Where the Other Half Dies: Analysis of Mortalities Occurring More Than 30 Days After Complex Cancer Surgery.

BACKGROUND: Nearly half of operative mortalities occur outside the traditionally studied 30-day period after surgery. To identify additional opportunities to improve surgical safety, the circumstances of deaths occurring 31-90 days after complex cancer surgery are analyzed. PATIENTS AND METHODS: Patients aged ≥ 65 years who died within 90 days of complex cancer surgery for nonmetastatic cancer were analyzed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare and the Connecticut Tumor Registry (CTR) databases. RESULTS: Of the 36,114 patients undergoing complex cancer surgery from 2004 to 2013 in SEER-Medicare, 1367 (3.8%) died within 31-90 days ("late mortalities"). Seventy-eight percent of late mortalities were readmitted prior to death. The highest proportion of late mortalities occurred during a readmission (49%), and 11% were never discharged from their index admission. Cause of death (COD) was largely attributed to the malignancy itself (56%), which is unlikely to be the underlying cause. Of the noncancer COD, cardiac causes were most frequent (34%), followed by pulmonary causes (18%). Death was rarely attributed to thromboembolic disease (< 1%). The CTR provided location of death, which was most commonly in a hospital (65%) or nursing facility (20%); death at home was rare (6%). CONCLUSIONS: The vast majority of patients dying between 31 and 90 days of surgery were admitted to a hospital or nursing facility at the time of their death after initially being discharged, and few patients died at home. Greater clarity in death documentation is needed to identify specific opportunities to rescue patients from fatal complications arising in the later postoperative period.

NCI SEER-Linked Virtual Tissue Repository Pilot.

BACKGROUND: The Surveillance, Epidemiology, and End Results (SEER) Program with the National Cancer Institute tested whether population-based cancer registries can serve as honest brokers to acquire tissue and data in the SEER-Linked Virtual Tissue Repository (VTR) Pilot. METHODS: We collected formalin-fixed, paraffin-embedded tissue and clinical data from patients with pancreatic ductal adenocarcinoma (PDAC) and breast cancer (BC) for two studies comparing cancer cases with highly unusual survival (≥5 years for PDAC and ≤30 months for BC) to pair-matched controls with usual survival (≤2 years for PDAC and ≥5 years for BC). Success was defined as the ability for registries to acquire tissue and data on cancer cases with highly unusual outcomes. RESULTS: Of 98 PDAC and 103 BC matched cases eligible for tissue collection, sources of attrition for tissue collection were tissue being unavailable, control paired with failed case, second control that was not requested, tumor necrosis ≥20%, and low tumor cellularity. In total, tissue meeting the study criteria was obtained for 70 (71%) PDAC and 74 (72%) BC matched cases. For patients with tissue received, clinical data completeness ranged from 59% for CA-19-9 after treatment to >95% for margin status, whether radiation therapy and chemotherapy were administered, and comorbidities. CONCLUSIONS: The VTR Pilot demonstrated the feasibility of using SEER cancer registries as honest brokers to provide tissue and clinical data for secondary use in research. Studies using this program should oversample by 45% to 50% to obtain sufficient sample size and targeted population representation and involve subspecialty matter expert pathologists for tissue selection.

The burden of cancer in Connecticut.

Considerable progress in cancer prevention, early detection and treatment has led to a reduction in the incidence and mortality of this disease, and resulted in significant improvements in cancer survival. Despite these advances, certain populations in Connecticut continue to suffer disparately from this frequently debilitating disease. In this article, we use data from the Connecticut Tumor Registry to examine trends in the four most commonly diagnosed cancers (breast, prostate, lung and colorectal) that collectively account for more than 50% of cancers diagnosed annually in Connecticut. We report on time trends and compare incidence and mortality rates, stage at diagnosis, survival and screening rates, giving insight into opportunities to improve health and reduce disparities in residents of the state.

Pathology Laboratory Policies and Procedures for Releasing Diagnostic Tissue for Cancer Research.

CONTEXT.­: The Surveillance, Epidemiology, and End Results (SEER) cancer registry program is currently evaluating the use of archival, diagnostic, formalin-fixed, paraffin-embedded (FFPE) tissue obtained through SEER cancer registries, functioning as honest brokers for deidentified tissue and associated data. To determine the feasibility of this potential program, laboratory policies for sharing tissue for research needed to be assessed. OBJECTIVE.­: To understand the willingness of pathology laboratories to share archival diagnostic tissue for cancer research and related policies. DESIGN.­: Seven SEER registries administered a 27-item questionnaire to pathology laboratories within their respective registry catchment areas. Only laboratories that processed diagnostic FFPE specimens and completed the questionnaire were included in the analysis. RESULTS.­: Of the 153 responding laboratories, 127 (83%) responded that they process FFPE specimens. Most (n = 88; 69%) were willing to share tissue specimens for research, which was not associated with the number of blocks processed per year by the laboratories. Most laboratories retained the specimens for at least 10 years. Institutional regulatory policies on sharing deidentified tissue varied considerably, ranging from requiring a full Institutional Review Board review to considering such use exempt from Institutional Review Board review, and 43% (55 of 127) of the laboratories did not know their terms for sharing tissue for research. CONCLUSIONS.­: This project indicated a general willingness of pathology laboratories to participate in research by sharing FFPE tissue. Given the variability of research policies across laboratories, it is critical for each SEER registry to work with laboratories in their catchment area to understand such policies and state legislation regulating tissue retention and guardianship.

