Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multistate Evaluation.

BACKGROUND: Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown. OBJECTIVE: This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income. DESIGN: Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted. SETTINGS: State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used. PATIENTS: This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery. MAIN OUTCOME MEASURES: Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed. RESULTS: Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1). LIMITATIONS: The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery. CONCLUSIONS: Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 . DISPARIDADES PERSISTENTES EN EL ACCESO A LA CIRUGA ELECTIVA DEL CNCER COLORRECTAL DESPUS DE LA EXPANSIN DE MEDICAID EN VIRTUD DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO UNA EVALUACIN MULTIESTATAL: ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.

Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes.

INTRODUCTION: Minimally invasive surgery (MIS) for colorectal cancer (CRC) is increasingly common; however, uptake has differed by hospital type. It is unknown how these trends have evolved for laparoscopic or robotic approaches in different types of hospitals. This study assesses temporal trends for MIS utilization and examines differences in surgical outcomes by hospital type. METHODS: The National Cancer Database was queried for patients who underwent CRC surgery between 2010 and 2015. Time-trend analysis of MIS utilization was performed for both approaches by hospital type (community, comprehensive community, integrated network, academic). Multivariate logistic regression models were used to examine MIS utilization, differences in case severity, and surgical outcomes by hospital type, after controlling for patient characteristics. RESULTS: Across all hospital types, community hospitals had the lowest rate of laparoscopic (36.8%) and robotic (3.3%) procedures for CRC (P < 0.001). Community hospitals also exhibited a significant lag in adoption rate of robotic surgery (colon = 0.84% versus 1.41%/y; rectum = 2.14% versus 3.88 %/y). Community hospitals performing MIS had worse outcomes, including the most frequent conversions to open (colon = 15.2%; rectal = 17.1%) and highest 90-day mortality (colon = 6%; rectal = 3.2%) (P < 0.001). Finally, compared with laparoscopic colon surgery at academic centers, community centers treated lower grade tumors (OR 0.938, P < 0.05) with higher 30-day (OR 1.332, P < 0.05) and 90-day mortality (OR 1.210, P < 0.05). CONCLUSIONS: MIS for CRC lags at the community level and experiences worse postoperative outcomes. Future initiatives must focus on understanding and correcting this trend to ensure uniform access to high-quality surgical care.

Comparative Age-Based Prospective Multi-Institutional Observations of 12,367 Patients Enrolled to the American College of Surgeons Oncology Group (ACOSOG) Z901101 Trials (Alliance).

BACKGROUND: The risk of surgery, particularly for older cancer patients with serious, extensive comorbidities, can make this otherwise curative modality precarious. Leveraging data from the American College of Surgeons Oncology Group, this study sought to characterize age-based comparative demographics, adverse event rates, and study completion rates to define how best to conduct research in older cancer patients. METHODS: This study relied on clinical data from 21 completed studies to assess whether older patients experienced more grade 3 or worse adverse events and were more likely to discontinue study participation prematurely than their younger counterparts. RESULTS: The study enrolled 12,367 patients. The median age was 60 years, and 36% of the patients were 65 years of age or older. Among 4008 patients with adverse event data, 1067 (27%) had experienced a grade 3 or worse event. The patients 65 years or older had higher rates of grade 3 or worse adverse events compared to younger patients [32% vs. 24%; odds ratio (OR), 1.5; 95% confidence interval (CI), 1.3-1.7; p < 0.0001]. This association was not observed in multivariate analyses. The study protocol was completed by 97% of the patients. No association was observed between age and trial completion (OR 0.8; 95% CI 0.7-1.1; p = 0.14). Only the older gastrointestinal cancer trial patients were less likely to complete their studies compared to younger patients (OR 0.50; 95% CI 0.30-0.70; p < 0.0001). CONCLUSION: Despite higher rates of adverse events, the older patients typically completed the study protocol, thereby contributing relevant data on how best to render care to older cancer patients and affirming the important role of enrolling these patients to surgical trials.

Utilization of Left Ventricular Assist Devices in Vulnerable Adults Across Medicaid Expansion.

