Emma C. Hamilton

Health disparities and impact on outcomes in children with primary central nervous system solid tumors.

OBJECTIVE Health disparities in access to care, early detection, and survival exist among adult patients with cancer. However, there have been few reports assessing how health disparities impact pediatric patients with malignancies. The objective in this study was to examine the impact of racial/ethnic and social factors on disease presentation and outcome for children with primary CNS solid tumors. METHODS The authors examined all children (age ≤ 18 years) in whom CNS solid tumors were diagnosed and who were enrolled in the Texas Cancer Registry between 1995 and 2009 (n = 2421). Geocoded information was used to calculate the driving distance between a patients home and the nearest pediatric cancer treatment center. Socioeconomic status (SES) was determined using the Agency for Healthcare Research and Quality formula and 2007-2011 US Census block group data. Logistic regression was used to determine factors associated with advanced-stage disease. Survival probability and hazard ratios were calculated using life table methods and Cox regression. RESULTS Children with advanced-stage CNS solid tumors were more likely to be < 1 year old, Hispanic, and in the lowest SES quartile (all p < 0.05). The adjusted odds ratios of presenting with advanced-stage disease were higher in children < 1 year old compared with children > 10 years old (OR 1.71, 95% CI 1.06-2.75), and in Hispanic patients compared with non-Hispanic white patients (OR 1.56, 95% CI 1.19-2.04). Distance to treatment and SES did not impact disease stage at presentation in the adjusted analysis. Furthermore, 1- and 5-year survival probability were worst in children 1-10 years old, Hispanic patients, non-Hispanic black patients, and those in the lowest SES quartile (p < 0.05). In the adjusted survival model, only advanced disease and malignant behavior were predictive of mortality. CONCLUSIONS Racial/ethnic disparities are associated with advanced-stage disease presentation for children with CNS solid tumors. Disease stage at presentation and tumor behavior are the most important predictors of survival.

The association of insurance status on the probability of transfer for pediatric trauma patients

BACKGROUND/PURPOSE The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers. METHODS A retrospective review of all pediatric trauma patients (age<16years) registered in the 2007-2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers. RESULTS Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status. CONCLUSIONS Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients. LEVEL OF EVIDENCE Case-control study, level III.

The digital divide in adoption and use of mobile health technology among caregivers of pediatric surgery patients

PURPOSE The purpose of this study was to identify mobile Health (mHealth) technology utilization among caregivers of pediatric surgery patients. METHODS We provided a modified version of the 2012 mobile health survey from the Pew Research Center to English and Spanish-speaking caregivers of children aged <18years presenting to pediatric surgical outpatient clinics from June to July of 2016. RESULTS A total of 171 caregivers completed the survey and included 57 (34%) whites, 30 (18%) blacks, 75 (44%) Hispanics, and 6 (4%) other races. Among these, 160 (94%) were smartphone owners. mHealth users were identified as individuals who used their phone to look up health information online, receive text updates from healthcare providers or pharmacists, or use any health-related smartphone applications. On univariate ordered logistic regression, race/ethnicity, primary language, education level, and income quartile were associated with level of mHealth technology use. The majority of responders (n=126, 76%) said that they would be very or moderately interested in trying a new smartphone app related to management of their childs health. CONCLUSION While the majority of pediatric caregivers are smartphone owners, there are significant racial and socioeconomic differences in mHealth usage. Understanding these differences may be important in identifying barriers to adoption of mHealth technology. LEVEL OF EVIDENCE Level IV case series with no comparison group.

Don't forget the dose: Improving computed tomography dosing for pediatric appendicitis

BACKGROUND A pediatric computed tomography (CT) radiation dose reduction program was implemented throughout our childrens associated hospital system in 2010. We hypothesized that the CT dose received for evaluation of appendicitis in children would be significantly higher among the 40 referral, nonmember hospitals (NMH) than the 9 member hospitals (MH). METHODS Preoperative CTs of pediatric (<18years) appendectomy patients between April 2012 and April 2015 were reviewed. Size specific dose estimate (SSDE), an approximation of absorbed dose incorporating patient diameter, and Effective Dose (ED) were calculated for each scan. RESULTS 1128 (65%) of 1736 appendectomy patients underwent preoperative CT. 936 patients seen at and 102 children evaluated at NMH had dosing and patient diameter data for analysis. SSDE and ED were significantly higher with greater variance at NMH across all ages (all p<0.05, Figure). NMHs SSDE and ED also exceeded reference levels. CONCLUSION Radiation exposure in CT scans for evaluation of pediatric appendicitis is significantly higher and more variable in NMH. A proactive approach to reduce dose, in addition to frequency, of CT scans in pediatric patients is essential. LEVEL OF EVIDENCE Level III.

