Cancer risk among World Trade Center rescue and recovery workers: A review.

Twenty years after the September 11th, 2001 terrorist attacks, the association between exposures present at the World Trade Center (WTC) site and the risk of several specific types of cancer has been reported among rescue and recovery workers. The authors' objective was to conduct an updated review of these data. Most studies have found elevated rates of both prostate and thyroid cancers compared with rates in the general population, and some have reported statistically significant differences for the rates of all cancers as well. Studies including a larger combined cohort of WTC-exposed rescue and recovery workers from 3 main cohorts have since replicated findings for these cancers, with additional years of follow-up. Among this combined cohort, although a lower-than-expected standardized incidence ratio for all cancers was observed, WTC exposure was also related to an increased risk of cutaneous melanoma and tonsil cancer. Importantly, another study found that WTC-exposed rescue and recovery workers who are enrolled in the federally funded medical monitoring and treatment program experienced improved survival post-cancer diagnosis compared with New York state patients with cancer. On the basis of these combined cohort studies, the full effect of WTC exposure on cancer risk is becoming clearer. Consequently, the authors believe that surveillance of those with WTC exposure should be continued, and in-depth analysis of epidemiologic, molecular, and clinical aspects of specific cancers in these workers should be pursued.

New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery.

OBJECTIVE: To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. BACKGROUND: Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. METHODS: A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. RESULTS: In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. CONCLUSIONS: Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

Robot-Assisted Surgery and Racial and Ethnic Disparities in Post-Prostatectomy Outcomes Among Prostate Cancer Patients.

BACKGROUND: We sought to determine whether the differences in short-term outcomes between patients undergoing robot-assisted radical prostatectomy (RARP) and those treated with open radical prostatectomy (ORP) differ by race and ethnicity. METHODS: This observational study used New York State Cancer Registry data linked to discharge records and included patients undergoing radical prostatectomy for localized prostate cancer during 2008-2018. We used logistic regression to examine the association between race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic), surgical approach (RARP, ORP), and postoperative outcomes (major events, prolonged length of stay [pLOS], 30-day re-admission). We tested interaction between race and ethnicity and surgical approach on multiplicative and additive scales. RESULTS: The analytical cohort included 18,926 patients (NHW 14,215 [75.1%], NHB 3195 [16.9%], Hispanic 1516 [8.0%]). The average age was 60.4 years (standard deviation 7.1). NHB and Hispanic patients had lower utilization of RARP and higher risks of postoperative adverse events than NHW patients. NHW, NHB, and Hispanic patients all had reduced risks of adverse events when undergoing RARP versus ORP. The absolute reductions in the risks of major events and pLOS following RARP versus ORP were larger among NHB {relative excess risk due to interaction (RERI): major events -0.32 [95% confidence interval (CI) -0.71 to -0.03]; pLOS -0.63 [95% CI -0.98 to -0.35]) and Hispanic (RERI major events -0.27 [95% CI -0.77 to 0.09]; pLOS -0.93 [95% CI -1.46 to -0.51]) patients than among NHW patients. The interaction was absent on the multiplicative scale. CONCLUSIONS: RARP use has not penetrated and benefited all racial and ethnic groups equally. Increasing utilization of RARP among NHB and Hispanic patients may help reduce disparities in patient outcomes after radical prostatectomy.

A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers.

INTRODUCTION: Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up. MATERIALS AND METHODS: We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk. RESULTS: There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members. CONCLUSIONS: We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

Cancer incidence in World Trade Center rescue and recovery workers by race and ethnicity.

INTRODUCTION: It is unclear whether differences in health outcomes by racial and ethnic groups among World Trade Center (WTC) rescue and recovery workers reflect those of the population of New York State (NYS) or show distinct patterns. We assessed cancer incidence in WTC workers by self-reported race and ethnicity, and compared it to population figures for NYS. METHODS: A total of 61,031 WTC workers enrolled between September 11, 2001 and January 10, 2012 were followed to December 31, 2015. To evaluate the association between race/ethnicity and cancer risk, Poisson regression analysis was used to estimate hazard ratios (HR) adjusted for WTC exposure, age, calendar year, sex and, for lung cancer, cigarette smoking. RESULTS: In comparison to Whites, Black workers had a higher incidence of prostate cancer (HR = 1.99, 95% CI = 1.69-2.34) and multiple myeloma (HR = 3.57, 95% CI = 1.97-6.45), and a lower incidence of thyroid (HR = 0.41, 95% CI = 0.22-0.78) and colorectal cancer (HR = 0.57; 95% CI = 0.33-0.98). Hispanic workers had a higher incidence of liver cancer (HR = 4.03, 95% CI = 2.23-7.28). Compared with NYS population, White workers had significantly higher incidence of prostate cancer (HR = 1.26, 95% CI = 1.18-1.35) and thyroid cancer (HR = 1.80, 95% CI = 1.55-2.08), while Black workers had significantly higher incidence of prostate cancer (HR = 1.22, 95% CI = 1.05-1.40). CONCLUSION: Cancer incidence in WTC workers generally reflects data from the NYS population, but some differences were identified that merit further investigation.

