Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database.

BACKGROUND: Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies. STUDY DESIGN: We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012-2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL. RESULTS: In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70-0.96], ABP [0.69, 95%CI: 0.52-0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51-0.86], ABP [0.56, 95%CI: 0.34-0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50-0.67; AL:OR = 0.46, 95%CI:0.36-0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13-0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37-0.69], AL [OR = 0.47, 95%CI: 0.25-0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47-0.72, AL [OR = 0.49, 95%CI: 0.35-0.68]). CONCLUSIONS: MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

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.

Commission on Cancer Standards for Lymph Node Sampling and Oncologic Outcomes After Lung Resection.

BACKGROUND: The newest Commission on Cancer standards recommend sampling 3 mediastinal and 1 hilar lymph node stations, 3 (N2) 1 (N1), for lung cancer resections. However, the relationship between the Commission on Cancer standards and outcomes has not been thoroughly investigated. METHODS: A prospective institutional database was queried for clinical stage I-III lung resections before the implementation of the new standards. The relationship between the 3 (N2) 1 (N1) standard ("guideline concordant") and outcomes (upstaging, complications, receipt of adjuvant therapy, locoregional/distant recurrence, and survival) was assessed with multivariable models and stratified by stage. RESULTS: Of 9289 pulmonary resections, 3048 (33%) were guideline concordant and 6241 (67%) were not. Compared with nonconcordant, those that were guideline concordant had higher rates of nodal upstaging (21% vs 13%; odds ratio [OR], 1.32 [95% CI, 1.14-1.51]; P < .001) and in-hospital complications (34% vs 27%; OR, 1.17 [95% CI, 1.05-1.30]; P = .004) but similar adjuvant systemic therapy administration (19% vs 13%; OR, 1.09 [95% CI, 0.95-1.24]; P = .2; 98% chemotherapy). Locoregional and distant recurrences were not significantly improved with guideline concordance across clinical stage I, II, and III subsets. Overall survival was similar in clinical stages I and II, but improved survival was observed for guideline concordant clinical stage III patients (hazard ratio, 0.85 [95% CI, 0.74-0.97]; P = .02). CONCLUSIONS: Sampling 3 (N2) 1 (N1) was associated with increased upstaging and complications but not with decreased recurrence or mortality in clinical stage I or II patients. Survival was improved for concordant, clinical stage III patients. Further study is indicated to determine the ideal lymph node sampling strategy across heterogeneous lung cancer patients.

Outcomes of surgically managed primary lung sarcomas: a National Cancer Database analysis.

BACKGROUND: Primary lung sarcoma (PLS) represents a rare form of lung cancer with outcomes that are poorly defined by small datasets. We sought to characterize clinical and pathological characteristics and associated survival within the surgically managed subgroup of these unusual pulmonary malignancies. METHODS: We performed a retrospective analysis of the National Cancer Database (NCDB), which was queried for cases of surgically managed PLS diagnosed between 2004-2014. Adjusted mortality was evaluated in a multivariable Cox proportional hazards model and compared to surgically manage non-small cell lung cancer (NSCLC) patients from the same time period. RESULTS: A total of 695 patients with surgically managed PLS were identified with 37 different histologic subtypes. The mean age of diagnosis was 57.7 years (range, 18-90 years). A majority of patients underwent surgical resection alone (64.3%) with an estimated 5-year overall survival (OS) of 51%. The multivariable Cox model identified increasing age, Charlson-Deyo score ≥2, high tumor grade, tumor size >5 cm, positive margins, and positive lymph nodes to be associated with higher risk for mortality (P<0.05). Compared to 101,428 surgically managed patients with adenocarcinoma, PLS patients were younger with fewer comorbidities but had larger tumors, higher grade tumors, and were more likely node negative (P<0.001). Surgery with adjuvant chemotherapy was associated with worse survival than surgery alone (HR 1.41, 95% CI: 1.05-1.88). The extent of parenchymal resection (lobar vs. sublobar) was not predictive for survival. Five-year OS was lower for patients with PLS (44%) than adenocarcinoma (53.6%, P<0.001). CONCLUSIONS: The survival of surgically managed PLS is reasonable and impacted by tumor attributes and the completeness of surgical resection. Further study to define the role of multimodal therapy is indicated.

