Nabil Wasif

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.

Impact of Tumor Grade on Prognosis in Pancreatic Cancer: Should We Include Grade in AJCC Staging?

BackgroundAJCC staging of pancreatic cancer (PAC) is used to determine prognosis, yet survival within each stage shows wide variation and remains unpredictable. We hypothesized that tumor grade might be responsible for some of this variation and that the addition of grade to current AJCC staging would provide improved prognostication.MethodsThe Surveillance, Epidemiology, and End Results (SEER) database (1991–2005) was used to identify 8082 patients with resected PAC. The impact of grade on overall and stage-specific survival was assessed using Cox regression analysis. Variables in the model were age, sex, tumor size, lymph node status, and tumor grade.ResultsFor each AJCC stage, survival was significantly worse for high-grade versus low-grade tumors. On multivariate analysis, high tumor grade was an independent predictor of survival for the entire cohort (hazard ratio [HR] 1.40, 95% confidence interval [95% CI] 1.31–1.48) as well as for stage I (HR 1.28, 95% CI 1.07–1.54), stage IIA (HR 1.43, 95% CI 1.26–1.61), stage IIB (HR 1.38, 95% CI 1.27–1.50), stage III (HR 1.28, 95% CI 1.02–1.59), and stage IV (HR 1.58, 95% CI 1.21–2.05) patients. The addition of grade to staging results in a statistically significant survival discrimination between all stages.ConclusionsTumor grade is an important prognostic variable of survival in PAC. We propose a novel staging system incorporating grade into current AJCC staging for pancreas cancer. The improved prognostication is more reflective of tumor biology and may impact therapy decisions and stratification of future clinical trials.

Does metastasectomy improve survival in patients with Stage IV melanoma? A cancer registry analysis of outcomes.

Patients with Stage IV melanoma have limited therapeutic options with few long‐term survivors. Our goal was to study the impact of metastasectomy on survival in these patients.

Underuse of Axillary Dissection for the Management of Sentinel Node Micrometastases in Breast Cancer

BACKGROUND Current American Society of Clinical Oncology guidelines for management of sentinel node micrometastases (SNMM) in breast cancer recommend axillary lymph node dissection (ALND) for all patients. OBJECTIVE To assess nationwide use of ALND for SNMM. DESIGN Population-based retrospective observational study. SETTING The National Cancer Institutes Surveillance, Epidemiology, and End Results database (1998-2005). PATIENTS Five thousand three hundred fifty-three patients with SNMM. MAIN OUTCOME MEASURE Use of ALND after identification of SNMM. RESULTS The prevalence of SNMM increased from 2.5% in 1998 to 17.7% in 2005. Of 5353 patients with SNMM, 2160 (40.4%) had no further nodal surgery and 3193 (59.6%) underwent ALND. In the latter group, histopathologic examination of nonsentinel nodes upstaged 18.6% of cases to N1, 2.2% to N2, and 0.1% to N3 disease. Multivariate analysis using logistic regression showed that age younger than 66 years (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.56-2.04), high tumor grade (OR, 1.22; 95% CI, 1.07- 1.40), and tumor size larger than 2 cm (OR, 1.16; 95% CI, 1.01-1.32) were predictive of ALND. Predictors of upstaging were infiltrating lobular histology (OR, 1.23; 95% CI, 1.00-1.51), T2 stage (OR, 1.38; 95% CI, 1.14-1.67), T3 stage (OR, 3.66; 95% CI, 1.70-7.90), and number of nodes examined (OR, 1.04; 95% CI, 1.03-1.05). CONCLUSIONS Only 60% of patients with SNMM from breast cancer are treated according to American Society of Clinical Oncology guidelines. Nodal staging based only on sentinel node biopsy may underestimate the extent of nodal disease in 20.9% of cases. Surgical management of SNMM should be standardized.

Metastasectomy and surgical resection of the primary tumor in patients with stage IV breast cancer: time for a second look?

Patients with metastatic or stage IV breast cancer have limited therapeutic options, and the mainstay of treatment remains systemic chemotherapy. Traditionally, the role of surgery has been confined to strict palliation. Improvements in the efficacy of chemotherapeutic regimens, coupled with the use of hormonal and targeted therapy, have resulted in an expansion of surgical resection beyond simple palliation. Several single-institution studies have reported improved survival and even long-term cures after surgical resection for oligometastatic stage IV breast cancer. Similarly, provocative new data suggest that removal of the primary tumor in some patients may confer a survival advantage. The aim of this review is to summarize studies in the medical literature pertaining to the use of surgical resection in patients with stage IV breast cancer. We believe there is enough evidence to challenge conventional thinking about the role of surgery in stage IV breast cancer and to consider a new multimodality treatment paradigm to optimize patient outcomes. It is time to conduct a carefully designed randomized trial to see whether surgery in stage IV breast cancer does indeed warrant a second look.

Distance bias and surgical outcomes.

Background:A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed “distance bias.” This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution. Methods:We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient. Results:The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2–5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63–0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00–1.42)]. Operations performed on patients from greater distances (quintiles 3–5) had an observed risk of severe complications which was similar to expected. Discussion:The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.

Risk factors associated with local and in-transit recurrence of cutaneous melanoma

BACKGROUND Understanding the risk factors for local and in-transit recurrences (LR/ITR) may help facilitate methods of prevention, early detection, and treatment. METHODS A retrospective review of a prospectively collected database was performed on patients diagnosed with single-lesion cutaneous melanoma. Clinical and pathologic characteristics of the tumors were evaluated. RESULTS Of 225 patients, 10% had LR/ITR. Patients with LR/ITR were older (P = .0002), had thicker tumors (P = .018), and positive angiolymphatic invasion more frequently (P < .0001). An increased tumor mitotic rate (TMR) was more common in LR/ITRs (P = .051). On univariate logistic regression, age, thickness, TMR of 11/mm(2) or greater, and angiolymphatic invasion were all significant risk factors for LR/ITR. Multivariate logistic regression showed age, thickness, and angiolymphatic invasion were the only significant risk factors. CONCLUSIONS Older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for LR/ITR. Such patients warrant consideration of preventative strategies and should receive close clinical follow-up evaluation for early recurrence.

Patient survival after surgical treatment of rectal cancer: Impact of surgeon and hospital characteristics

Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood.

Validation of the Updated 7th Edition AJCC TNM Staging Criteria for Gastric Adenocarcinoma

IntroductionThe recently published 7th edition of the American Joint Committee on Cancer (AJCC) TNM staging criteria for gastric adenocarcinoma contains important revisions to T and N classifications, as well as overall stage grouping. Our goal was to validate the new staging system using a cancer registry.MethodsRetrospective review of gastric cancer patients from Surveillance, Epidemiology, and End Results (SEER) registry data (2004–2007). Patients were staged according to both 6th and 7th edition criteria, and 3-year disease-specific survival was compared.ResultsThirteen thousand five hundred forty-seven patients with gastric adenocarcinoma were identified with complete staging information. When using 7th edition criteria, there was an increase in the number of patients classified as stage III (23% vs. 13%), and a decrease in patients classified as stage IV (47% vs. 53%). Statistically significant differences in 3-year disease-specific survival were observed for all T and N categories and re-staging the same population according to the 7th edition criteria improved survival discrimination. Multivariate analysis revealed statistically significant differences in survival and linear progression of hazard ratios for each stage grouping.ConclusionsThe 7th edition AJCC staging criteria for gastric adenocarcinoma demonstrate better survival discrimination and risk stratification than previous criteria.

Patient survival after surgical treatment of rectal cancer

Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood.