Textbook Outcome and Survival in Patients With Gastric Cancer: An Analysis of the Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO).

OBJECTIVE: To examine the association between Textbook Outcome (TO)-a new composite quality measurement-and long-term survival in gastric cancer surgery. BACKGROUND: Single-quality indicators do not sufficiently reflect the complex and multifaceted nature of perioperative care in patients with gastric adenocarcinoma. METHODS: All patients undergoing gastrectomy for nonmetastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO) between 2004 and 2015 were included. TO was defined according to negative margins; >15 lymph nodes sampled; no severe complications; no re-interventions; no unplanned ICU admission; length of stay ≤21 days; no 30-day readmission; and no 30-day mortality. Three-year survival was estimated using the Kaplan-Meier method. A marginal multivariable Cox proportional-hazards model was used to estimate the association between achieving TO metrics and long-term survival. E-value methodology was used to assess for risk of residual confounding. RESULTS: Of the 1836 patients included in this study, 402 (22%) achieved all TO metrics. TO patients had a higher 3-year survival rate compared to non-TO patients (75% vs 55%, log-rank P < 0.001). After adjustments for covariates and clustering within hospitals, TO was associated with a 41% reduction in mortality (adjusted hazards ratio 0.59, 95% confidence interval 0.48, 0.72, P < 0.001). These results were robust to potential residual confounding. CONCLUSIONS: Achieving TO is strongly associated with improved long-term survival in gastric cancer patients and merits further focus in surgical quality improvement efforts.

The cost of chemotherapy administration: a systematic review and meta-analysis.

PURPOSE: Cancer treatment is a significant driver of healthcare costs worldwide, however, the economic impact of treating patients with anti-neoplastic agents is poorly elucidated. We conducted a systematic review and meta-analysis to estimate the direct costs associated with administering intravenous chemotherapy in an outpatient setting. METHODS: We systematically searched four databases from 2010 to present and extracted hourly administration costs and the respective components of each estimate. Separate analyses were conducted of Canadian and United States (US) studies, respectively, to address a priori hypotheses regarding heterogeneity amongst estimates. The Drummond checklist was used to assess risk-of-bias. Data were summarized using medians with interquartile ranges and five outliers were identified; costs were presented in 2019 USD. RESULTS: Forty-four studies were analyzed, including sub-analyses of 19 US and seven Canadian studies. 26/44 studies were of moderate-high quality. When components of administration cost were evaluated, physician costs were reported most frequently (24 studies), followed by lab tests (13) and overhead costs (9). The median estimate (excluding outliers) was $142/hour (IQR = $103-166). The median administration cost in the US was $149/hour (IQR = $118-158), and was $128/hour (IQR = $102-137) in Canada. CONCLUSIONS: There is currently a paucity of literature addressing the costs of chemotherapy administration, and existing studies utilize a patchwork of reporting methodologies which renders direct comparison challenging. Our results demonstrate that the cost of administering chemotherapy is approximately $125-150/hour, globally. This value is dependent upon the region of analysis, inclusiveness of cost subcomponents as well as the methodology used to estimate unit prices, as described here.

Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO): protocol for a multicentre clinical and pathological database including 25 000 patients.

INTRODUCTION: Oesophagogastric cancers carry a high mortality, economic burden and rising incidence. There is a need to monitor and improve care for this disease. Pathologic information is a cornerstone of cancer diagnosis, treatment and prognosis. Few population-based studies combine pathology information and clinical outcomes. The objective of this study is to develop a clinical and pathological database of oesophagogastric cancers to study practice patterns, resource utilisation and clinical outcomes. METHODS AND ANALYSIS: The Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO) will include all patients with oesophagogastric cancer diagnosed from 2002 onwards within the province of Ontario. We estimate that the sample over the first 14 years of the study will include 26 000 patients. Pathologic information from diagnostic procedures, endomucosal resection specimens and surgical resection specimens is being abstracted into a purpose-built database. Pathology information will be linked to administrative data, which capture baseline demographics, patient-reported symptoms, physician billings, hospital visits, hospital characteristics, geography and vital statistics. The registry will be updated prospectively. ETHICS AND DISSEMINATION: Ethics approval for this study was obtained from the Sunnybrook Health Sciences Centre Research Ethics Board. The PRESTO database will enable the study of oesophagogastric cancer in Ontario under six themes of inquiry: treatment, surgical outcomes, pathology, survival, health system and resource utilisation and cost. This information will be a valuable addition to the global efforts to understand ways to optimise care for these diseases.