Critical challenges ahead in bioterrorism preparedness training for clinicians.

PURPOSE: A survey was distributed to determine physicians' confidence levels in recognizing potential Category-A bioterrorism disease threats (e.g., smallpox, anthrax), preferred means of obtaining continuing medical education (CME) credits, and their knowledge of the Connecticut Department of Public Health's (DPH) disease reporting requirements. METHODS: Surveys were mailed to all physicians in the three-hospital Yale New Haven Health (YNHH) System (2,174) from January to March 2004; there were 820 respondents for a 37.7% response rate. RESULTS: A total of 71% of physicians indicated that they were "not confident" that they could recognize five of the infectious agents named; they had higher confidence rates for smallpox (48.8%). Infectious diseases and emergency medicine physicians had the highest rates of confidence. Seventy-eight percent of physicians indicated conferences and lectures as their preferred CME learning modality. Nearly 72% of physicians reported a low familiarity with the DPH reporting requirements. DISCUSSION: The results highlighted the breadth of perceived weaknesses among clinicians from disease recognition to reporting incidents, which signifies the need for greater training in these areas. As clinicians themselves emphasized their lack of skills and knowledge in this area, there should be a rapid development and dissemination of problem-based learning CME courses in bioterrorism preparedness.

Erratum: Author Correction: Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study.

[This corrects the article DOI: 10.1038/npjbcancer.2016.17.].

Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study.

The 21-gene Recurrence Score assay is validated to predict recurrence risk and chemotherapy benefit in hormone-receptor-positive (HR+) invasive breast cancer. To determine prospective breast-cancer-specific mortality (BCSM) outcomes by baseline Recurrence Score results and clinical covariates, the National Cancer Institute collaborated with Genomic Health and 14 population-based registries in the the Surveillance, Epidemiology, and End Results (SEER) Program to electronically supplement cancer surveillance data with Recurrence Score results. The prespecified primary analysis cohort was 40-84 years of age, and had node-negative, HR+, HER2-negative, nonmetastatic disease diagnosed between January 2004 and December 2011 in the entire SEER population, and Recurrence Score results (N=38,568). Unadjusted 5-year BCSM were 0.4% (n=21,023; 95% confidence interval (CI), 0.3-0.6%), 1.4% (n=14,494; 95% CI, 1.1-1.7%), and 4.4% (n=3,051; 95% CI, 3.4-5.6%) for Recurrence Score <18, 18-30, and ⩾31 groups, respectively (P<0.001). In multivariable analysis adjusted for age, tumor size, grade, and race, the Recurrence Score result predicted BCSM (P<0.001). Among patients with node-positive disease (micrometastases and up to three positive nodes; N=4,691), 5-year BCSM (unadjusted) was 1.0% (n=2,694; 95% CI, 0.5-2.0%), 2.3% (n=1,669; 95% CI, 1.3-4.1%), and 14.3% (n=328; 95% CI, 8.4-23.8%) for Recurrence Score <18, 18-30, ⩾31 groups, respectively (P<0.001). Five-year BCSM by Recurrence Score group are reported for important patient subgroups, including age, race, tumor size, grade, and socioeconomic status. This SEER study represents the largest report of prospective BCSM outcomes based on Recurrence Score results for patients with HR+, HER2-negative, node-negative, or node-positive breast cancer, including subgroups often under-represented in clinical trials.

A new estimation approach for combining epidemiological data from multiple sources.

We propose a novel two-step procedure to combine epidemiological data obtained from diverse sources with the aim to quantify risk factors affecting the probability that an individual develops certain disease such as cancer. In the first step we derive all possible unbiased estimating functions based on a group of cases and a group of controls each time. In the second step, we combine these estimating functions efficiently in order to make full use of the information contained in data. Our approach is computationally simple and flexible. We illustrate its efficacy through simulation and apply it to investigate pancreatic cancer risks based on data obtained from the Connecticut Tumor Registry, a population-based case-control study, and the Behavioral Risk Factor Surveillance System which is a state-based system of health surveys.

Melanoma epidemic: an analysis of six decades of data from the Connecticut Tumor Registry.

PURPOSE: Melanoma is the most commonly fatal form of skin cancer, with nearly 50,000 annual deaths worldwide. We sought to assess long-term trends in the incidence and mortality of melanoma in a state with complete and consistent registration. METHODS: We used data from the Connecticut Tumor Registry, the original National Cancer Institute SEER site, to determine trends in invasive melanoma (1950-2007), in situ melanoma (1973-2007), tumor thickness (1993-2007), mortality (1950-2007), and mortality to incidence (1950-2007) among the 19,973 and 3,635 Connecticut residents diagnosed with invasive melanoma (1950-2007) and who died as a result of melanoma (1950-2007), respectively. Main outcome measures included trends in incidence and mortality by age, sex, and birth cohort. RESULTS: In the initial period (1950-1954), a diagnosis of invasive melanoma was rare, with 1.9 patient cases per 100,000 for men and 2.6 patient cases per 100,000 for women. Between 1950 and 2007, overall incidence rates rose more than 17-fold in men (1.9 to 33.5 per 100,000) and more than nine-fold in women (2.6 to 25.3 per 100,000). During these six decades, mortality rates more than tripled in men (1.6 to 4.9 per 100,000) and doubled in women (1.3 to 2.6 per 100,000). Mortality rates were generally stable or decreasing in men and women through age 54 years. CONCLUSION: Unremitting increases in incidence and mortality of melanoma call for a nationally coordinated effort to encourage and promote innovative prevention and early-detection efforts.