Factors Associated with Receipt of Adjuvant Chemotherapy in Stage II Colon Cancer.

BACKGROUND: The benefits of chemotherapy in stage II colon cancer remain unclear, but it is recommended for high-risk stage II disease. Which patients receive chemotherapy and its impact on survival remains undetermined. METHODS: The National Cancer Database was surveyed between 2004 and 2016 for stage II colon cancer patients. Patients were categorized as high- or average-risk as defined by the National Comprehensive Cancer Network. The demographic characteristics of high- and average-risk patients who did and did not receive chemotherapy were compared using univariate and multivariable analyses. The survival of high- and average-risk patients was compared based on receipt of chemotherapy with Cox hazard ratios and Kaplan-Meier curves. RESULTS: Overall, 84,424 patients met the inclusion criteria. A total of 34,868 patients were high-risk and 49,556 were average-risk. In high-risk patients, the risk factors for not receiving chemotherapy included increasing age, distance from the treatment facility, Charlson-Deyo score, and lack of insurance. In average-risk patients, factors associated with receipt of chemotherapy were decreasing age, distance from the treatment facility, Charlson-Deyo score, and non-academic association of the treatment facility. In both, chemotherapy was significantly associated with increased survival on the Kaplan-Meier curve. In the Cox hazard ratio, only high-risk patients benefited from chemotherapy (hazard ratio 1.183, confidence interval 1.116-1.254). CONCLUSIONS: Factors associated with not receiving chemotherapy in high-risk stage II colon cancers included increasing age, medical comorbidities, increasing distance from the treatment facility, and lack of insurance. Chemotherapy is associated with improved overall survival in high-risk patients.

An analysis of publications originating from abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting.

BACKGROUND: Research presentation has benefits, including CV building, networking, and collaboration. A measurable standard for achievement is publication in a peer-reviewed journal. Expectations regarding the likelihood of publication are unknown for studies presented at a national surgical scientific meeting. This study aims to evaluate predictors of manuscript publication arising from abstracts presented at a national surgical scientific meeting. METHODS: Abstracts presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting 2019 were reviewed. Identification of published manuscripts was completed using MedLine, Embase, and Google Scholar 28 months after the presentation to allow for time for publication. Factors evaluated for association with publication included author and abstract measures. Descriptive analyses and multivariable statistics were performed. RESULTS: 724 abstracts (160 podiums, 564 posters) were included. Of the podium presentations, 128 (80%) were published in a median of 4 months after the presentation. On univariable and multivariable analyses, there was no association between publication and abstract topic, gender, degree, number of publications, or H-indices of first and senior authors. 154 (27.3%) poster presentations were published with a median of 13 months. On univariable analysis, there was a statistically significant difference regarding the abstract topic (p = 0.015) and senior author degree (p = 0.01) between published and unpublished posters. Multivariable analysis demonstrated that colorectal surgery (OR 2.52; CI 1.02-6.23) and metabolic/obesity (OR 2.53; CI 1.09-5.84) are associated with an increased odd of publication. There was an inverse association with female senior authors (OR 0.53; CI 0.29-0.98), while additional degrees (e.g., doctorate and/or master's degree) of the senior authors were associated with an increased publication rate (OR 1.80; CI 1.00-3.22). CONCLUSION: 80% of podiums but only 27% of posters were ultimately published. While some predictors of poster publication were noted, it is unclear if these are why these projects fail to publish. Future research is warranted to determine if there are effective strategies to increase poster publication rates.

General Surgery Residents' Retention of Knowledge After an Anorectal Skills Workshop.