Optimal Radiation Dose for Stage III Lung Cancer-Should "Definitive" Radiation Doses Be Used in the Preoperative Setting?

INTRODUCTION: There are currently two recommended radiation strategies for clinical stage III NSCLC: a lower "preoperative" (45-54 Gy) and a higher "definitive/nonsurgical" (60-70 Gy) dose. We sought to determine if definitive radiation doses should be used in the preoperative setting given that many clinical stage III patients planned for surgery are ultimately managed with chemoradiation alone. METHODS: Using the National Cancer Database data from 2006 to 2016, we performed a comparative effectiveness analysis of stage III N2 patients who received chemoradiotherapy. Patients were stratified into subgroups across 2 parameters: (1) radiation dose: lower (45-54 Gy) and higher (60-70 Gy); and (2) the use of surgery (i.e., surgical and nonsurgical treatment approaches). Long-term survival and perioperative outcomes were evaluated using multivariable Cox proportional hazards and logistic regression models. RESULTS: A cohort of 961 patients received radiation before surgery including 321 who received a higher dose and 640 who received a lower dose. A higher preoperative dose revealed similar long-term mortality risk (hazard ratio = 0.99, 95% confidence interval: 0.82-1.21, p = 0.951) compared with a lower dose. There was no significant association between radiation dose and 90-day mortality (p = 0.982), 30-day readmission (p = 0.931), or prolonged length of stay (p = 0.052) in the surgical cohort. A total of 17,904 clinical-stage IIIA-N2 patients were treated nonsurgically, including 15,945 receiving higher and 1959 treated with a lower dose. A higher dose was associated with a reduction in long-term mortality risk (hazard ratio = 0.64, 95% confidence interval: 0.60-0.67, p < 0.001) compared with a lower dose. CONCLUSIONS: For clinical stage III NSCLC, the administration of 60 to 70 Gy of radiation seems to be more effective than the lower dose for nonsurgical patients without compromising surgical safety for those that undergo resection. This evidence supports the implementation of 60 to 70 Gy as a single-dose strategy for both preoperative and definitive chemoradiotherapy.

A National Study of Surgically Managed Atypical Pulmonary Carcinoid Tumors.

BACKGROUND: Atypical pulmonary carcinoid tumors represent a subset of non-small cell lung cancer; however, their relative infrequency has left prognosis, management and long-term survival associated with atypical carcinoids, incompletely characterized. METHODS: Patients aged 18 years or more diagnosed with atypical or typical pulmonary carcinoid between 2010 and 2015 within the National Cancer Database were evaluated. Survival was measured using Kaplan-Meier survival and multivariable Cox proportional hazards regression, adjusting for patient and tumor attributes. RESULTS: A total of 816 atypical and 5688 typical carcinoid patients were identified in the cohort. Patients with atypical carcinoids tended to be older, have larger tumors, and later stage disease. The unadjusted overall 5-year survival for atypical carcinoid patients was 84%, 74%, 52%, and 51% for stages I, II, III, and IV, respectively. The unadjusted 5-year survival for typical carcinoids was 93%, 93%, 89%, and 87% for stages I, II, III, and IV, respectively. Nodal upstaging (ie, lymph node metastases identified in surgical specimens of clinically staged N0 patients) was seen in 16% of atypical and 7% of typical carcinoid patients. Increasing age, comorbidities, and stage were identified as significant predictors of mortality for atypical patients in multivariable analysis. Extent of surgical resection (lobectomy vs sublobar) was not identified as a predictor of survival for atypical carcinoid. CONCLUSIONS: Atypical carcinoid tumors represent a distinct subset of carcinoid tumors, with a tendency toward more aggressive behavior. Further study of the optimal surgical management is warranted.

Application of Advanced Bioinformatics to Understand and Predict Burnout Among Surgical Trainees.

OBJECTIVE: Physician burnout, including surgical trainees, is multidimensional. Input variables used to predict burnout include grit, exhaustion, and financial stress. Each instrument has intrinsic limitations of scope and strength. We hypothesize that bioinformatics methods borrowed from oncogenetics may allow meta-analysis of existing predictive tools to improve identification of subpopulations at highest risk of burnout. DESIGN: A composite survey was created using widely accepted instruments: demographic factors, burnout using the Single-Item Maslach Burnout Inventory Emotional Exhaustion Measure, grit using the Duckworth Grit Scale, occupational fatigue using the Occupational Fatigue Exhaustion/Recovery Scale, financial well-being, perceptions of physician leadership, and attitudes towards robotic surgery. Surveys were analyzed using k-means analysis and supervised/unsupervised clustering. SETTING: Yale General Surgery Residency. PARTICIPANTS: Survey participants consisted of Yale General Surgery residents. Of 70 residents, 53 responded (75.7%). Males comprised 57.1% and each postgraduate year had majority representation, 68.8% to 100%. RESULTS: Unsupervised hierarchical clustering showed heterogeneous resident answer patterns and suggested clusters of responders. To define groups of dissimilar responders, we performed k-means clustering, testing 15 iterations with 50 attempts. The analysis revealed 3 discrete clusters of responders with differential risk for burnout (p = 0.021). The highest risk group demonstrated the lowest grit score, low interest in innovation and leadership, higher financial stress, and concordantly, the highest rates of anxiety, dread, and self-reported burnout. (p = 0.0004; 0.0014; 0.1217; 0.0625; 0.021; 0.0011; 0.0224) CONCLUSIONS: The limited scope of common tools aiming to predict burnout constrains their utility. The machine-learning technique of cluster analysis organizes compound data to describe complex outcomes such as oncologic risks. We apply this analysis technique to create a composite predictor of burnout among surgical residents. Our method determines subgroups of residents sharing unique traits predictive of burnout. Residencies can use this tool to allocate resources to best support resident well-being.

Invasive Staging Procedures Do Not Prevent Nodal Metastases From Being Missed in Stage I Lung Cancer.

BACKGROUND: Up to 20% of clinical stage I lung cancer patients harbor lymph node metastases that go undetected (missed) during the clinical staging evaluation. We investigated to what degree the addition of invasive nodal staging procedures to imaging, as currently practiced, prevents radiographically occult nodal metastases from being missed during the clinical staging evaluation. METHODS: Treatment-naive patients, imaged by positron emission tomography and computed tomography, who underwent lobectomy for clinical stage I lung cancer from 2012 to 2017 in The Society of Thoracic Surgeons General Thoracic Surgery Database were studied. Rates of missed nodal metastases (MNM) (ie, nodal metastases in lobectomy specimens undetected during clinical staging evaluation) were determined. Risk factors were assessed with multivariable modeling. RESULTS: Of the 30,685 clinical stage I patients identified, 3895 (12.7%) underwent preoperative endobronchial ultrasound and 3341 (10.9%) underwent mediastinoscopy. Invasive staging was more common with tumors > 2 cm (66.4% vs 50.2%, P < .001) and squamous histology (26.9% vs 16.9%, P < .001). MNM were discovered in 14.7% of patients, including 20.1% of patients (95% confidence interval, 18.8%-21.5%) who had undergone endobronchial ultrasound and 18.2% (95% confidence interval, 16.7%-19.6%) who had undergone mediastinoscopy. Hilar nodes were most often "missed" (9.5%). Using cut-points in tumor size, histology, laterality, and age, patients could be stratified into particularly high-risk (25% MNM) and low-risk (6% MNM) cohorts. CONCLUSIONS: Substantial risk of occult lymph node metastases persists in patients with clinical stage I lung cancer despite negative invasive nodal staging, positron emission tomography, and computed tomography. In the absence of a thorough surgical nodal evaluation, early-stage lung cancer patients are at risk of under-treatment.

Liver-first approach to stage IV colon cancer with synchronous isolated liver metastases.

