Jessica B. O’Connell

Do young colon cancer patients have worse outcomes

Previous studies on colon cancer have noted rising incidence rates among young individuals and suggest that they may have more aggressive disease and worse 5-year survivals than their older counterparts. Our study uses a nationwide population-based cancer registry to analyze colon cancer presentations and outcomes in a young versus an older population. The records of patients with colon carcinoma were obtained from the Surveillance, Epidemiology, and End Results (SEER) national cancer database (1991–1999). Two cohorts based on age at diagnosis (20–40 years, n = 1334 vs. 60–80 years, n = 46,457) were compared for patient and tumor characteristics, treatment, and 5-year cancer-specific survival. A multivariate Cox regression was performed to identify predictors of survival. The young group had a higher proportion of black and Hispanic patients than did the older group (p < 0.001). Young patients had less stage I or II disease, more stage III or IV disease (p < 0.001), and worse-grade (poorly differentiated or anaplastic) tumors (p < 0.001). The 5-year stage-specific survival was similar for stage I and III disease (p = NS) but was significantly better for young patients with stage II and IV disease (p < 0.01). Using a nationally representative cancer registry, we found that young colon cancer patients tend to have later-stage and higher-grade tumors. However, they have equivalent or better 5-year cancer-specific survival compared to older patients. This population-based finding contradicts prior single-institution reports.

Cancer-directed surgery for localized disease: decreased use in the elderly.

Background: Previous studies report underuse of radiation and chemotherapy in the elderly, yet few have examined the rates of use (or underuse) of surgery. Using national data, we examined rates of surgical resection for patients with local-stage cancers.Methods: By using the Surveillance, Epidemiology, and End Results database (1988–1997), patients (≧40 years) were identified with localized adenocarcinoma of the breast, esophagus, stomach, pancreas, colon, or rectum; non–small-cell lung carcinoma; and sarcoma (n = 200,360). Rates of cancer-directed surgery (CDS) were compared across age groups (at 5-year intervals). Multivariate regression was used to identify predictors of receipt of CDS in each tumor group.Results: Rates of CDS declined steadily with increasing age for all nine localized tumors. Most striking were the low rates of CDS for patients >70 years with esophagus, stomach, pancreas, and lung cancers (range, 0%–83%). However, CDS rates were >90% for breast and colon and >84% for rectal cancer in all age groups. Multivariate regression found lower odds of CDS for elderly patients for all cancers except colon. For example, age significantly decreased the odds of receiving CDS beginning at 60 years for lung cancer (odds ratio [OR], .550; P = .03), at 70 years for liver cancer (OR, .109; P = .003), and at 80 years for pancreatic cancer (OR, .120; P < .05).Conclusions: Although CDS for localized disease is being performed regularly in the elderly for some cancers (e.g. breast, colon, and rectum), this analysis shows that elderly patients are not receiving surgery for many potentially curable cancers. Whether these rates are appropriate or too low requires further evaluation. This is particularly essential because our population is aging.

Survival After Resection of Ampullary Carcinoma: A National Population-Based Study

BackgroundAmpullary cancer is the second most common periampullary cancer, with a resection and survival rate more favorable than that for pancreatic cancer. However, most reports have been conducted at single institutions with small sample sizes, and results may not reflect the practices and outcomes in the community. Our objective was to complete a population-based analysis of patients undergoing resection for ampullary carcinoma and compare it with outcomes in the published literature.MethodsPatients diagnosed with ampullary cancer reported in the Surveillance, Epidemiology, and End Results program (1988–2003) were collected. Primary outcome was survival (5-year), and secondary outcome was stage at presentation. Comparisons were made with outcomes reported in the literature (resection rate, perioperative mortality, and 5-year survival).ResultsOf the 3292 ampullary cancer patients, 1301 (40%) underwent resection. Thirty-seven percent presented with stage I tumors. Perioperative mortality (30 day) was 7.6% after resection, and 5-year survival was 36.8%. Few patients died if they survived at least 5 years. The cancer registry data showed less early stage disease, higher perioperative mortality, and lower 5-year survival compared with published reports.ConclusionsThis is the largest population-based analysis of ampullary carcinoma. Resection rates and survival at the national level are lower, in general, compared with cancer center reports, which may have implications for regionalizing these procedures. Many patients surviving at least 5 years seem to be cured by surgical resection.

Workload Projections for Surgical Oncology: Will We Need More Surgeons?

AbstractBackground: Over the next two decades, the US population will experience dramatic growth in the number and relative proportion of older individuals. The aim of this study was to quantify the effect of these changes on the demand for oncological procedures. Methods: The 2000 Nationwide Inpatient Sample and the 1996 National Survey of Ambulatory Surgery were used to compute age-specific incidence rates for oncological procedures of the breast, colon, rectum, stomach, pancreas, and esophagus. Procedure rates were combined with census projections for 2010 and 2020 to estimate the future utilization of each procedure. Results: By 2020, the number of patients undergoing oncological procedures is projected to increase by 24% to 51%. The bulk of growth in procedures is derived from outpatient procedures, but significant growth will also be seen in inpatient procedures. Conclusions: The aging of the population will generate an enormous growth in demand for oncological procedures. If a shortage of surgeons performing these procedures does occur, the result will inevitably be decreased access to care. To prevent this from happening, the ability of surgeons to cope with an increased burden of work needs to be critically evaluated and improved.

