Axillary de-escalation after neoadjuvant chemotherapy for advanced lymph node involvement in breast cancer.

INTRODUCTION: Sentinel lymph node biopsy reduces morbidity in patients with clinically node-positive breast cancer who achieve axillary pathologic complete response following neoadjuvant therapy (NACT). De-escalation trials primarily addressed cN1 disease, with underrepresentation of cN2 disease. This study evaluates the role of de-escalation in patients with cN2 breast cancer. METHODS: A retrospective analysis of the National Cancer Database (2013-2020) included women over 18 with T1-2 invasive breast cancer and clinical N2 disease who received NACT followed by ALND or SLNB then ALND. The primary outcome was pathologic nodal status post-NACT. RESULTS: Of 5852 cN2 patients treated, 18.15 â€‹% achieved ypN0, 0.97 â€‹% had isolated tumor cells, 19.14 â€‹% were ypN1, 49.64 â€‹% were ypN2, and 12.20 â€‹% were ypN3 following NACT. Achieving ypN0 was associated with pCR in the breast, HER2-positive and triple-negative receptor status, cT2 tumors, and younger age. CONCLUSION: Despite some patients with cN2 disease achieving ypN0, most exhibited residual axillary disease post-NACT. These findings indicate that axillary de-escalation may not be feasible for most patients with cN2 disease, underscoring the importance of meticulous patient selection and assessment.

Outcomes of carotid revascularization stratified by procedure in patients with an estimated glomerular filtration rate of <30 and dialysis patients.

OBJECTIVE: Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis. METHODS: Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. RESULTS: In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P = .049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P = .001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P = .011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P < .001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P = .3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P < .001). CONCLUSIONS: CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.

Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy.

OBJECTIVE: This study utilizes the latest data from the Vascular Quality Initiative (VQI), which now encompasses over 50,000 transcarotid artery revascularization (TCAR) procedures, to offer a sizeable dataset for comparing the effectiveness and safety of TCAR, transfemoral carotid artery stenting (tfCAS), and carotid endarterectomy (CEA). Given this substantial dataset, we are now able to compare outcomes overall and stratified by symptom status across revascularization techniques. METHODS: Utilizing VQI data from September 2016 to August 2023, we conducted a risk-adjusted analysis by applying inverse probability of treatment weighting to compare in-hospital outcomes between TCAR vs tfCAS, CEA vs tfCAS, and TCAR vs CEA. Our primary outcome measure was in-hospital stroke/death. Secondary outcomes included myocardial infarction and cranial nerve injury. RESULTS: A total of 50,068 patients underwent TCAR, 25,361 patients underwent tfCAS, and 122,737 patients underwent CEA. TCAR patients were older, more likely to have coronary artery disease, chronic kidney disease, and undergo coronary artery bypass grafting/percutaneous coronary intervention as well as prior contralateral CEA/CAS compared with both CEA and tfCAS. TfCAS had higher odds of stroke/death when compared with TCAR (2.9% vs 1.6%; adjusted odds ratio [aOR], 1.84; 95% confidence interval [CI], 1.65-2.06; P < .001) and CEA (2.9% vs 1.3%; aOR, 2.21; 95% CI, 2.01-2.43; P < .001). CEA had slightly lower odds of stroke/death compared with TCAR (1.3% vs 1.6%; aOR, 0.83; 95% CI, 0.76-0.91; P < .001). TfCAS had lower odds of cranial nerve injury compared with TCAR (0.0% vs 0.3%; aOR, 0.00; 95% CI, 0.00-0.00; P < .001) and CEA (0.0% vs 2.3%; aOR, 0.00; 95% CI, 0.0-0.0; P < .001) as well as lower odds of myocardial infarction compared with CEA (0.4% vs 0.6%; aOR, 0.67; 95% CI, 0.54-0.84; P < .001). CEA compared with TCAR had higher odds of myocardial infarction (0.6% vs 0.5%; aOR, 1.31; 95% CI, 1.13-1.54; P < .001) and cranial nerve injury (2.3% vs 0.3%; aOR, 9.42; 95% CI, 7.78-11.4; P < .001). CONCLUSIONS: Although tfCAS may be beneficial for select patients, the lower stroke/death rates associated with CEA and TCAR are preferred. When deciding between CEA and TCAR, it is important to weigh additional procedural factors and outcomes such as myocardial infarction and cranial nerve injury, particularly when stroke/death rates are similar. Additionally, evaluating subgroups that may benefit from one procedure over another is essential for informed decision-making and enhanced patient care in the treatment of carotid stenosis.