INTRODUCTION: Studies have demonstrated suboptimal resident exposure to anorectal pathology. A workshop was developed at an academic general surgery residency. This study assesses durability of learning from the workshop. METHODS: Thirty-six residents participated in a skills laboratory addressing diagnosis and management of anorectal complaints. The skills laboratory was broken into didactic and hand-on skills stations. Residents completed pre-, post- and 6-mo after workshop assessments to evaluate knowledge and confidence. Knowledge and confidence-based scores pre-, post- and 6-mo after workshop were compared. RESULTS: Scores demonstrated retention of information. Knowledge-based question median scores improved from 63.2% pre-workshop to 73.7% post-workshop and 76.3% at 6 mo (P = 0.0005). Median confidence scores improved from 31 pre-workshop to 40 post-workshop, and were stable at 6 mo (P = 0.0001). CONCLUSIONS: Knowledge and confidence gained from an anorectal skills workshop was stable or improved at 6 mo. These results suggest that an anorectal curriculum is effective at improving general surgery resident background knowledge and confidence when managing anorectal complaints.

Primary Colorectal Tumor Location and Predictors for Metastasis to the Brain.

Introduction Although rectal cancer is thought to have a higher rate of metastasis to the brain compared with colon cancer, there is limited and contradictory data on the subject. This study aims to determine the prevalence of brain metastasis for colon and rectal cancers (CRC), and to explore associations and predictors of brain metastasis (BM). Methods The 2010-2016 National Cancer Database (NCDB) was queried for patients with stage IV CRC. Patients with missing data on site of metastasis and primary tumor location were excluded. Chi-square test was used for categorical data and multivariate logistic regression analysis was performed to evaluate the predictors of BM. Results Of 108,540 stage IV CRC patients, the prevalence of BM was 1.21% from the right colon, 1.29% from the left colon, and 1.59% from the rectal adenocarcinoma (p<0.001). The presence of lung, bone, and liver metastases were the strongest predictors for BM. Bone and lung metastases increased the odds for BM by 3.87 (95% CI: 3.36-4.46) and 3.38 (95% CI: 3.01-3.80), respectively while the presence of liver metastasis decreased odds for BM by 55% (OR: 0.45; 95% CI: 0.40-0.50). On multivariate analysis, primary tumor location was not predictive of BM. Discussion This study helps to characterize the prevalence and associations of BM from CRC using the NCDB. The correlation between BM and bone and lung metastases, along with negative association of liver metastasis further supports the hypothesis of systemic transmission of tumor cells. Further identification of predictors and correlations with BM may help guide surveillance among patients with advanced CRC.

Standardized Letter of Recommendation: Can Everyone Be Awesome?

OBJECTIVE: Standardized letters of recommendation (SLOR) are hypothesized to decrease bias and provide consistent domains for evaluation. However, their ability to differentiate among applicants is unknown. The utilization and functionality of SLOR and the impact of SLOR domain rating on matching for colon and rectal surgery (CRS) residency applicants have yet to be assessed. DESIGN: Descriptive statistics and bivariate analysis were employed. Applicants were categorized into 3 groups; Top-tier(TT): applicants rated 100% Excellent/Very Good; Mid-Tier(MT) applicants rated 80-99% Excellent/Very Good; and Non-Top Tier(NTT) applicants rated <80% Excellent/Very Good. SETTING: University of Hospitals Cleveland Medical Center. PARTICIPANTS: SLORs submitted to a single colorectal surgery residency in 2019 were analyzed RESULTS: A total of 101 applicants were included, 54 (53.5%) of the applicants were male. 75 (74.2%) applicants who applied to our residency matched into a CRS residency, compared to the national rate of 66%. Of the 101 applicants with SLOR, 54 (53.5%) were categorized as TT, 26 (25.7%) as MT, and 21(20.8%) as NTT. The univariable analysis demonstrated a statistically significant difference in research experience (p=0.029) and match status (p=0.01) between applicant tiers. There were no statistically significant differences between applicant-tier and demographics, foreign medical graduates (FMG), H-indices, ABSITE scores, type of residency, preliminary year, completing an unaccredited CRS, and applicants with an additional degree. On multivariable analysis age (OR=0.65; CI=0.48-0.87) and FMG applicants (OR=0.05; CI=0.01-0.44) were inversely associated with successfully matching. Compared to TT applicants, MT (OR=0.07; CI=0.01-0.57) and NTT (OR=0.04; CI=0.01-0.34) applicants were inversely associated with a successful match. Individuals who completed research prior to residency but after medical school was associated with successfully matching (p=0.009). CONCLUSIONS: The presence of MT and NTT ratings is associated with failure to match and may represent an area of concern for CRS programs rather than a tool to discern differences between candidates.