Variability of child access prevention laws and pediatric firearm injuries

BACKGROUND State-level child access prevention (CAP) laws impose criminal liability on adults who negligently allow children access to firearms. The CAP laws can be further divided into strong CAP laws which impose criminal liability for negligently stored firearms and weak CAP laws that prohibit adults from intentionally, knowingly, and/or recklessly providing firearms to a minor. We hypothesized that strong CAP laws would be associated with a greater reduction in pediatric firearm injuries than weak CAP laws. METHODS We constructed a cross-sectional national study using the Healthcare Cost and Utilization Project-Kids Inpatient Database from 2006 and 2009 using weighted counts of firearm-related admissions among children younger than 18 years. Poisson regression was used to estimate the association of CAP laws with pediatric firearm injuries. RESULTS After adjusting for race, sex, age, and socioeconomic income quartile, strong CAP laws were associated with a significant reduction in all (incidence rate ratio, 0.70; 95% confidence interval, 0.52–0.93), self-inflicted (incidence rate ratio, 0.46; 95% confidence interval, 0.26–0.79), and unintentional (incidence rate ratio, 0.56; 95% confidence interval, 0.43–0.74) pediatric firearm injuries. Weak CAP laws, which only impose liability for reckless endangerment, were associated with an increased risk of all pediatric firearm injuries. CONCLUSION The association of CAP laws on hospitalizations for pediatric firearm injuries differed greatly depending on whether a state had adopted a strong CAP law or a weak CAP law. Implementation of strong CAP laws by each state, which require safe storage of firearms, has the potential to significantly reduce pediatric firearm injuries. LEVEL OF EVIDENCE Prognostic and epidemiology study, level III.

Liver transplantation for primary hepatic malignancies of childhood: The UNOS experience

BACKGROUND/PURPOSE The purpose of this study was to determine factors associated with patient and graft survival following orthotopic liver transplantation (OLT) in children and adolescents with primary hepatic malignancies. METHODS The United Network for Organ Sharing (UNOS) database was queried for all patients <18years old who received an OLT with a primary malignant liver tumor between 1987 and 2012 (n=544). Five-year patient and graft survival were determined using Kaplan-Meier methodology, and independent predictors of survival were determined using multivariate Cox proportional hazards model. RESULTS The majority of patients were diagnosed with hepatoblastoma (HB) (n=376, 70%) with 84 (15%) hepatocellular carcinoma (HCC) and 84 (15%) other. HCC patients were older, more often hospitalized at the time of transplant, and more likely to receive a cadaveric organ compared to HB patients. Five-year patient and graft survival for the entire cohort was 73% and 74%, respectively, with the majority of deaths owing to malignancy. On multivariate analysis, independent predictors of 5-year patient and graft survival included diagnosis, transplant era, and medical condition at transplant. CONCLUSIONS In recent years, there has been significant improvement in posttransplant patient and graft survival for children and adolescents with primary hepatic malignancies. However, patients with HCC continue to have worse outcomes than those with other cancer types. TYPE OF STUDY Case series with no comparison group. LEVEL OF EVIDENCE IV.

Treatment outcomes in pediatric melanoma—Are there benefits to specialized care?

PURPOSE The purpose of this study was to evaluate the impact of hospital specialization on survival in pediatric melanoma. METHODS We reviewed all patients under 18years old with cutaneous melanoma evaluated at MD Anderson Cancer Center, a National Cancer Institute (NCI)-designated center, from 2000 to 2014. We compared overall survival (OS) and disease-free survival (DFS) between patients who underwent all treatments at MDACC (Group A, n=146) and those who underwent initial surgical treatment at a non-NCI center (Group B, n=58). Kaplan-Meier survival curves were compared using the log-rank test. RESULTS Group A patients had significantly better OS and DFS (both p<0.001). Five-year OS was 97% (95% CI 92%-99%) in Group A versus 88% (95% CI 74%-94%) in Group B. Group survival differences were most notable in Stage 3 and 4 patients. Group A patients presenting with stage III or IV disease had a 5-year OS rate of 91.2% (95% CI 75.1%-97.1%) compared to 80.8% (95% CI 59.8%-91.5%) in Group B. The DFS rate was 94.4% (95% CI 88.5%-97.3%) in Group A versus 77.2% (95% CI 62.5%-86.7%) in Group B. CONCLUSION Surgical treatment at a comprehensive cancer center may improve outcomes for pediatric melanoma especially for patients presenting with later stage disease. LEVEL OF EVIDENCE Case-control study: Level III.

Abdominal Wall Reconstruction in the Pediatric Population

Definitive closure of large congenital abdominal wall defects poses a challenge to surgeons due to the degree of visceroabdominal disproportion and the loss of abdominal domain. Additionally, many patients have an underdeveloped abdominal cavity and can have a large abdominal wall defect making primary fascial closure difficult. Although the armamentarium of strategies to treat congenital abdominal wall defects continues to expand, no single operative technique has achieved universal acceptance or success. In this chapter, we review current surgical treatment options for neonates born with gastroschisis and omphalocele.