Epidemiology of Cervical Adenocarcinoma and Squamous Cell Carcinoma Among Women Living With Human Immunodeficiency Virus Compared With the General Population in the United States.

BACKGROUND: Although cervical cancer risk overall is elevated among women living with human immunodeficiency virus (HIV; WLH), it is unclear whether risks are similarly elevated across histologic subtypes. METHODS: Data from the HIV/AIDS Cancer Match Study, a linkage of 12 US HIV and cancer registries during 1996 -2016, were used. Cervical cancers were categorized as adenocarcinoma (AC), squamous cell carcinoma (SCC), or other histologic subtype. Standardized incidence ratios compared rates of AC and SCC in WLH to those in general population. For WLH, risk factors for AC and SCC were evaluated using Poisson regression. Five-year survival was estimated by HIV status and histology. RESULTS: Overall, 62 615 cervical cancers were identified, including 609 in WLH. Compared with the general population, incidence of AC was 1.47 times higher (95% confidence interval [CI]: 1.03-2.05) and SCC was 3.62 times higher among WLH (95% CI: 3.31-3.94). Among WLH, there was no difference in AC rates by race/ethnicity or HIV transmission group, although SCC rates were lower among White women (vs Black) and higher among women who inject drugs (vs heterosexual transmission). Among WLH, 5-year overall survival was similar for AC (46.2%) and SCC (43.8%) but notably lower than for women not living with HIV. CONCLUSIONS: Among WLH, AC rates were modestly elevated, whereas SCC rates were greatly elevated compared with the general population. These findings suggest there may be differences in the impact of immunosuppression and HIV in the development of AC versus SCC, given their common etiology in human papillomavirus infection.

The risks of birth defects and childhood cancer with conception by assisted reproductive technology.