Beyond the Clinical Trials: How Often Is Sentinel Lymph Node Dissection Performed for Breast Cancer?

BackgroundSentinel lymph node dissection (SLND) has been shown to be a reasonable treatment option for early-stage breast cancer. Until recently, SLND was limited to clinical trials. Because this technique is now offered outside of trials, its prevalence is unknown.MethodsAll patients with stage I or II breast cancer in the Surveillance, Epidemiology, and End Results national cancer registry (1998–2000) were evaluated. Data were collected for demographics, tumor characteristics, surgical resection, lymph node evaluation (SLND or complete axillary dissection), registry site, and year of diagnosis. Multivariate regression analysis was performed to identify predictors for receiving SLND.ResultsA total of 54,772 patients diagnosed with breast cancer had undergone surgical lymph node evaluation; 27.2% patients with stage I disease underwent SLND, as compared with 22.7% for stage II. Older patients and minority groups were less likely to receive SLND. Receipt of SLND varied by registry site (7.9%–32.7%). Multivariate regression showed that older patients had lower odds of receiving SLND (60–69 years: odds ratio, .73; P < .0001) as compared with younger patients. Additionally, blacks, Hispanics, and Asians had lower odds of receiving SLND (odds ratio of .64, .58, and .80, respectively; P < .0001). SLND use increased over the 3 years in the study (P < .0001).ConclusionsThis population-based analysis showed relatively infrequent use of SLND for early-stage breast cancer. These results suggest a slow transition of this procedure from clinical trials into the community. Future work should be targeted at improving the rate at which patients receive this procedure, particularly for elderly and minority groups and low-use regions.

Success of endovenous saphenous and perforator ablation in patients with symptomatic venous insufficiency receiving long-term warfarin therapy.

BACKGROUND Endovenous ablation of great (GSV) and short saphenous vein (SSV) reflux has become the initial procedure for most patients with symptomatic venous insufficiency, and perforator ablation is increasingly used to assist in healing venous ulceration. Many patients have comorbid conditions, which require long-term anticoagulation with warfarin; however, the impact of a long-term anticoagulation therapy on endovenous ablation procedures is not understood. This study aims to determine the effects of chronic anticoagulation on the outcomes of endovenous ablation procedures in patients with chronic venous insufficiency (CVI). METHODS Consecutive patients undergoing endovenous ablation for to Clinical severity (CEAP) class 2 through 6 CVI between January 1, 2005 and May 1, 2011 were evaluated; 781 patients with chronic venous reflux underwent 1,180 endovenous ablation procedures. We identified 45 patients receiving long-term anticoagulation therapy who underwent 71 endovenous ablation procedures, including 37 GSVs, 12 SSVs, and 22 perforator vein procedures. All patients underwent wound examination and duplex ultrasonography within 48 to 72 hours. Outcomes evaluated included closure rate and postoperative complications. RESULTS The mean age of the patients was 69.7 ± 13 years. Most patients treated presented with active venous ulceration (59% CEAP 6). Indications for anticoagulation included atrial fibrillation (n = 9, 20%), previous deep venous thrombosis (n = 16, 36%), hypercoagulable state (n = 9, 20%), prosthetic valve (n = 2, 4%), and others (n = 9, 20%). All patients receiving warfarin therapy (100%) underwent a postprocedure ultrasonography, which confirmed the successful closure of the GSVs and SSVs; successful initial perforator closure was achieved in 59% of patients (13/22). Repeat perforator ablation yielded a closure rate of 77%. Compared with a matched cohort group of 35 patients (61 perforators) undergoing perforator ablation without anticoagulation, treated during the same period, there was no significant difference in the rates of successful closure between the groups. No patients developed postoperative deep venous thrombosis or pulmonary embolus. No additional thrombotic complications were noted. Three patients (4.2%) developed a small hematoma after the procedure, which resolved with conservative treatment. No patients required postoperative hospital admission, and no postprocedure deaths occurred. CONCLUSIONS Based on our protocol, patients with severe CVI who were receiving long-term warfarin therapy can be treated safely and effectively with endovenous radiofrequency ablation for incompetent GSVs, SSVs, and perforator veins. Long-term warfarin therapy did not have a significant effect on perforator closure rates compared with no anticoagulation.

Quality of Care

It is sometimes difficult for surgeons(or any clinician)to define quality of care—particularly as a policy measure.In practice,we tend to know it when we see it(or when we do not),but there are still controversies as to what is and what is not quality care.For example, should high-quality care be defined as state-of-the-art care? Reasonable care? Or given the trend toward levels of evidence, should high-quality care be only evidence-based care?