BACKGROUND: Continuous-flow left ventricular assist device (LVAD) implantation is a payor sensitive procedure influenced by preoperative comorbidities and social factors. Whether expansion in insurance coverage will further influence device utilization is unknown. This study sought to assess the effects of Medicaid expansion on vulnerable populations (namely racial-ethnic minorities and those with low-income status) undergoing continuous-flow LVAD implantation after the enactment of the 2014 Affordable Care Act (ACA). METHODS: Data from the 2012 to Q3 2015 State Inpatient Database were used to examine a cohort of 624 nonelderly adults (aged 18-64 y) who were given a continuous-flow LVAD in three expansion states (Kentucky, New Jersey, and Maryland) and two nonexpansion states (North Carolina and Florida). The cohort excluded patients who had a heart transplant, heart-lung transplant, or noncontinuous-flow LVAD. Poisson Interrupted Time Series was used with three-way interactions and change of slope and intercept parameters at 2014 to determine the impact of the ACA expansion on utilization of continuous-flow LVAD by race and insurance strata. RESULTS: Poisson Interrupted Time Series models show that within expansion states, the population of Medicaid and uninsured patients saw an increase in the utilization of LVAD's immediately after ACA expansion, from 2.8 in Q4 2013 to 9.83 Q1 2014 (incidence rate ratio [IRR] 5.26, P = 0.02). Utilization eventually declined to pre-ACA levels, however, ending with 3.04 LVADs in Q3 2015 (IRR 0.84, 95% confidence interval 0.58-1.20). Models testing for racial effect showed no statistically preferential or disparate effects (immediate effect IRR 1.608, P = 0.506; marginal effect IRR 0.897, P = 0.512). CONCLUSIONS: These findings show that despite expanded insurance coverage, the utilization of continuous-flow LVADs was not increased in nonelderly racial and ethnic minorities following the ACA Medicaid expansion. Although these findings are preliminary and require further long-term evaluation, they suggest that insurance coverage alone does not play a significant role in increased utilization of continuous-flow LVAD. These findings point toward the importance of further exploring social, medical, and hospital drivers of these disparities.

Underuse of exon mutational analysis for gastrointestinal stromal tumors.

BACKGROUND: Tyrosine kinase inhibitors (TKI) have become the guideline-recommended therapy for high-risk resected and advanced gastrointestinal stromal tumors (GISTs). Exon mutational analysis (EMA) is used to inform pretherapy response to TKI and may predict overall prognosis. Despite these benefits, EMA remains underused, and its impact on TKI therapy decision-making remains unexplored. MATERIALS AND METHODS: A retrospective cohort was established from 104 patients receiving treatment for GISTs from 2006 to 2017. Current National Comprehensive Cancer Network guidelines indicate that EMA should be considered for all patients undergoing TKI therapy to identify genotypes that are likely, or unlikely, to respond to treatment. We first tracked guideline-considered EMA use and subsequent impact on treatment decision-making. A questionnaire was then administered to gastrointestinal medical oncologists to assess EMA perception. RESULTS: Among 104 GIST patients, 54 (52%) received TKI therapy. Of these, only 22 (41%) received EMA. Informed by EMA, treatment decisions included 59% who continued with original TKI therapy, 32% who switched to an alternative TKI, and 9% who discontinued or received no TKI. Although 92% of physicians indicated EMA was a valuable tool, only 62% indicated they used it "frequently" or "always" to inform treatment decisions. CONCLUSIONS: Less than half of patients receiving TKI therapy for GISTs received EMA at a comprehensive cancer center. Despite this low uptake, when it was performed, EMA guided alternative treatment decision in 41% of patients. Physician survey responses indicated that interventions targeting physician education and an electronic medical record reminder may improve EMA uptake.

Correction to: International Scholarship Programs of the American College of Surgeons: Expansion of the Global Surgical Network.

In the original article, the top of Fig. 1 was inadvertently cut off. The original article has been corrected. The publisher regrets the error.

International Scholarship Programs of the American College of Surgeons: Expansion of the Global Surgical Network.

BACKGROUND: The American College of Surgeons has always promoted education and collaborations with other countries and their scientific organizations. The International Guest Scholarship program was established in 1968 to support the travel of foreign surgeons to medical Institutions in the USA and Canada. The program has grown substantially over time and now includes different categories of scholarships and surgeons. The objective of this article is to describe the experiences gained by the international scholars who visited US and Canadian institutions through these ACS programs. STUDY DESIGN: In order to collect information regarding these scholarships from the surgeons who have already participated in the program, an Internet-based survey was e-mailed to alumni. The surveys were constructed to gather career information on former scholars and to analyze the perceived impact of these programs on their careers. RESULTS: Among the international scholarships alumni, most are now Fellows of the American College of Surgeons. The majority of respondents maintained contact with their host surgeons in the USA or Canada; they began or continued research, surgical education and surgical quality improvement initiatives in their country of origin based upon their experiences as international scholars. Most of the alumni reported that the experience they had during the scholarship was inspiring, opened their minds and broadened their horizons. CONCLUSIONS: The overall effect of ACS international scholarship program should be considered as positive, as 80-90% of respondent alumni consider their experience very helpful and feel that it provided them with opportunities that would not have been possible without it. It is incumbent upon the ACS to continue along this path by identifying funding and donation sources, as well as enriching the content and goals.