STUDY QUESTION: Is there an association between fertility status, method of conception and the risks of birth defects and childhood cancer? SUMMARY ANSWER: The risk of childhood cancer had two independent components: (i) method of conception and (ii) presence, type and number of birth defects. WHAT IS KNOWN ALREADY: The rarity of the co-occurrence of birth defects, cancer and ART makes studying their association challenging. Prior studies have indicated that infertility and ART are associated with an increased risk of birth defects or cancer but have been limited by small sample size and inadequate statistical power, failure to adjust for or include plurality, differences in definitions and/or methods of ascertainment, lack of information on ART treatment parameters or study periods spanning decades resulting in a substantial historical bias as ART techniques have improved. STUDY DESIGN, SIZE, DURATION: This was a population-based cohort study linking ART cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) from 1 January 2004 to 31 December 2017 that resulted in live births in 2004-2018 in Massachusetts and North Carolina and live births in 2004-2017 in Texas and New York. A 10:1 sample of non-ART births were chosen within the same time period as the ART birth. Non-ART siblings were identified through the ART mother's information. Children from non-ART births were classified as being born to women who conceived with ovulation induction or IUI (OI/IUI) when there was an indication of infertility treatment on the birth certificate, and the woman did not link to the SART CORS; all others were classified as being naturally conceived. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study population included 165 125 ART children, 31 524 non-ART siblings, 12 451 children born to OI/IUI-treated women and 1 353 440 naturally conceived children. All study children were linked to their respective State birth defect registries to identify major defects diagnosed within the first year of life. We classified children with major defects as either chromosomal (i.e. presence of a chromosomal defect with or without any other major defect) or nonchromosomal (i.e. presence of a major defect but having no chromosomal defect), or all major defects (chromosomal and nonchromosomal), and calculated rates per 1000 children. Logistic regression models were used to generate adjusted odds ratios (AORs) and 95% CIs of the risk of birth defects by conception group (OI/IUI, non-ART sibling and ART by oocyte source and embryo state) with naturally conceived children as the reference, adjusted for paternal and maternal ages; maternal race and ethnicity, education, BMI, parity, diabetes, hypertension; and for plurality, infant sex and State and year of birth. All study children were also linked to their respective State cancer registries. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs of cancer by birth defect status (including presence of a defect, type and number of defects), and conception group. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 29 571 singleton children (2.0%) and 3753 twin children (3.5%) had a major birth defect (chromosomal or nonchromosomal). Children conceived with ART from autologous oocytes had increased risks for nonchromosomal defects, including blastogenesis, cardiovascular, gastrointestinal and, for males only, genitourinary defects, with AORs ranging from 1.22 to 1.85; children in the autologous-fresh group also had increased risks for musculoskeletal (AOR 1.28, 95% CI 1.13, 1.45) and orofacial defects (AOR 1.40, 95% CI 1.17, 1.68). Within the donor oocyte group, the children conceived from fresh embryos did not have increased risks in any birth defect category, whereas children conceived from thawed embryos had increased risks for nonchromosomal defects (AOR 1.20, 95% CI 1.03, 1.40) and blastogenesis defects (AOR 1.74, 95% CI 1.14, 2.65). The risk of cancer was increased among ART children in the autologous-fresh group (HR 1.31, 95% CI 1.08, 1.59) and non-ART siblings (1.34, 95% CI 1.02, 1.76). The risk of leukemia was increased among children in the OI/IUI group (HR 2.15, 95% CI 1.04, 4.47) and non-ART siblings (HR 1.63, 95% CI 1.02, 2.61). The risk of central nervous system tumors was increased among ART children in the autologous-fresh group (HR 1.68, 95% CI 1.14, 2.48), donor-fresh group (HR 2.57, 95% CI 1.04, 6.32) and non-ART siblings (HR 1.84, 95% CI 1.12, 3.03). ART children in the autologous-fresh group were also at increased risk for solid tumors (HR 1.39, 95% CI 1.09, 1.77). A total of 127 children had both major birth defects and cancer, of which 53 children (42%) had leukemia. The risk of cancer had two independent components: (i) method of conception (described above) and (ii) presence, type and number of birth defects. The presence of nonchromosomal defects increased the cancer risk, greater for two or more defects versus one defect, for all cancers and each type evaluated. The presence of chromosomal defects was strongly associated with cancer risk (HR 8.70 for all cancers and HR 21.90 for leukemia), further elevated in the presence of both chromosomal and nonchromosomal defects (HR 21.29 for all cancers, HR 64.83 for leukemia and HR 4.71 for embryonal tumors). Among the 83 946 children born from ART in the USA in 2019 compared to their naturally conceived counterparts, these risks translate into an estimated excess of 761 children with major birth defects, 31 children with cancer and 11 children with both major birth defects and cancer. LIMITATIONS, REASONS FOR CAUTION: In the SART CORS database, it was not possible to differentiate method of embryo freezing (slow freezing versus vitrification), and data on ICSI were only available in the fresh embryo ART group. In the OI/IUI group, it was not possible to differentiate type of non-ART treatment utilized, and in both the ART and OI/IUI groups, data were unavailable on duration of infertility. Since OI/IUI is underreported on the birth certificate, some OI/IUI children were likely included among the naturally conceived children, which will decrease the difference between all the groups and the naturally conceived children. WIDER IMPLICATIONS OF THE FINDINGS: The use of ART is associated with increased risks of major nonchromosomal birth defects. The presence of birth defects is associated with greater risks for cancer, which adds to the baseline risk in the ART group. Although this study does not show causality, these findings indicate that children conceived with ART, non-ART siblings, and all children with birth defects should be monitored more closely for the subsequent development of cancer. STUDY FUNDING/COMPETING INTEREST(S): This project was supported by grant R01 HD084377 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development, or the National Institutes of Health, nor any of the State Departments of Health which contributed data. M.L.E. reports consultancy for Ro, Hannah, Dadi, Sandstone and Underdog; presidency of SSMR; and SMRU board member. The remaining authors report no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Healthcare Access Dimensions and Guideline-Concordant Ovarian Cancer Treatment: SEER-Medicare Analysis of the ORCHiD Study.