Early Postoperative Hemorrhage After First Rib Resection for Vascular Thoracic Outlet Syndrome

BACKGROUND Thrombosis and embolization are the most frequent complications associated with the vascular presentation of thoracic outlet syndrome (VTOS). Therefore, surgery for these conditions requires careful balancing of anticoagulation and hemostasis. Our goal is to identify the optimal postoperative anticoagulation management of these patients. METHODS A prospective database of consecutive patients who have presented to our institution with the diagnosis of thoracic outlet syndrome was reviewed from 1996 through 2010 for instances of postoperative hemorrhage. All venous cases were managed with transaxillary first rib resection followed by postoperative venography and percutaneous angioplasty when required. All arterial cases first underwent thrombolysis, then decompression with transaxillary first and cervical rib resection with concomitant arterial repair when indicated. RESULTS Over the study period, 423 patients diagnosed with thoracic outlet syndrome underwent 551 procedures. Of these, 108 presented with VTOS (12 arterial and 96 venous). Mean age of the patients in the cohort was 33.7 ± 11.5 years, with 53 women and 55 men. Postoperative hemorrhage occurred in four patients (4%): three venous cases and one arterial case. Three patients required tube thoracostomy (average blood return: 800 mL) and two required video-assisted thoracoscopic surgery for decortication. Age, gender, preoperative anticoagulation, interval from thrombolysis to surgery, operative duration, and operative blood loss had no effect on the risk of bleeding. No hemorrhage occurred in patients treated with postoperative coumadin alone (82 patients) or with no anticoagulant (24 patients). The four cases of hemorrhage occurred only in patients treated with postoperative low-molecular-weight heparin (LMWH; 14 patients; p < 0.01). CONCLUSION Postoperative hemorrhage was not a common complication of first rib resection for VTOS. In our experience, it occurred exclusively in patients receiving LMWH postoperatively. Postoperative LMWH should be used with caution in patients with VTOS.

Gibt es unterschiedliche Überlebensraten für jüngere und ältere Patienten mit Rektumkarzinom

ZusammenfassungZiel:Obwohl allgemein geglaubt wird, dass junge Patienten mit Rektumkarzinom schlechtere Überlebensraten als ältere haben, ist noch keine umfassende Analyse vorgelegt worden. Diese Studie basiert auf einem nationalen, das Bevölkerungsspektrum berücksichtigenden Krebsregister, um Ergebnisse von Rektumkarzinomen zwischen jungen und älteren Bevölkerungsteilen zu vergleichen.Methodik:Ausgewertet wurden alle Patienten mit einem Rektumkarzinom aus der „Surveillance, Epidemiology, and End Results cancer database“ von 1991–1999. Junge (20–40 Jahre; n = 466) und ältere Patienten (60–80 Jahre; n = 11 312) wurden hinsichtlich Patienten- und Tumorcharakteristika, Behandlungsmuster sowie ihrem allgemein- und stadiumspezifischen Überleben innerhalb einer Fünfjahresspanne verglichen. Eine Multivarianz-Regressionsanalyse nach Cox wurde durchgeführt, um Prädiktoren für das Überleben zu identifizieren.Ergebnisse:Durchschnittsalter für die Gruppen waren 34,1 und 70 Jahre. Die Gruppe der Jungen umfasste mehr schwarze und hispanische Patienten im Vergleich zu der älteren Gruppe (p < 0,001). Bei jungen Patienten war ein fortgeschritteneres Stadium der Krankheit häufiger (jung vs. älter: Stadium III, 27 vs. 20%, p < 0,001; Stadium IV, 17,4 vs. 13,6%, p < 0,02). Die Gruppe der jüngeren Patienten zeigte auch ein schlechteres Tumorgrading (schlecht differenziert 24,3 vs. 14%, p < 0,001). Obwohl die Mehrzahl in beiden Gruppen operiert wurde (jeweils 85%), erhielten signifikant mehr junge Patienten eine Strahlentherapie (p < 0,001). Wichtig ist: sowohl allgemein als auch stadiumspezifisch fielen die Fünfjahres-Überlebensraten für beide Gruppen ähnlich aus (p = nicht signifikant unterschiedlich).Schlussfolgerung:Obwohl frühere Studien bei jungen Rektumkarzinompatienten eine schlechtere Überlebenschance verglichen mit der bei älteren Patienten herausgefunden haben, zeigt diese bevölkerungsbasierte Studie, dass junge Patienten mit Rektumkarzinom eine äquivalente allgemeine und stadiumspezifische Überlebenschance zu haben scheinen.AbstractPurpose:Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.Methods:All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991–1999 were evaluated. Young (range, 20–40 years; n = 466) and older groups (range, 60–80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.Results:Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (p < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20% respectively, p < 0.001; Stage IV, 17.4 vs. 13.6% respectively, p < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14% respectively, p < 0.001). Although the majority of both groups received surgery (85% for each), significantly more young patients received radiation (p < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (p = not significant).Conclusions:Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.