Waseem Lutfi

Increased utilization of postmastectomy radiotherapy in the United States from 2003 to 2011 in patients with one to three tumor positive nodes

There have been few recent studies that have examined the use of postmastectomy radiotherapy (PMRT) for patients with 1–3 positive nodes.

Minimally Invasive Esophagectomy Provides Equivalent Survival to Open Esophagectomy: An Analysis of the National Cancer Database

The use of minimally invasive esophagectomy (MIE) is increasing despite limited evidence to support its efficacy. We compared overall survival and perioperative mortality for MIE vs open esophagectomy (OE). We queried the National Cancer Database for all patients having esophagectomy as the primary procedure for primary squamous cell cancer and adenocarcinoma from 2010 through 2012. A propensity score analysis was performed. Postoperative pathology and quality, as well as overall patient survival outcomes, were compared between OE and MIE. The use of MIE increased from 26.9% in 2010 to 36.3% in 2012 (P < 0.001). Of 3032 patients (2050 OE and 982 MIE) who were identified, propensity score matching (1:1) yielded 977 patients in each group. Mean lymph nodes examined were higher in the MIE group (16.3 vs 14.5, P < 0.001). However, final pathologic nodal stage was not significantly different in the matched sample. There was also no difference in pathologic upstaging or margin status between the groups. All other postoperative variables were equivalent, including an average length of stay of 14 days, unplanned readmission rate of 6.5%, and 30-day and 90-day mortality rates of 3% and 7%, respectively. There was no survival difference, with a median survival of 48.7 months for OE and 46.6 months for MIE (Kaplan-Meier analysis, P = 0.376). During the 3-year period analyzed, there were no significant differences in postoperative outcomes and quality metrics between OE and MIE. Although short-term outcomes are limited in the National Cancer Database, MIE appears to have equivalent oncological outcomes and survival when compared with the open approach.

Thyroid lobectomy is not sufficient for T2 papillary thyroid cancers

Background: Histologic subtypes of papillary thyroid cancer affect prognosis. The objective of this study was to examine whether survival is affected by extent of surgery for conventional versus follicular‐variant papillary thyroid cancer when stratified by tumor size. Methods: Using the National Cancer Data Base, we evaluated 33,816 adults undergoing surgery for papillary thyroid cancer from 2004 to 2008 for 1.0‐3.9 cm tumors and clinically negative lymph nodes. Conventional and follicular‐variant papillary thyroid cancers were divided into separate groups. Cox regression models stratified by tumor size were used to determine if extent of surgery affected overall survival. Results: A total of 30,981 patients had total thyroidectomy and 2,835 had thyroid lobectomy; 22,899 patients had conventional papillary thyroid cancer and 10,918 had follicular‐variant papillary thyroid cancer. On unadjusted KM analysis, total thyroidectomy was associated with improved survival for conventional (P = 0.02) but not for follicular‐variant papillary thyroid cancer patients (P = 0.42). For conventional papillary thyroid cancer, adjusted analysis showed total thyroidectomy was associated with improved survival for 2.0‐3.9 cm tumors (P = 0.03) but not for 1.0‐1.9 cm tumors (P = 0.16). For follicular‐variant, lobectomy and total thyroidectomy had equivalent survival for 1.0‐1.9 cm (P = 0.45) and 2.0‐3.9 cm (P = 0.88) tumors. Conclusion: Tumor size, histologic subtype, and surgical therapy are important factors in papillary thyroid cancer survival. Total thyroidectomy was associated with improved survival in patients with 2.0‐3.9 cm conventional papillary thyroid cancer, and should be considered for 2.0‐3.9 cm papillary thyroid cancers when preoperative molecular analysis is not used to distinguish conventional from follicular‐variant.

Neoadjuvant Chemoradiation Shows No Survival Advantage to Chemotherapy Alone in Stage IIIA Patients