BACKGROUND: Racial disparities exist in receipt of guideline-concordant treatment of ovarian cancer (OC). However, few studies have evaluated how various dimensions of healthcare access (HCA) contribute to these disparities. METHODS: We analyzed data from non-Hispanic (NH)-Black, Hispanic, and NH-White patients with OC diagnosed in 2008 to 2015 from the SEER-Medicare database and defined HCA dimensions as affordability, availability, and accessibility, measured as aggregate scores created with factor analysis. Receipt of guideline-concordant OC surgery and chemotherapy was defined based on the NCCN Guidelines for Ovarian Cancer. Multivariable-adjusted modified Poisson regression models were used to assess the relative risk (RR) for guideline-concordant treatment in relation to HCA. RESULTS: The study cohort included 5,632 patients: 6% NH-Black, 6% Hispanic, and 88% NH-White. Only 23.8% of NH-White patients received guideline-concordant surgery and the full cycles of chemotherapy versus 14.2% of NH-Black patients. Higher affordability (RR, 1.05; 95% CI, 1.01-1.08) and availability (RR, 1.06; 95% CI, 1.02-1.10) were associated with receipt of guideline-concordant surgery, whereas higher affordability was associated with initiation of systemic therapy (hazard ratio, 1.09; 95% CI, 1.05-1.13). After adjusting for all 3 HCA scores and demographic and clinical characteristics, NH-Black patients remained less likely than NH-White patients to initiate systemic therapy (hazard ratio, 0.86; 95% CI, 0.75-0.99). CONCLUSIONS: Multiple HCA dimensions predict receipt of guideline-concordant treatment but do not fully explain racial disparities among patients with OC. Acceptability and accommodation are 2 additional HCA dimensions which may be critical to addressing these disparities.

Temporal association of prostate cancer incidence with World Trade Center rescue/recovery work.

BACKGROUND: The World Trade Center (WTC) attacks on 11 September 2001 created a hazardous environment with known and suspected carcinogens. Previous studies have identified an increased risk of prostate cancer in responder cohorts compared with the general male population. OBJECTIVES: To estimate the length of time to prostate cancer among WTC rescue/recovery workers by determining specific time periods during which the risk was significantly elevated. METHODS: Person-time accruals began 6 months after enrolment into a WTC cohort and ended at death or 12/31/2015. Cancer data were obtained through linkages with 13 state cancer registries. New York State was the comparison population. We used Poisson regression to estimate hazard ratios and 95% CIs; change points in rate ratios were estimated using profile likelihood. RESULTS: The analytic cohort included 54 394 male rescue/recovery workers. We observed 1120 incident prostate cancer cases. During 2002-2006, no association with WTC exposure was detected. Beginning in 2007, a 24% increased risk (HR: 1.24, 95% CI 1.16 to 1.32) was observed among WTC rescue/recovery workers when compared with New York State. Comparing those who arrived earliest at the disaster site on the morning of 11 September 2001 or any time on 12 September 2001 to those who first arrived later, we observed a positive, monotonic, dose-response association in the early (2002-2006) and late (2007-2015) periods. CONCLUSIONS: Risk of prostate cancer was significantly elevated beginning in 2007 in the WTC combined rescue/recovery cohort. While unique exposures at the disaster site might have contributed to the observed effect, screening practices including routine prostate specific antigen screening cannot be discounted.

Cancer survival among World Trade Center rescue and recovery workers: A collaborative cohort study.