BACKGROUND: The only possibility for cure in patients with colon adenocarcinoma (CAC) with isolated liver metastases (ILM) is resection of both primary and metastatic tumors. Little is known about the implication of the sequence in which a colectomy and hepatectomy are performed on outcomes. This study analyzes whether resection sequence impacts clinical outcomes. METHODS: The National Cancer Database was queried for CAC cases with hepatic metastases from 2010-2015 with exclusion of extrahepatic metastases. We compared patients treated with a liver-first approach (LFA) to those treated with a colectomy-first or simultaneous approach using Kaplan Meier and multivariable Cox proportional hazards analysis. RESULTS: In 21,788 CAC patients identified, the LFA was uncommon (2%), but was associated with higher rates of completion resection of remaining tumor (41% vs. 22%, P<0.001). Patients selected for LFA were younger, less comorbid, and more commonly received upfront chemotherapy (P<0.05). The LFA was associated with increased median survival [34 months, 95% CI (30.5-39.6 months) vs. 24 months, 95% CI (23.7-24.6 months), logrank P<0.001] and decreased risk of death [HR 0.783; 95% CI (0.67-0.89), P=0.001]. CONCLUSIONS: The LFA to CAC with synchronous ILM is uncommon but is associated with greater likelihood of receiving chemotherapy prior to surgery and increased survival in selected candidates.

Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted "Star Ratings," which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated. METHODS: Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method). RESULTS: There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life). CONCLUSIONS: Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.

Surgically Managed Signet Ring Cell Esophageal Carcinomas in the National Cancer Database.

BACKGROUND: Signet ring cell adenocarcinoma (SRC) is a less common histologic variant of esophageal adenocarcinoma (ACA). The low frequency of SRC limits the ability to make data-driven clinical recommendations for these patients. METHODS: The National Cancer Database was queried for adult patients with clinical stage I, II, or III adenocarcinoma of the noncervical esophagus diagnosed between 2004 and 2015 and stratified by SRC versus all other ACA variants. Cox proportional hazard regression models were adjusted for patient, tumor, and treatment characteristics. The role of surgery in SRC was evaluated among patients treated with chemoradiation alone versus chemoradiation with esophagectomy. RESULTS: Of the 681 SRC and 13,543 ACA patients who underwent esophagectomy, no significant differences in age, sex, race, or comorbidities were identified. Patients with SRC were more likely to have high-grade tumors (84% vs 41%, P < .001) and stage III tumors (47% vs 39%, P < .001) compared with patients with ACA. Complete (R0) resection was less common in SRC (81% vs 90%, P < .001). Adjusted 5-year mortality risk from surgery was higher for SRC patients compared with ACA patients (hazard ratio, 1.242; 95% confidence interval, 1.126-1.369; P < .001). Among SRC tumors, chemoradiation with esophagectomy was associated with superior survival (hazard ratio, 0.429; 95% confidence interval, 0.339-0.546; P < .001) compared with chemoradiation alone. CONCLUSIONS: Among surgically managed patients SRC appears to have a worse prognosis than ACA, which may reflect the tendency of SRC tumors to be higher grade and more locally advanced. However SRC histology does not appear to diminish the role of esophagectomy in the management of locoregionally confined esophageal cancer.

Big data, big contributions: outcomes research in thoracic surgery.

In recent years, analysis of registry data has defined clinically significant practice patterns and treatment strategies that optimize cancer care for thoracic surgery patients. These higher-order outcome studies rely on large patient cohorts that minimize the risk of selection bias and allow for a powered analysis that is not achievable with single- or multi-institutional data. This review uses recent study examples to highlight important contributions to our knowledge of thoracic surgery and describes how outcomes research using large data can address high impact clinical questions.

Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis.

Importance: The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. Objective: To investigate the association of the timing of colostomy reversal with operative outcomes. Design, Setting, and Participants: This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Exposures: Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Main Outcomes and Measures: Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. Results: In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Conclusions and Relevance: Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.

Prophylactic cranial irradiation is associated with improved survival following resection for limited stage small cell lung cancer.

