Erin K. Greenleaf

Trends in the use and impact of neoadjuvant chemotherapy on perioperative outcomes for resected gastric cancer: Evidence from the American College of Surgeons National Cancer Database

BACKGROUND Standard of care for patients with advanced gastric cancer includes administration of neoadjuvant chemotherapy (NAC) before resection. This study assesses the pattern of use and impact of NAC on perioperative outcomes in US medical centers. METHODS Using the American College of Surgeons National Cancer Database, 16,128 patients underwent gastrectomy for cancer from 2003 to 2012. Treatment groups were categorized as NAC or no NAC (ie, adjuvant chemotherapy and surgery only). Univariate and multivariate analyses were performed to estimate trends in utilization and impact of treatment on perioperative outcomes. RESULTS Of patients undergoing gastrectomy, 36.6% received NAC and 63.4% did not receive chemotherapy in the neoadjuvant setting. Patients who received NAC were more frequently younger, male, white, privately insured, with fewer comorbidities, and treated at an academic center (all P < .0001). After controlling for demographics, comorbidities, and tumor-related factors, patients who received NAC had a postoperative duration of stay 0.43 days shorter than patients who did not receive chemotherapy (5.79 vs 6.22 days; P = .050). They had a 36% lower odds of 30-day mortality (odds ratio, 0.64, P < .0001) but nonsignificant lower odds of 90-day mortality. Use of NAC increased annually, with the greatest increases seen in academic facilities and in the Northeast and North Central United States. CONCLUSION With concerns regarding the toxicity of NAC, these findings suggest that NAC is not associated with worse postoperative outcomes. In light of evidence touting the benefits of NAC, its adoption as a component in the multimodality care of gastric cancer is slowly increasing, although use of NAC remains poor overall.

Tumor regression grade in gastric cancer: Predictors and impact on outcome.

The clinical value and prognostic implications of histologic response to neoadjuvant chemotherapy in gastric cancer is unknown.

Attributable cost of obesity in breast surgery: a matched cohort analysis

BACKGROUND The purpose of this study was to determine the economic impact of obesity on patients undergoing mastectomy and breast conservation (BC) for breast cancer. METHODS An analysis of female patients greater than or equal to 18 years undergoing mastectomy and BC for breast cancer between 2004 and 2010 using the Nationwide Inpatient Sample was conducted. RESULTS Of 55,903 patients in our study (49,985 mastectomy, 5,918 BC), 3,308 patients (5.92%) were obese. After propensity score matching, the cost for obese patients was higher at

Marital Status and Survival in Patients with Carcinoid Tumors

1,826 (P < .0001) for mastectomy and

Correlation of clinical and pathological staging and response to neoadjuvant therapy in resected pancreatic cancer

1,702 for BC (P < .0001). These costs were not significantly associated with overall complications and length of stay for mastectomy in the matched comparison group and not associated with overall complications and minimally associated with longer length of stay in the BC group. CONCLUSION By controlling for other patient factors, this study shows that obesity is attributable to a significantly higher cost for both BC (29%) and mastectomy (23%).

Neck hematoma after major head and neck surgery: Risk factors, costs, and resource utilization

Background Marital status is a known prognostic factor in overall and disease-specific survival in several types of cancer. The impact of marital status on survival in patients with carcinoid tumors remains unknown. We hypothesized that married patients have higher rates of survival than similar unmarried patients with carcinoid tumors. Methods Using the Surveillance, Epidemiology, and End Results database, we identified 23,126 people diagnosed with a carcinoid tumor between 2000 and 2011 and stratified them according to marital status. Univariate and multivariable analyses were performed to compare the characteristics and outcomes between patient cohorts. Overall and cancer-related survival were analyzed using the Kaplan–Meier method. Multivariable survival analyses were performed using Cox proportional hazards models (hazards ratio [HR]), controlling for demographics and tumor-related and treatment-related variables. Propensity score analysis was performed to determine surgical intervention distributions among married and unmarried (ie, single, separated, divorced, widowed) patients. Results Marital status was significantly related to both overall and cancer-related survival in patients with carcinoid tumors. Divorced and widowed patients had worse overall survival (HR, 1.33 [95% confidence interval {CI}, 1.08–1.33] and 1.34 [95% CI, 1.22–1.46], respectively) and cancer-related survival (HR, 1.15 [95% CI, 1.00–1.31] and 1.15 [95% CI, 1.03–1.29], respectively) than married patients over five years. Single and separated patients had worse overall survival (HR, 1.20 [95% CI, 1.08–1.33] and 1.62 [95% CI, 1.25–2.11], respectively) than married patients over five years, but not worse cancer-related survival. Unmarried patients were more likely than matched married patients to undergo definitive surgical intervention (62.67% vs 53.11%, respectively, P < 0.0001). Conclusions Even after controlling for other prognostic factors, married patients have a survival advantage after diagnosis of any carcinoid tumor, potentially reflecting better social support and financial means than patients without partners.