Sarcopenia in Patients With Rectal Adenocarcinoma: An Opportunity for Preoperative Rehabilitation.

BACKGROUND: Sarcopenia, defined as low skeletal muscle mass, affects up to 60% of rectal adenocarcinoma patients receiving neoadjuvant chemoradiation (NACRT), with negative impact on patient outcomes. Identifying modifiable risk factors may decrease morbidity and mortality. METHODS: A retrospective review of rectal cancer patients from a single academic center from 2006 to 2020 was performed. Sixty-nine patients with pre- and post-NACRT CT imaging were included. Skeletal muscle index (SMI) was calculated as total L3 skeletal muscle divided by height squared. Sarcopenia thresholds were 52.4 cm2/m2 for men and 38.5 cm2/m2 for women. Student T-test, chi-square test, multivariable regression, and multivariable Cox hazard analysis were performed. RESULTS: 62.3% of patients lost SMI from pre- to post-NACRT imaging, with a mean change of -7.8% (±19.9%). Eleven (15.9%) patients were sarcopenic at presentation, increasing to 20 (29.0%) following NACRT. Mean SMI decreased from 49.0 cm2/m2 (95% CI: 42.0 cm2/m2-56.0 cm2/m2) to 38.2 cm2/m2 (95% CI: 33.6 cm2/m2-42.9 cm2/m2) (P = .003). Pre-NACRT sarcopenia correlated with post-NACRT sarcopenia (OR 20.6, P = .002). Percent decrease in SMI was associated with a 5% increased mortality risk. CONCLUSION: The presence of sarcopenia at diagnosis and its association with post-NACRT sarcopenia suggests an opportunity for a high-impact intervention.

Lymph node yield after rectal resection is a predictor of survival among patients with node-negative rectal adenocarcinoma.

BACKGROUND: Pathologic review of at least 12 lymph nodes is recommended by the American Joint Committee on Cancer following surgical resection of rectal cancer. However, implications of lymph node yield on prognosis are unclear. This study evaluates the impact of lymph node yield on survival among pathologic node-negative patients who received appropriate neoadjuvant chemoradiation. METHODS: The National Cancer Database from 2010 to 2016 was queried for clinical stage II and III rectal adenocarcinoma with neoadjuvant chemoradiation, resection of the primary tumor, negative surgical margins, and pN0M0 pathologic stage. Data were analyzed with χ2, student's t test, or Mann-Whitney U test as appropriate. Propensity score matching controlled for clinicodemographic variation. Survival was estimated with Kaplan-Meier curves and Cox hazards analysis. RESULTS: Inadequate lymph node yield (1-11 nodes on pathology) led to a 29% increased risk of mortality compared to adequate lymph node yield (≥12 nodes on pathology). Among patients with an incomplete pathologic complete response to neoadjuvant therapy, 5-year survival was estimated to be 73% for inadequate lymph node yield and 78% for adequate lymph node yield (P = .002). Among patients with a complete pathologic response, 5-year survival estimated to be 82% for inadequate lymph node yield and 90% for adequate lymph node yield (P = .006). Among patients with inadequate lymph node yield and complete pathologic response, 5-year survival improved with the use of adjuvant chemotherapy (90.4%), compared to those without adjuvant chemotherapy (78.5%, P < .001). CONCLUSION: These findings suggest an inadequate lymph node yield can negatively impact survival, despite negative nodal status and a pathologic complete response to neoadjuvant therapy.

Functional Not Medical Frailty Is Associated With Long-Term Disability After Surgery for Colorectal Cancer.