BACKGROUND: Brain metastases are a major cause of mortality in patients with small cell lung cancer (SCLC). Prophylactic cranial irradiation (PCI) may improve survival among patients that respond to chemotherapy. Less is known about the outcomes of PCI following surgical resection of SCLC. The purpose of this study was to determine if patients who underwent initial surgical resection of SCLC benefit from PCI. METHODS: Adult patients in the National Cancer Database (NCDB) who underwent complete resection for primary, non-metastatic SCLC between 2004 and 2015 were identified. Patients that received preoperative chemotherapy or who did not receive appropriate adjuvant chemotherapy were excluded. Patients were grouped by treatment with or without cranial radiation within 8 months of resection. Survival was estimated using Kaplan-Meier and Cox multivariable analysis, adjusting for patient and tumor characteristics. RESULTS: A total of 859 patients met inclusion criteria (202 received PCI and 657 did not). Kaplan-Meier analysis demonstrated that patients treated with PCI had significantly improved survival compared to no PCI (5-year survival 59% vs. 50%, logrank P=0.0038). Multivariable cox models confirmed a significantly decreased hazard of death for patients receiving PCI (HR: 0.70, 95% CI: 0.55-0.89, P=0.003). In subset analyses, PCI was associated with significantly improved survival for node positive patients, but not node negative patients. CONCLUSIONS: PCI is associated with increased survival for patients following surgical resection of SCLC. Patients with positive lymph nodes appear to benefit the most, while it remains unclear if patients with negative lymph nodes derive a benefit. Further study is warranted to clarify which subsets of patients should be treated with PCI.

Variable impact of prior cancer history on the survival of lung cancer patients.

INTRODUCTION: Non-Small Cell Lung Cancer (NSCLC) is commonly diagnosed in patients who have survived a prior malignancy. However, it is currently unclear whether NSCLC patient survival is impacted by the potential for previously-treated malignancies to recur. Understanding the impact of a prior cancer history on NSCLC survival could not only enhance decision making but could affect eligibility for NSCLC studies. METHODS: The National Cancer Database (NCDB) was queried for NSCLC patients (stage I-IV) diagnosed between 2004-2014. Kaplan-Meier survival curves and multivariable Cox proportional hazards regression models were estimated to analyze overall survival across a variety of treatment approaches and stages in the presence and absence of a prior cancer history. RESULTS: A total of 821,323 patients with a newly diagnosed NSCLC were identified including 179,512 (21.9%) with a prior history of cancer. The unadjusted 5-year overall survival of patients with a prior cancer history (9.8%) was slightly better to those without a cancer history (9.5%, 95% CI 11.76-11.84, P < 0.0001). However, adjusted analyses revealed the impact of prior cancer history was extremely heterogenous across stage and treatment approach. Ultimately, 51.4% of patients fell into a subgroup in which prior cancer history appeared to compromise survival, 16.3% in which the difference was not significant, and 32.3% in which prior cancer was associated with increased survival. Patients with earlier-staged tumors were the most negatively NSCLC impacted by prior cancer history. CONCLUSIONS: The association between prior cancer history and survival of newly diagnosed NSCLC patients is highly variable and to some degree reflects a patient's potential for cure.

Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery.

Importance: Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. Objective: To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. Design, Setting, and Participants: A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. Exposures: Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. Main Outcomes and Measures: Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. Results: A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). Conclusions and Relevance: The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.

Evaluating the adoption of primary anastomosis with proximal diversion for emergent cases of surgically managed diverticulitis.

BACKGROUND: Although Hartmann procedure is common for operatively managed acute diverticulitis, there is accumulating evidence that primary anastomosis with proximal small bowel diversion is safe, even in emergent cases. This study seeks to clarify the current adoption of primary anastomosis with proximal small bowel diversion among emergent, operatively managed cases of acute diverticulitis and compare outcomes between primary anastomosis with proximal small bowel diversion and Hartmann procedure. METHODS: Patients who underwent open, emergent Hartmann procedure or primary anastomosis with proximal small bowel diversion for a primary diagnosis of diverticulitis between 2005 and 2015 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program. Outcomes were compared with logistic regression adjusted for patient and operative characteristics. RESULTS: From 2005-2015 the proportion of primary anastomosis with proximal small bowel diversion decreased from 33% to 17% among emergent cases. Although mortality and complications were similar, primary anastomosis with proximal small bowel diversion resulted in a greater risk of returning to the operating room in emergent cases (odds ratio = 1.35, 95% confidence interval: 1.06-1.74). CONCLUSION: Despite previous suggestions of clinical equipoise, the adoption of primary anastomosis with proximal small bowel diversion for emergent, operatively managed acute diverticulitis among National Surgical Quality Improvement Program hospitals appears to be decreasing. Primary anastomosis with proximal small bowel diversion resulted in increased return to the operating room for emergent cases, suggesting that caution should be exercised in selecting primary anastomosis with proximal small bowel diversion for emergent cases.