Soft-Tissue Sarcomas of the Abdomen and Pelvis: Radiologic-Pathologic Features, Part 1-Common Sarcomas: From the Radiologic Pathology Archives.

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies that can arise at any location in the body and affect all age groups. These sarcomas are most common in the extremities, trunk wall, retroperitoneum, and head and neck. In the adult population, soft-tissue sarcomas arising in the abdomen and pelvis are often large masses at the time of diagnosis because they are usually clinically silent or cause vague or mild symptoms until they invade or compress vital organs. In contrast, soft-tissue sarcomas arising from the abdominal wall come to clinical attention earlier in the course of disease because they cause a palpable mass, abdominal wall deformity, or pain that is more clinically apparent. The imaging features of abdominal and pelvic sarcomas and abdominal wall sarcomas can be nonspecific and overlap with more common pathologic conditions, making diagnosis difficult or, in some cases, delaying diagnosis. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor (GIST) are the most common intra-abdominal primary sarcomas. Any soft-tissue sarcoma can arise in the abdominal wall. Knowledge of the classification and pathologic features of soft-tissue sarcomas, the anatomic locations where they occur, and their cross-sectional imaging features helps the radiologist establish the diagnosis or differential diagnosis so that patients with soft-tissue sarcomas can receive optimal treatment and management. In part 1 of this article, the most common soft-tissue sarcomas (liposarcoma, leiomyosarcoma, and GIST) are reviewed, with a discussion on anatomic locations, classification, clinical considerations, and differential diagnosis. Part 2 will focus on the remainder of the soft-tissue sarcomas occurring in the abdomen and pelvis.

Approach to the surgical management of resectable gastric cancer.

The rates of gastric cancer, which is the third leading cause of cancer-related deaths worldwide, vary depending on geographic location. Margin-negative gastrectomy and adequate lymphadenectomy (removal of ≥15 lymph nodes) are the cornerstones of multimodal treatment for operable gastric cancer. Diagnostic laparoscopy should be included in the armamentarium for newly diagnosed gastric cancer in order to overcome the limitations of cross-sectional imaging in identifying sub-radiographic hepatic or peritoneal metastases. The benefit of surgical therapy is enhanced by at least 13% when it is integrated with multimodal therapy: either surgery followed by adjuvant chemoradiotherapy or surgery with perioperative systemic therapy. This multidisciplinary approach to treatment will continue to be an evolving paradigm, especially with the emergence of systemic and targeted therapies.

Approach to the surgical management of resectable gastric cancer.

The rates of gastric cancer, which is the third leading cause of cancer-related deaths worldwide, vary depending on geographic location. Margin-negative gastrectomy and adequate lymphadenectomy (removal of ≥15 lymph nodes) are the cornerstones of multimodal treatment for operable gastric cancer. Diagnostic laparoscopy should be included in the armamentarium for newly diagnosed gastric cancer in order to overcome the limitations of cross-sectional imaging in identifying sub-radiographic hepatic or peritoneal metastases. The benefit of surgical therapy is enhanced by at least 13% when it is integrated with multimodal therapy: either surgery followed by adjuvant chemoradiotherapy or surgery with perioperative systemic therapy. This multidisciplinary approach to treatment will continue to be an evolving paradigm, especially with the emergence of systemic and targeted therapies.

Perioperative Blood Transfusion and the Prognosis of Pancreatic Cancer Surgery: Systematic Review and Meta-analysis.

BACKGROUND: Perioperative blood transfusion (PBT) is common in pancreatic surgery. Recent studies have suggested that PBT may be associated with worse long-term outcomes. METHODS: A systematic review and meta-analysis of studies comparing long-term clinical outcomes of cancer patients undergoing curative-intent pancreatic surgery with regard to occurrence of PBT was performed. RESULTS: A total of 23 studies (4339 patients) were included in the systematic review, and 19 studies (3646 patients) were included in the meta-analysis. Nearly half (45.8 %) of all patients were female (range 25-60 %), and median age ranged from 59 to 72 years. About half (46.5 %, range 19-72 %) of the patients were transfused. Most had pancreatic ductal adenocarcinoma (69.5 %), while others had ampullary carcinoma (15.0 %), cholangiocarcinoma (7.4 %), or exocrine tumors of pancreas (8.1 %). Most (91.1 %) underwent pancreaticoduodenectomy, while the remaining patients underwent a total or distal pancreatectomy. The 5-year overall survival for all patients ranged from 0 to 65 %. Thirteen and nine of 19 studies reported a detrimental effect of PBT on survival on univariable and multivariable analysis, respectively. Overall, PBT was associated with shorter overall survival (pooled odds ratio 2.43, 95 % confidence interval 1.90-3.10); this finding was reproduced in sensitivity analysis. CONCLUSIONS: Patients receiving PBT had significantly lower 5-year survival after curative-intent pancreatic surgery. Further research should focus on implementing guidelines for and discerning factors associated with the poor outcomes after PBT.