BACKGROUND: Frailty has been associated with increased morbidity after surgery. However, few studies investigate long-term functional outcomes. METHODS:  Patients ≥ 65 years old who underwent surgery for colorectal cancer were surveyed regarding their ability to perform activities of daily living, measured by Barthel Index, before and after surgery. Patients also reported time to return to their functional baseline. RESULTS: Pre-operative moderate dependency was associated with declining function at six months (OR: 8.8; CI: 1.8-42.6) and one year post-operatively (OR: 17.5; CI: 2.8-109.8). Pre-operative functional frailty was associated with subjective failure to return to baseline (OR: 4.8 and 4.2) for slightly and moderately dependent patients and a longer time to return to baseline. Medical frailty, based on the modified Frailty Index, was not significantly associated with failure to return to baseline. CONCLUSIONS: Measures of functional frailty are better predictors of failure to return to baseline, than measures of medical frailty.

Predictors of curative-intent oncologic management among patients with stage IV rectal cancer.

BACKGROUND: Management of stage IV rectal adenocarcinoma is categorized into curative and palliative-intent strategies. The aim of this study is to determine the incidence of and associations with curative-intent treatment in stage IV rectal cancer. METHODS: The National Cancer Database from 2010 to 2016 was queried for patients with stage IV rectal adenocarcinoma and were grouped into curative-intent and non-curative management. Multivariable logistic regression was used to predict use of curative-intent management. RESULTS: 16,862 patients were included in this study: 4886 (30.0%) curative-intent and 11,975 (71.0%) non-curative. Multivariable regression demonstrated curative intent was associated with young age, female gender, white race, private insurance, mucinous histology and anaplastic grade. CONCLUSION: Use of curative intent oncologic management among patients with stage IV rectal adenocarcinoma is influenced by age, tumor biology and location of metastatic disease. Association with gender and insurance imply the presence of disparity in the delivery of cancer care among this patient population.

Evaluation of Demographics and Management of Rectal Cancer by Age Group: A Retrospective Propensity Matched Cohort Analysis of the National Cancer Database.

Background Data suggests there are demographic and biological differences in colon cancer between young and typical-onset patients. However, it is unclear if these differences persist in rectal cancer patients, exclusive of colon cancer. This is a retrospective review of a large national database to evaluate age-based differences in demographics, tumor features, and treatment among patients with rectal adenocarcinoma. Methods The National Cancer Database from 2004-2014 was queried for rectal adenocarcinoma. Patients were grouped by age at diagnosis: early-onset, defined as <40 years, mid-onset 40-49, and late-onset ≥50. Propensity matching controlled for demographic variation among cohorts. Pairwise Chi-square with Bonferroni correction was used for analysis. Results Thirty thousand nine hundred seventy-eight patients were included: 1,249 (4%) early-onset, 4,156 (13%) middle-onset, and 25,573 (83%) late-onset. Significant differences existed between all three cohorts in nearly all demographic and pathologic metrics. Control for demographic variation revealed early-onset and middle-onset cohorts differed only with respect to the stage at presentation, while early-onset and late-onset cohorts differed more significantly on the basis of stage, histology, and oncologic management. Conclusion The demographic differences observed demonstrate that patients under 50 should not be considered one cohort. Propensity matching led to a decrease in tumor trait differences among cohorts, suggesting that demographics other than age drive variation in tumor biology. Young patients received more aggressive management, implying the presence of an age bias. Age-based screening is likely insufficient and may exclude the rising proportion of young patients at risk for disease, while age-based management may lead to under- or overtreatment of patients at either end of the age spectrum.

More to the picture of the psychological impact of endocarditis and thoracic aortic pathology.

Over the years there has been substantial advanced in the diagnosis and surgical management of complex thoracic aortic disease and complex endocarditis. As these therapies are being offered to a growing segment of patients-and more and more patients are felt to potentially benefit from such therapies, the long-term consequences of these interventions is sometimes poorly understood. While traditional medical complications, such as stroke, renal failure, respiratory failure, and even death are often the focus of outcomes studies, little is known on the impact of these diseases and therapies on mental health. This commentary emphasizes the importance of better understanding the psychologic impact of endocarditis and thoracic aortic pathology as reviewed by Dr. Bagnasco.