Surgical Feeding Tubes in Pediatric and Adolescent Cancer Patients: A Single-institution Retrospective Review

The purpose of our study was to evaluate surgical enteric access in pediatric cancer patients to determine factors associated with postoperative complications. We performed a single-institution retrospective review of all patients below 21 years old with a primary cancer diagnosis who underwent surgical procedures for enteral access between 2004 and 2014. Multivariate logistic regression was performed to determine independent predictors of postoperative complications. During the study period, 122 patients had surgically placed feeding tubes, of whom 58% developed ≥1 complication(s) and 16% experienced a major complication. No single factor was significantly associated with developing any complication or major complication. Several trends were noted including increased complications associated with jejunostomy tubes, percutaneous endoscopic gastrostomy tubes, and abdominal radiation. Surgically placed enteric access in pediatric and adolescent cancer patients is associated with an extremely high complication rate emphasizing the importance of careful evaluation of these patients before embarking on surgical feeding access. Future work should evaluate mechanisms to decrease complications and/or explore alternative methods to provide supplemental nutrition in children and adolescents with cancer.

Abstract C47: The impact of racial/ethnic disparities on survival for children and young adults with chest wall sarcoma: A population-based study

Purpose: To determine whether there are racial/ethnic disparities in disease presentation and survival outcomes among children and young adults with chest wall sarcomas. Methods: The Surveillance, Epidemiology and End Results (SEER) database from 1973-2013 was analyzed for all patients less than 24 years old and diagnosed with chest wall based on primary tumor histology and primary tumor site. Tumor histology was categorized as skeletal for histologic subtypes arising from bone and extra-skeletal for histologic subtypes arising from soft tissues. Tumor sites included thorax, clavicle, sternum and ribs. We performed multivariate logistic regression to investigate the association of race/ethnicity with advanced stage of disease at presentation and likelihood of undergoing surgical resection after adjusting for age, sex, treatment, tumor size and sarcoma type. Overall survival (OS) was evaluated using Cox regression to estimate hazard ratios with 95% confidence intervals. All statistics were calculated with SPSS Statistics Version 23. Results: A total of 598 patients were identified and included 363 non-Hispanic whites (61%), 129 Hispanics (22%), 57 non-Hispanic blacks (10%), and 49 other race/ethnicity (8%). The mean age at diagnosis was 14 + 6.6 years. Most patients presented with advanced stage disease defined as regional or distant disease (393, 66%). Race/ethnicity was not associated with stage of disease at presentation. However, patients with advanced stage disease were more likely to have a skeletal sarcoma (OR= 2.55, 95% CI: 1.71-3.80), tumor size ≥8 cm (OR= 3.66, 95% CI: 2.35-5.71) and undergone radiation therapy (OR= 1.80, 95% CI: 1.22-2.67). Those who underwent surgical resection were less likely to present with advanced disease (OR=0.34; 95% CI: 0.20-0.59). The 5- and 10-year OS for the entire cohort were 62% and 58%, respectively. Non-Hispanic blacks had a worse 5-year and 10-year OS compared to Non-Hispanic whites (54% versus 65%, 48% versus 60%, respectively). In the univariate analysis, non-Hispanic Blacks were 63% more likely to die than non-Hispanic whites (95% CI 1.07-2.49); however, this association was mitigated after controlling for age at diagnosis, sex, tumor type, tumor size, disease stage, surgical resection and radiation treatment in the multivariate analysis. In the multivariate analysis, predictors of worse OS included older age at diagnosis (HR 1.05, 95% CI 1.03-1.07), tumor size > 8cm (HR 2.15, 95% CI 1.50-3.10), regional disease (HR 1.79, 95% CI 1.19-2.69), distant disease (HR 3.99, 95% CI 2.67-5.96), and failure to undergo surgical resection (HR 2.08, 95% CI 1.55-2.81). Most patients (79%) underwent surgical resection. However, non-Hispanic blacks were less likely than non-Hispanic whites to undergo surgical resection even after controlling for sex, age at diagnosis, tumor type, tumor size, disease stage, and radiation therapy (OR 0.49, 95% CI 0.25-0.97). Conclusions: Non-Hispanic black children and young adults with chest wall sarcomas have decreased overall survival compared to non-Hispanic whites. In addition, Non-Hispanic blacks are less likely to undergo surgical resection of their tumors which may contribute to the survival disparities identified in this study. Citation Format: Michael Joseph, Emma Hamilton, Winston Huh, Andrea Hayes-Jordan, Mary Austin. The impact of racial/ethnic disparities on survival for children and young adults with chest wall sarcoma: A population-based study. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C47.