond 30-day mortality: Colorectal cancer surgery in oldest old

Background: Resections for elderly colorectal cancer (CRC) are forecasted to grow, particularly in those beyond the age limit of screening (>80 years). However, literature on operative outcomes after CRC procedures in the oldest old is focused primarily on operative mortality. We hypothesize that older age will additionally impact operative morbidity after CRC resections in a multihospital, risk-adjusted database. Study Design: We identified 19,375 patients >40 years who underwent CRC procedures in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Pre-, intra-, and postoperative factors were compared by age groups. Multivariable techniques were used to assess the effects of older age on operative outcome measures, adjusting for covariates. Results: Over 20% of our cohort was older than 80 years. Of those, 17% developed major complications and 29% experienced prolonged length of stay (LOS). Older patients also experienced higher rates of 30-day operative mortality (>80 years vs. 45–55 years; 6% vs. <1%), major complications (>80 years vs. 45–55 years; 21% vs. 14%), and prolonged LOS after open (>80 years vs. 45–55 years; 37% vs. 24%) and laparoscopic procedures (>80 years vs. 45–55 years; 40.5% vs. 18%). These unadjusted comparisons persisted in multivariable analyses demonstrating that older age independently predicted worse operative outcomes after CRC procedures. Conclusions: The effects of older age extend to other important outcome measures after CRC procedures beyond operative mortality. As one of the largest multihospital studies, our study identified increased morbidity in the oldest old, a growing population. Our results should stimulate review of current policy and resource allocation.

A Matter Of Race: Early-Versus Late-Stage Cancer Diagnosis

We compared the stage at which cancer is diagnosed and survival rates between African Americans and whites, for thirty-four solid tumors, using the population-based Surveillance Epidemiology and End Results (SEER) database. Whites were diagnosed at earlier stages than African Americans for thirty-one of the thirty-four tumor sites. Whites were significantly more likely than blacks to survive five years for twenty-six tumor sites; no cancer site had significantly superior survival among African Americans. These differences cannot be explained by screening behavior or risk factors; they point instead to the need for broad-based strategies to remedy racial inequality in cancer survival.

Who Receives Their Complex Cancer Surgery at Low-Volume Hospitals?

BACKGROUND Previous literature has consistently shown worse operative outcomes at low-volume hospitals (LVH) after complex cancer surgery. Whether patient-related factors impact this association remains unknown. We hypothesize that patient-related factors contribute to receipt of complex cancer surgery at LVH. STUDY DESIGN Using the 2003-2008 National Inpatient Sample, we identified 59,841 patients who underwent cancer operations for lung, esophagus, and pancreas tumors. Logistic regression models were used to examine the impact of sociodemographic factors on receipt of complex cancer surgery at LVH. RESULTS Overall, 38.4% received their cancer surgery at LVH. A higher proportion of esophagectomies were performed at LVH (70.3%), followed by pancreatectomy (38.2%) and lung resection (33.8%). Patients who were non-white, with non-private insurance, and had more comorbidities were all more likely to receive their cancer surgery at LVH (for all, p < 0.05). Multivariate analyses continued to demonstrate that non-white race, insurance status, increased comorbidities, region, and nonelective admission predicted receipt of cancer surgery at LVH across all 3 procedures. CONCLUSIONS In this large national study, non-white race and increased comorbidities contributed to receipt of cancer surgery at LVH. Patient selection and access to high-volume hospitals are likely reasons worthy of additional investigation. This study provides additional insight into the volume-outcomes relationship. Given the demonstrated outcomes disparity between high-volume hospitals and LVH, future policy and research should encourage mechanisms for referral of patients with cancer to high-volume hospitals for their surgical care.

The Changing Landscape of Vestibular Schwannoma Management in the United States—A Shift Toward Conservatism

Objective To characterize the evolving management of vestibular schwannoma (VS) in the United States. Study Design Retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database. Setting SEER database. Subjects and Methods All patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression. Results A total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P < .01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P < .05). Management trend analysis revealed that microsurgery was used less frequently over time (P < .0001), observation was used more frequently (P < .0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation. Conclusion While the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.