BACKGROUND: World Trade Center (WTC)-exposed responders may be eligible to receive no-cost medical monitoring and treatment for certified conditions, including cancer. The survival of responders with cancer has not previously been investigated. METHODS: This study compared the estimated relative survival of WTC-exposed responders who developed cancer while enrolled in two WTC medical monitoring and treatment programs in New York City (WTC-MMTP responders) and WTC-exposed responders not enrolled (WTC-non-MMTP responders) to non-responders from New York State (NYS-non-responders), all restricted to the 11-southernmost NYS counties, where most responders resided. Parametric survival models estimated cancer-specific and all-cause mortality. Follow-up ended at death or on December 31, 2016. RESULTS: From January 1, 2005 to December 31, 2016, there were 2,037 cancer cases and 303 deaths (248 cancer-related deaths) among WTC-MMTP responders, 564 cancer cases, and 143 deaths (106 cancer-related deaths) among WTC-non-MMTP responders, and 574,075 cancer cases and 224,040 deaths (158,645 cancer-related deaths) among the NYS-non-responder population. Comparing WTC-MMTP responders with NYS-non-responders, the cancer-specific mortality hazard ratio (HR) was 0.72 (95% confidence interval [CI] = 0.64-0.82), and all-cause mortality HR was 0.64 (95% CI = 0.58-0.72). The cancer-specific HR was 0.94 (95% CI = 0.78-1.14), and all-cause mortality HR was 0.93 (95% CI = 0.79-1.10) comparing WTC-non-MMTP responders to the NYS-non-responder population. CONCLUSIONS: WTC-MMTP responders had lower mortality compared with NYS-non-responders, after controlling for demographic factors and temporal trends. There may be survival benefits from no-out-of-pocket-cost medical care which could have important implications for healthcare policy, however, other occupational and socioeconomic factors could have contributed to some of the observed survival advantage.

Impact of healthcare services on thyroid cancer incidence among World Trade Center-exposed rescue and recovery workers.

BACKGROUND: A recent study of World Trade Center (WTC)-exposed firefighters and emergency medical service workers demonstrated that elevated thyroid cancer incidence may be attributable to frequent medical testing, resulting in the identification of asymptomatic tumors. We expand on that study by comparing the incidence of thyroid cancer among three groups: WTC-exposed rescue/recovery workers enrolled in a New York State (NYS) WTC-medical monitoring and treatment program (MMTP); WTC-exposed rescue/recovery workers not enrolled in an MMTP (non-MMTP); and the NYS population. METHODS: Person-time began on 9/12/2001 or at enrollment in a WTC cohort and ended at death or on 12/31/2015. Cancer data were obtained through linkages with 13 state cancer registries. We used Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for MMTP and non-MMTP participants. NYS rates were used as the reference. To estimate potential changes over time in WTC-associated risk, change points in RRs were estimated using profile likelihood. RESULTS: The thyroid cancer incidence rate among MMTP participants was more than twice that of NYS population rates (RR = 2.31; 95% CI = 2.00-2.68). Non-MMTP participants had a risk similar to NYS (RR = 0.96; 95% CI = 0.72-1.28). We observed no change points in the follow-up period. CONCLUSION: Our findings support the hypothesis that no-cost screening (a benefit provided by WTC-MMTPs) is associated with elevated identification of thyroid cancer. Given the high survival rate for thyroid cancer, it is important to weigh the costs and benefits of treatment, as many of these cancers were asymptomatic and may have been detected incidentally.

Variation in Adequate Lymph Node Yield for Gastric, Lung, and Bladder Cancer: Attributable to the Surgeon, Pathologist, or Hospital?

BACKGROUND: The Commission on Cancer recently released quality-of-care measures regarding adequate lymphadenectomy for colon, gastric, lung, and bladder cancer. There is currently little information regarding variation in adequate lymph node yield (ALNY) for gastric, lung, and bladder cancer. METHODS: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I-III gastric, stage I-II lung, and stage II-III bladder cancer resections from 2004 to 2014. Hierarchical models assessed factors associated with ALNY (gastric ≥ 15; lung ≥ 10; bladder ≥ 2). Additionally, the proportions of variation attributable to surgeons, pathologists, and hospitals were estimated among Medicare patients. RESULTS: Among 3716 gastric, 18,328 lung, and 1512 bladder cancer resections, there were low rates of ALNY (gastric = 53%, lung = 36%, bladder = 67%). When comparing 2004-2006 and 2012-2014, there was significant improvement in ALNY for gastric cancer (39% vs. 68%), but more modest improvement for lung (33% vs. 38%) and bladder (65% vs. 71%) cancer. Large provider-level variation existed for each organ system. After controlling for patient-level factors/variation, the majority of variation was attributable to hospitals (gastric: surgeon = 4%, pathologist = 2.8%, hospital = 40%; lung: surgeon = 13.8%, pathologist = 1.5%, hospital = 18.3%) for gastric and lung cancer. For bladder cancer, most of the variation was attributable to pathologists (surgeon = 3.3%, pathologist = 10.5%, hospital = 6.2%). CONCLUSIONS: ALNY rates are low for gastric, lung, and bladder cancer, with only modest improvement over time for lung and bladder cancer. Given that the proportion of variation attributable to the surgeon, pathologist, and hospital is different for each organ system, future quality improvement initiatives should target the underlying causes, which vary by individual organ system.