Large Databases for Health Services Research in Endocrine Surgery

BACKGROUND Neoadjuvant therapy (NAT) has been increasingly employed to optimize outcomes in pancreatic cancer; however, little is known about its pathologic impact. METHODS The National Cancer Data Base (2003-2011) was retrospectively reviewed for patients with pancreatic carcinoma who underwent initial surgery or NAT followed by resection. Response to NAT, determined by comparing clinical and pathologic stage, and survival were evaluated. RESULTS 16,087 patients underwent initial pancreatectomy and 2307 patients received NAT. Clinical stage correlated poorly with pathological stage in patients who received initial surgery (κ = 0.2865, p < 0.001). With NAT, 21.9% were downstaged, 47.9% had no stage change, and 30.3% progressed. In clinical stage II disease, patients downstaged with neoadjuvant chemotherapy or multimodality therapy demonstrated improved survival over patients who did not respond or who progressed (P = 0.0022, P = 0.0012, respectively). This benefit was not preserved in stage III disease (P = 0.7380, P = 0.0726, respectively). In multivariable analysis, downstage in disease was associated with a 19% lower hazard of mortality (HR 0.81, 95% CI: 0.7-0.92, P = 0.002). CONCLUSIONS Clinical stage correlates poorly with pathological stage in resectable pancreatic cancer. The majority of patients do not experience a change in stage with NAT. Those with early stage disease, responsive to NAT, experience a survival benefit.

Health Services and Health Care Economics Related to Hyperparathyroidism and Parathyroid Surgery

Postoperative cervical hematoma after major head and neck surgery is a feared complication. However, risk factors for developing this complication and attributable costs are not well‐established.

Timing of adjuvant chemotherapy and impact on survival for resected gastric cancer.

Studies using large, publicly available databases are providing new insights into treatment effects and comparative effectiveness in endocrine surgery. While observational studies using retrospective data have unique strengths, such as large sample sizes and a real-world context, they also have important limitations. This chapter reviews nine large databases that contain information on patients with endocrine diseases, many of whom may receive endocrine surgery. For each database, we provide a summary of the source of the data, a description of the outcomes that are available, a general description of covariates for which controls can be constructed, the primary strengths and limitations of the database, and a few examples of important research questions that has been addressed using the data. These descriptions may give investigators insights into the usefulness and appropriateness of such data for undertaking health services research.

Time to the initiation of adjuvant chemotherapy does not impact survival in patients with resected pancreatic cancer

Primary hyperparathyroidism (PHPT) is a prevalent and costly disease. This chapter discusses recent health services and health economics research related to PHPT. We cover first the epidemiology of PHPT in the USA, using primary data from the Truven Health MarketScan database. We then discuss several dimensions of costs of management. We review the evidence regarding medical approaches to managing PHPT relative to surgical approaches, showing that definitive surgical management soon after diagnosis appears to yield cost savings. We then examine the costs associated with surgical management, comparing economic implications of alternative surgical approaches, including limited exploration after preoperative gland localization, which appears to have reasonable evidence in favor of cost-effectiveness, and intraoperative adjuncts, for which cost-effectiveness evidence is weak. We finally review the economic evidence for medical management of patients who are not good candidates for surgery.