Does patient rurality predict quality colon cancer care?: A population-based study.

BACKGROUND: More than 50 million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening. OBJECTIVE: Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care. DESIGN: We constructed a retrospective cohort of 123,129 patients with stage 0 to IV colon cancer. Rural residence was established based on the patient medical service study area designated by the registry. SETTINGS: The study was conducted using the 1996-2008 California Cancer Registry. PATIENTS: All of the patients diagnosed between 1996 and 2008 with tumors located in the colon were eligible for inclusion in this study. MAIN OUTCOME MEASURES: Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I to III disease, and receipt of chemotherapy for stage III disease. Proportional-hazards regression was used to examine the impact of rurality on cancer-specific survival. RESULTS: Of all of the patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I to III disease, and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer-specific survival. LIMITATIONS: We could not account for socioeconomic status directly, although we used insurance status as a surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities, or complications. CONCLUSIONS: A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures, and survival. Future endeavors should help improve care to this vulnerable population (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A143).

Travel patterns of cancer surgery patients in a regionalized system.

BACKGROUND: Regionalization of complex surgeries has increased patient travel distances possibly leaving a substantial burden on those at risk for poorer surgical outcomes. To date, little is known about travel patterns of cancer surgery patients in regionalized settings. To inform this issue, we sought to assess travel patterns of those undergoing a major cancer surgery within a regionalized system. MATERIALS AND METHODS: We identified 4733 patients who underwent lung, esophageal, gastric, liver, pancreatic, and colorectal resections from 2002-2014 within a multihospital system in the Mid-Atlantic region of the United States. Patient age, race and/or ethnicity, and insurance status were extracted from electronic health records. We used Geographical Information System capabilities in R software to estimate travel distance and map patient addresses based on cancer surgery type and these characteristics. We used visual inspection, analysis of variance, and interaction analyses to assess the distribution of travel distances between patient populations. RESULTS: A total of 48.2% of patients were non-white, 49.9% were aged >65 y, and 54.9% had private insurance. Increased travel distance was associated with decreasing age and those undergoing pancreatic and esophageal resections. Also, black patients tend to travel shorter distances than other racial and/or ethnic groups. CONCLUSIONS: These maps offer a preliminary understanding into variations of geospatial travel patterns among patients receiving major cancer surgery in a Mid-Atlantic regionalized setting. Future research should focus on the impact of regionalization on timely delivery of surgical care and other quality metrics.

Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery.

Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.

Adjuvant chemotherapy for stage III colon cancer in the oldest old: results beyond clinical guidelines.

BACKGROUND: Randomized trials demonstrating the benefits of chemotherapy in patients with American Joint Committee on Cancer stage III colon cancer underrepresent persons aged ≥ 75 years. The generalizability of these studies to a growing elderly population remains unknown. METHODS: Using the California Cancer Registry for 1994 through 2008, the authors conducted a population-based study of postcolectomy patients aged 50 years to 94 years with stage III (N1M0) colon adenocarcinoma. A 2-sided chi-square test and Cochran-Armitage test for trend were used to compare patient and tumor characteristics associated with receipt of chemotherapy across age groups. Multivariate regression was used to assess the association between older age and receipt of chemotherapy. Kaplan-Meier methods and Cox proportional hazards modeling were used to evaluate the association between chemotherapy and mortality, with propensity score adjustment. RESULTS: Approximately 44% (12,382 patients) of the study cohort was aged ≥ 75 years. Persons aged ≥ 75 years were found to be less likely to have received adjuvant chemotherapy than those aged < 75 years (30% vs 68% in patients aged 50 years-74 years; P < .0001). On multivariate analysis, patients aged 75 years to 84 years were 13 times less likely, and those aged 85 years to 94 years were 24 times less likely, to have received chemotherapy as patients aged 50 years to 64 years. Nevertheless, age-stratified multivariate survival analyses indicated that chemotherapy provided comparable mortality reduction across age groups. CONCLUSIONS: The percentage of persons aged ≥ 75 years receiving adjuvant chemotherapy remains low despite demonstrated survival benefits. These findings deserve attention within the context of a patient's life expectancy, underlying comorbidities, and performance status, as well as clinician bias. The results of the current study support the call for phase II/III studies assessing the toxicities and benefits of adjuvant chemotherapy for the treatment of stage III colon cancer in the elderly.