Learning curve of transfemoral carotid artery stenting in the Vascular Quality Initiative registry.

OBJECTIVE: With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data. METHODS: We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians. RESULTS: We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. CONCLUSIONS: In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.

An Analysis of Trainee Status of the Primary Care Physician and Ambulatory Care Outcomes.

PURPOSE: Prior studies report disparities in outcomes for patients cared for by trainees versus faculty physicians at academic medical centers. This study examined the effect of having a trainee as the primary care physician versus a faculty member on routine population health outcomes after adjusting for differences in social determinants of health and primary care retention. METHOD: This cohort study assessed 38,404 patients receiving primary care at an academic hospital-affiliated practice by 60 faculty and 110 internal medicine trainees during academic year 2019. The effect of primary care practitioner trainee status on routine ambulatory care metrics was modeled using log-binomial regression with generalized estimating equation methods to account for physician-level clustering. Risk estimates before and after adjusting for social determinants of health and loss to follow-up are presented. RESULTS: Trainee and faculty cohorts had similar distributions of acute illness burden; however, patients in the trainee cohort were significantly more likely to identify as a race other than White (2,476 [52.6%] vs 14,785 [38.5%], P < .001), live in a zip code associated with poverty (1,688 [35.9%] vs 9,122 [23.8%], P < .001), use public health insurance (1,021 [21.7%] vs 6,108 [15.9%], P < .001), and have limited English proficiency (1,415 [30.1%] vs 5,203 [13.6%], P < .001). In adjusted analyses, trainee status of primary care physician was not associated with lack of breast cancer screening but was associated with missed opportunities to screen for colorectal cancer (relative risk [RR], 0.77; 95% confidence interval [CI], 0.68-0.88), control type 2 diabetes mellitus (RR, 0.78; 95% CI, 0.64-0.94), and control hypertension (RR, 0.80; 95% CI, 0.69-0.94). CONCLUSIONS: Primary care physician trainee status was associated with poorer quality of care in the ambulatory setting after adjusting for differences in socioeconomic factors and loss to follow-up, highlighting a potential ambulatory training gap.

Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021.

Introduction: Substantial barriers to screening exist for medically underserved populations, especially adults with limited English proficiency (LEP). We examined the proportion of US adults aged 45-75 up-to-date with colorectal cancer (CRC) screening by LEP after 2018. The American Cancer Society began recommending CRC screening for adults 45-49 in 2018. Methods: We analyzed cross-sectional data of adults 45-75 years old participating in the 2019 or 2021 National Health Interview Survey (N = 25,611). Adults were considered up-to-date with screening if they reported any stool test within 1 year, stool-DNA testing within 3 years, or colonoscopy within 10 years. Adults who interviewed in a language other than English were considered to have LEP. Adults not up-to-date with screening were asked if a healthcare professional (HCP) recommended screening, and if so which test(s). Regression models conducted in 2022-2023 evaluated receipt of screening, adjusting for sociodemographics, year, and healthcare access. Results: Overall, 54.0 % (95 % CI 53.1-54.9 %) of participants were up-to-date with screening (9.4 % aged 45-49 vs 75.5 % aged 65-75); prevalence increased from 2019 (52.9 %) to 2021(55.2 %). Adults with LEP (vs English proficiency) were less likely to be up-to-date with screening (31.6 % vs. 56.8 %, [aPR 0.86 (0.77-0.96)]). Among adults not up-to-date, 15.0 % reported their HCP recommended screening (8.4 % among adults with LEP). Conclusions: Nearly half of US adults were not up-to-date with CRC screening in 2019 and 2021 and few reported being recommended screening. Adults with LEP and those 45-49 were least likely to be screened suggesting targeted interventions are needed for these populations.