BACKGROUND For operable patients with clinical stage IIIA non-small cell lung cancer, the optimum neoadjuvant treatment strategy remains unclear. Our aim was to compare perioperative and long-term outcomes for patients receiving neoadjuvant chemoradiotherapy (NCRT) versus neoadjuvant chemotherapy (NCT) alone. METHODS We queried the National Cancer Database to identify all patients with N2 and either T1-T2 non-small cell lung cancer who received either NCRT or NCT followed by lobectomy between 2006 and 2012. Patients with T3 tumors were excluded. A propensity match analysis was performed incorporating preoperative variables, and the incidence of postoperative complications, pathologic downstaging, and long-term survival were compared. RESULTS In all, 1,936 patients met criteria, 745 NCT and 1,191 NCRT. The NCRT patients were younger, less likely to be treated at an academic medical center, and more likely to have adenocarcinoma. After propensity matching, patients in the NCT group showed lower 30-day mortality (1.3% versus 2.9%) and 90-day mortality (2.9% versus 6.0%), and were more likely to undergo a minimally invasive resection (25.7% versus 14.1%). The NCRT patients were more likely to have a pathologic complete response (14.2% versus 4.0%) and to be N0 at the time of resection (45.2% versus 38.7%). In the multivariable analysis, NCRT patients were at a greater risk of mortality than NCT patients (hazard ratio 1.18, 95% confidence interval: 1.03 to 1.36). CONCLUSIONS In our cohort, combined neoadjuvant chemotherapy and radiation therapy was associated with improved pathologic downstaging but showed increased perioperative mortality with no improvement in long-term overall survival. For stage IIIA patients with smaller tumors without local invasion, chemotherapy alone may be the preferred neoadjuvant treatment.

Health Disparities Impact Expected Treatment of Pancreatic Ductal Adenocarcinoma Nationally

Background and PurposeNational adherence to treatment guidelines for pancreatic ductal adenocarcinoma (PDAC) is a concern. This study aims to evaluate national expected treatment (ET) adherence for all PDAC stages. We hypothesized that both patient and hospital demographics are associated with national ET disparities for PDAC.MethodsClinical stage I through IV PDAC patients were evaluated using the National Cancer Data Base from 2004 to 2013. ET was defined as surgery for stage I/II, chemotherapy or radiation for stage III, and chemotherapy for stage IV. Unexpected treatment (UT) was defined as no surgery for stage I/II, surgery for stage III, and radiation or surgery for stage IV. No treatment is denoted by NT.Results171,351 patients were identified, of whom 56,589 (33.0%) were stage I/II, 23,459 (13.7%) were stage III, and 91,303 (53.3%) were stage IV. Of patients, 48.4% received ET, 14.7% received UT, and 36.9% received NT. ET rates were 41.1% for stage I/II, 65.4% for stage III, and 48.5% for stage IV patients. On multivariable analysis, older age, non-White race, lower socioeconomic status, being uninsured or Medicaid, increased comorbidities, nonacademic centers, and low-volume hospitals were independent negative predictors of receiving ET (P < 0.01). On subgroup analysis, high-volume academic centers had similar negative predictors of ET despite higher ET adherence overall (P < 0.01).ConclusionsPatient and hospital factors impact ET of PDAC on a national level. These treatment disparities for PDAC are concerning, even at high-volume academic centers. Future studies need to identify the causes of treatment disparities for PDAC with intervention measures aimed to relieve treatment disparities.

CONCORDANCE OF PRE-OPERATIVE CLINICAL STAGE WITH PATHOLOGIC STAGE IN PATIENTS ≥45 YEARS OLD WITH WELL-DIFFERENTIATED THYROID CANCER

OBJECTIVE Clinical stage (cStage) in thyroid cancer determines extent of surgical therapy and completeness of resection. Pathologic stage (pStage) is an important determinant of outcome. The rate of discordance between clinical and pathologic stage in thyroid cancer is unknown. METHODS The National Cancer Data Base was queried to identify 27,473 patients ≥45 years old with cStage I through IV differentiated thyroid cancer undergoing surgery from 2008-2012. RESULTS There were 16,286 (59.3%) cStage I patients; 4,825 (17.6%) cStage II; 4,329 (15.8%) cStage III; and 2,013 (7.3%) cStage IV patients. The upstage rate was 15.1%, and the downstage rate was 4.6%. For cStage II, there was a 25.5% upstage rate. The change in cStage was a result of inaccurate T-category in 40.8%, N-category in 36.3%, and both in 22.9%. On multivariate analysis, the patients more likely to be upstaged had papillary histology, tumors 2.1 to 4 cm, total thyroidectomy, nodal surgery, positive margins, or multifocal disease. Upstaged patients received radioiodine more frequently (75.3% vs. 48.1%; P<.001). CONCLUSION Approximately 20% of cStage is discordant to pStage. Certain populations are at risk for inaccurate staging, including cT2 and cN0 patients. Upstaged patients are more likely to receive radioactive iodine therapy. ABBREVIATIONS CI = confidence interval; cStage = clinical stage; DTC = differentiated thyroid cancer; NCDB = National Cancer Data Base; OR = odds ratio; pStage = pathologic stage; RAI = radioactive iodine.