Gastrectomy case volume and textbook outcome: an analysis of the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO).

OBJECTIVE: To determine the association between gastric cancer surgery case-volume and Textbook Outcome, a new composite quality measurement. BACKGROUND: Textbook Outcome included (a) negative resection margin, (b) greater than 15 lymph nodes sampled, (c) no severe complication, (d) no re-intervention, (e) no unplanned ICU admission, (f) length of stay of 21 days or less, (g) no 30-day readmission and (h) no 30-day mortality following surgery. METHODS: All patients undergoing gastrectomy for non-metastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario between 2004 and 2015 were included. We used multivariable generalized estimating equation (GEE) logistic regression modelling to estimate the association between gastrectomy volume (surgeon and hospital annual volumes) and Textbook Outcome. Volumes were considered as continuous variables and quintiles. RESULTS: Textbook Outcome was achieved in 378 of 1660 patients (22.8%). The quality metrics least often achieved were inadequate lymph node sampling and presence of severe complications, which occurred in 46.1% and 31.7% of patients, respectively. Accounting for covariates and clustering, neither surgeon volume nor hospital volume were significantly associated with Textbook Outcome. However, hospital volume was associated with adequate lymphadenectomy and fewer unplanned ICU admissions. CONCLUSIONS: Higher case volume can impact certain measures of quality of care but may not address all care structures necessary for ideal Textbook recovery. Future quality improvement strategies should consider using case-mix adjusted Textbook Outcome rates as a surgical quality metric.

Pediatric thyroid FNA biopsy: Outcomes and impact on management over 24 years at a tertiary care center.

BACKGROUND: Thyroid malignancy is rare in young children, although the incidence increases sharply during adolescence. Nodular thyroid disease and thyroid cancer in children differ substantially from those in adults, because the rates of malignancy among children are roughly 5-fold higher, and local and distant metastases as well as recurrences are more common. Even with the recent introduction of pediatric guidelines, there remains a paucity of pediatric data on which to base clinical decision making. The objectives of this study were to characterize the outcomes of fine-needle aspiration biopsy (FNAB) of nodular thyroid disease at a pediatric tertiary-care institution over a 24-year period and to relate cytopathology to histopathology and management decisions in this population. METHODS: A retrospective review of patients who underwent preoperative FNAB and thyroid surgery between 1992 and 2015 was conducted. In total, 207 nodules were biopsied among 178 patients. RESULTS: Adequate FNAB samples were obtained in 74% of biopsies. Sixty-five patients underwent thyroidectomy after FNAB. In this group, the malignancy rates for lesions deemed benign, atypical, suspicious, and malignant on FNAB cytology were 16%, 67%, 71%, and 100%, respectively. Twenty-seven individuals underwent >1 biopsy; however, no malignancies were identified in these patients. Surprisingly, the rate of malignancy in patients who underwent preoperative FNAB was not significantly different from the rate in those who proceeded directly to surgery (n = 146). CONCLUSIONS: FNAB remains a valuable tool for preoperative assessment of pediatric thyroid nodules. When samples are adequate for assessment, cytology other than clearly "benign" merits referral for diagnostic or therapeutic thyroidectomy. In this series, FNAB did not reduce rates of surgery for benign disease. Cancer Cytopathol 2016;124:801-10. © 2016 American Cancer Society.