Disparities in pancreas cancer care.

BACKGROUND: Prior literature shows demographic differences in patients surgically treated for pancreatic cancer (PC). We hypothesized that socioeconomic disparities also exist across all aspects of PC care, in both surgically and non-surgically treated patients. METHODS: We identified a cohort of patients with American Joint Committee on Cancer (AJCC) stage I-IV PC in the 1994-2008 California Cancer Registry. We used multivariate logistic regression to examine the impact of race, sex, and insurance status on (1) resectability (absence of advanced disease), (2) receipt of surgery, and (3) receipt of adjuvant/primary chemotherapy (+/- radiotherapy). RESULTS: Among 20,312 patients, 7,585 (37 %) had resectable disease; 40 % who met this definition received surgery (N = 3,153). On multivariate analysis, males were less likely to present with resectable tumors [odds ratio (OR) 0.91, 95 % confidence interval (CI) 0.85-0.96], but sex did not otherwise predict treatment. Black patients were as likely as White patients to show resectable disease, yet were less likely to receive surgery (OR 0.66, 95 % CI 0.54-0.80), and adjuvant (OR 0.75, 95 % CI 0.58-0.98) or primary chemotherapy +/- radiation. Compared with Medicaid recipients, non-Medicare/Medicaid enrollees were more likely to receive surgery (OR 1.7, 95 % CI 1.4-2.2), and the uninsured were less likely to receive adjuvant therapy (OR 0.54, 95 % CI 0.30-0.98). CONCLUSIONS: Though Black patients appear to present with comparable rates of resectability, they receive care that deviates from current guidelines. Insurance status is associated with inferior profiles of resectability and treatments. Future policies and research should identify effective strategies to ensure receipt of standard care.

Do hospital attributes predict guideline-recommended gastric cancer care in the United States?

BACKGROUND: Hospital attributes have been shown to impact short- and long-term outcomes after cancer surgery. However, the effect of hospital attributes on processes of cancer care in terms of delivery of guideline recommended care has not been evaluated. We examined the impact of hospital attributes (volume and type) on guideline-recommended care in patients treated for gastric cancer. METHODS: We identified patients who were surgically treated for gastric cancer at Commission on Cancer (CoC) hospitals from 2001 to 2006. Patient, tumor, and treatment factors were compared separately by hospital volume and type. Multivariable analyses were used to evaluate the impact of hospital attributes on delivery of guideline recommended gastric cancer care: adequate lymphadenectomy (≥15 lymph nodes), and adjuvant multimodality therapy (for AJCC Ib-IVM0), controlling for covariates. RESULTS: More than 1,490 CoC hospitals performed 37,124 gastrectomies. High-volume and teaching CoC hospitals were more likely to treat younger patients, non-whites, patients with lower AJCC stage, and to perform adequate lymphadenectomy than low-volume and community CoC hospitals (p ≤ 0.001). Hospital volume and type, however, were not associated with receipt of adjuvant multimodality therapy. These associations persisted in our multivariable analyses to show that CoC hospital attributes were associated with adequate lymphadenectomy, but marginally predictive of receipt of adjuvant multimodality therapy. CONCLUSIONS: The strong association between CoC hospital volume or type and guideline-recommended care diminishes after gastric cancer surgery. Variations in referral, insurance, and documentation patterns are potential explanations for these findings. These results highlight some limitations of using hospital attributes as a sole predictor of optimal cancer care.

Are cancer trials valid and useful for the general surgeon and surgical oncologist?

Cancer trials represent a rigorous and clear approach to testing whether an intervention or treatment will alter the outcomes of individuals with cancer in an experimental manner that is beyond the level of observational studies. As such, they remain useful and valid to the day-to-day practice of general surgeons and surgical oncologists. However, the shortcomings of current cancer clinical trials need to be recognized, especially when less than 1% of adults persons with cancer participate in cancer clinical trials, thus leaving the ability to generalize these trials to patients and their surgeons in the real-world setting an open question. Moving forward, physicians, payers, professional societies, advocates, the NCI, and other stakeholders need to develop broader cancer trials to benefit the millions of patients with cancer in the United States.