Centralizing Rectal Cancer Surgery: What Is the Impact of Travel on Patients?

BACKGROUND: It is unclear what impact centralizing rectal cancer surgery may have on travel burden for patients. OBJECTIVE: This study aimed to determine the impact of centralizing rectal cancer surgery to high-volume centers on patient travel distance. DESIGN: This is a population-based study. SETTINGS: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for patients with rectal cancer undergoing proctectomy. PATIENTS: Patients with stage I to III rectal cancer who underwent surgical resection between 2004 and 2014 were included. MAIN OUTCOME MEASURES: The outcome of interest was travel distance calculated as the straight-line distance between the centroid of the patient residence zip code and the hospital zip code. Mean distance was compared by using the Student t test. RESULTS: A total of 5860 patients met inclusion criteria. The total number of hospitals performing proctectomies for rectal cancer decreased between 2004 and 2014. The average number of proctectomies performed at high-volume centers (20+ resections/year) increased from 16.6 to 24.4 during this time. The average number of miles traveled by patients was 12.1 miles in 2004, and this increased to 15.4 in 2014. If proctectomies were centralized to high-volume centers, there would be 11 facilities. The mean distance traveled would be 24.5 miles. LIMITATIONS: This study is subject to the limitations of an administrative data set. There are no patient preference or referral data. CONCLUSIONS: The number of hospitals performing rectal cancer resections in New York State is decreasing and volume by center is increasing. There was a statistically significant difference in the mean distance traveled by patients over time. If rectal cancer resections were centralized to high-volume centers, the mean travel distance would increase by 9.5 miles. There would be a 321% increase in the number of patients having to travel 50+ miles for surgery. Any plan for centralization in New York State will require careful planning to avoid placing undue travel burden on patients. See Video Abstract at http://links.lww.com/DCR/B138. CENTRALIZACIÓN DE LA CIRUGÍA DE CÁNCER RECTAL: ¿CUÁL ES EL IMPACTO DEL VIAJE PARA LOS PACIENTES?: No está claro qué impacto puede tener la centralización de la cirugía de cáncer rectal en la carga de viaje para los pacientes.Determinar el impacto de centralizar la cirugía de cáncer rectal en centros de alto volumen sobre la distancia de viaje del paciente.Este es un estudio basado en cohorte poblacional.El Registro de Cáncer del Estado de Nueva York y el Sistema Cooperativo de Planificación e Investigación Estatal fueron consultados para pacientes con cáncer rectal sometidos a proctectomía.Pacientes con cáncer rectal en estadio I-III que se sometieron a resección quirúrgica entre 2004-2014.El resultado de interés fue la distancia de viaje calculada como la distancia en línea recta entre el centroide de la residencia del paciente y el código postal del hospital. La distancia media se comparó mediante la prueba t de Student.Un total de 5,860 pacientes cumplieron los criterios de inclusión. El número total de hospitales que realizaron proctectomías para cáncer rectal disminuyó entre 2004-2014. El número promedio de proctectomías realizadas en centros de alto volumen (más de 20 resecciones/año) aumentó de 16.6 a 24.4 durante este tiempo. El número promedio de millas recorridas por los pacientes fue de 12.1 millas en 2004 y esto aumentó a 15.4 en 2014. Si las proctectomías se centralizaran en centros de alto volumen, habría 11 instalaciones. La distancia media recorrida sería de 24.5 millas.Limitaciones inherentes a un conjunto de datos administrativos. No existen datos sobre preferencia del paciente o sobre referencia de los mismos.El número de hospitales que realizan resecciones de cáncer rectal en Nueva York está disminuyendo y el volumen por centro está aumentando. Hubo una diferencia estadísticamente significativa en la distancia media recorrida por los pacientes a lo largo del tiempo. Si las resecciones por cáncer rectal se centralizaran en centros de gran volumen, la distancia media de viaje aumentaría 9.5 millas. Habría un aumento del 321% en el número de pacientes que tienen que viajar más de 50 millas para la cirugía. Cualquier plan de centralización en Nueva York requerirá una planificación cuidadosa para evitar imponer una carga de viaje excesiva a los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B138.

A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer.

BACKGROUND: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer.

BACKGROUND: We examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. METHODS: Patients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. RESULTS: Among 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). CONCLUSIONS: Although extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.

Surgeon, Hospital, and Geographic Variation in Minimally Invasive Colectomy.

OBJECTIVE: To identify sources of variation in the use of minimally invasive surgery (MIS) for colectomy. BACKGROUND: MIS is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study identified factors explaining variation in MIS use for colectomy. METHODS: The Statewide Planning and Research Cooperative System was queried for scheduled admissions in which a colectomy was performed for neoplastic, diverticular, or inflammatory bowel disease between 2008 and 2015. Mixed-effects analyses were performed assessing surgeon, hospital, and geographic variation and factors associated with an MIS approach. RESULTS: Among 45,714 colectomies, 68.1% were performed using an MIS approach. Wide variation in the rate of MIS was present across 1253 surgeons (median 50%, interquartile range 10.9%-84.2%, range 0.3%-99.7%). Calculating intraclass correlation coefficients after controlling for case-mix, 62.8% of the total variation in MIS usage was attributable to surgeon variation compared with 28.5% attributable to patient variation, 7% attributable to hospital variation, and 1.6% attributable to geographic variation. Surgeon-years in practice since residency/fellowship completion explained 19.2% of the surgeon variation, surgeon volume explained 5.2%, hospital factors explained 0.1%, and patient factors explained 0%. CONCLUSIONS: Wide surgeon variation exists regarding an MIS approach for colectomy, and most of the total variation is attributable to individual surgeon practices-much of which is related to year of graduation. As increasing surgeon age is inversely proportional to the rate of MIS, patient referral and/or providing tailored training to older surgeons may be constructive targets in increasing the use of MIS and reducing healthcare utilization.

The impact of age on complications, survival, and cause of death following colon cancer surgery.

BACKGROUND: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. METHODS: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I-III colon cancer resections (2004-2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65-74, ⩾75), complications, 1-year survival, and cause of death. RESULTS: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65-74: HR=1.59, 95% CI=1.26-2.00; ⩾75: HR=2.57, 95% CI=2.09-3.16; sepsis: HR=2.58, 95% CI=2.13-3.11) and cardiovascular disease-specific death (65-74: HR=3.72, 95% CI=2.29-6.05; ⩾75: HR=7.02, 95% CI=4.44-11.10; sepsis: HR=2.33, 95% CI=1.81-2.99). CONCLUSIONS: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.

Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection.

OBJECTIVE: To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery. BACKGROUND: Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients. METHODS: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival. RESULTS: Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival. CONCLUSIONS: Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.

Geographic epidemiology of hepatocellular carcinoma, viral hepatitis, and socioeconomic position in New York City.

PURPOSE: Liver cancer (hepatocellular carcinoma (HCC)) incidence and mortality rates are increasing in the United States. New York City (NYC) has a high burden of liver cancer risk factors, including hepatitis C (HCV) and hepatitis B (HBV) infection, which disproportionately affect persons of low socioeconomic position. Identifying neighborhoods with HCC disparities is essential to effectively define targeted cancer control strategies. METHODS: New York State Cancer Registry data from 1 January 2001 through 31 December 2012 were matched with NYC HCV and HBV surveillance data. HCC data were aggregated to NYC Zip Code Tabulation Areas (ZCTAs). Moran's I cluster analysis, Poisson regression, and geographically weighted Poisson regression were used to identify hotspots in HCC incidence and to examine the spatial associations with viral hepatitis rates, poverty, and uninsured status. RESULTS: Among NYC residents, 8,827 HCC cases were diagnosed during 2001-2012. Significant clustering was detected in the HCC rates (Moran's I = 0.25) with the strongest clustering found in HCC patients with comorbid HCV infection (Moran's I = 0.47). Poverty and uninsured status were associated (p < 0.05) with increased rates of HCC patients with HBV or HCV infection. Neighborhoods with high rates of HCC without viral hepatitis infection had lower rates of poverty and uninsured status. CONCLUSIONS: The geographic variation in HCC highlights the need for neighborhood-targeted interventions to address risk factors and barriers to care. The clusters of HCC by viral hepatitis status may serve as a basis for healthcare policymakers and practitioners to prioritize neighborhoods for cancer screening and control efforts.