Primary Salivary Type Lung Cancers in the National Cancer Database.

BACKGROUND: Primary salivary type lung cancers such as adenoid cystic carcinoma (ACC) and mucoepidermoid carcinoma (MEC) are uncommon primary lung tumors that, given their rarity, remain incompletely understood. This study aimed to characterize the management and outcomes associated with these less common pulmonary malignancies. METHODS: Patients in the National Cancer Database diagnosed with primary lung and bronchial (not tracheal) MEC and ACC between 2004 and 2014 were identified. Adjusted mortality risk of surgically managed patients was evaluated in multivariable Cox proportional hazards regression models. RESULTS: In all, 699 MEC patients and 424 ACC patients were identified. The MEC tumors were smaller (mean size 3.1 cm versus 3.8 cm, p < 0.001), less likely to have lymph node metastases (16% versus 38%, p < 0.001), and less likely to undergo pneumonectomy (9% versus 39%, p < 0.001) compared with ACC. Adjusted Cox models of the surgically managed subset of MEC patients identified high tumor grade (hazard ratio [HR] 3.0, 95% confidence interval [CI]: 1.31 to 7.1, p = 0.01), tumor size greater than 4 cm (HR 6.7, 95% CI: 2.0 to 22.0, p = 0.01), and wedge resection (HR 3.7, 95% CI: 1.1 to 12.0, p = 0.03) to be associated with increased risk of death. For ACC patients, incomplete tumor resection, R1 versus R0 (HR 4.0, 95% CI: 1.5 to 10.6, p = 0.006), and distant metastases (HR 12.6, 95% CI: 2.5 to 64.4, p = 0.002) were associated with increased mortality. CONCLUSIONS: Pulmonary MEC and ACC appear to have distinct physical and oncologic attributes in the National Cancer Database. Although the overall prognosis appears to be favorable, there are subsets of primary salivary type lung cancers with increased mortality risk, and efforts should be made to completely resect these tumors.

Motivators, Barriers, and Facilitators to Traveling to the Safest Hospitals in the United States for Complex Cancer Surgery.

Importance: Directing patients to safer hospitals for complex cancer surgery (regionalization) may prevent thousands of mortalities in the United States. Objective: To understand the potential for individuals to move to safer hospitals: what would inspire them to travel (motivators), what challenges would they face (barriers), and what would enable them to travel (facilitators). Design, Setting, and Participants: This nationally representative online survey study asked respondents to consider complex cancer surgery at their local hospital or a hospital specializing in cancer an hour farther away. Completed surveys were weighted across sociodemographics to be nationally representative and outcomes were reported as weighted percentages. In January 2018, a panel of 1817 US adults recruited by address- and telephone-based sampling to be nationally representative were invited to take the survey. Data analysis was conducted from January 24, 2018, to September 19, 2018. Main Outcomes and Measures: Proportion of respondents motivated to travel by specific quality and safety indicators (motivators), magnitude in difference that would be necessary, proportion facing specific barriers, and proportion enabled to move by facilitators. Resistant individuals were identified as people who would not travel except for the largest (top quartile) outcomes differences. Results: There were 1016 completed surveys (response rate of 55.9%). The weighted median age was 48 years, 52% were female, median annual income was between $60 000 and $75 000, and 85% lived in a metropolitan area. Nonresponders were more likely than responders to be female, younger, nonwhite, less educated, and lower income (female: 54.4% vs 48.3%; P = .01; younger [aged <45 years]: 56.3% vs 37.1%; P < .001; nonwhite: 41.6% vs 30.0%; P < .001; less than college education: 43.8% vs 32.4%; P < .001; income <$30 000: 22.1% vs 17.1%; P = .01). Superior safety or oncologic outcomes, presented separately, motivated an average of 92% of respondents (95% CI, 90%-94%) to travel. One-third were easily motivated, requiring less than 1% advantage in safety or quality, while 12% were particularly resistant across outcomes. Respondents with lower income (income <$25 000: odds ratio, 2.01; 95% CI, 1.19-3.39) and nonwhite race (odds ratio, 1.60; 95% CI, 1.05-2.42) were more resistant to travel. At least 1 barrier was identified by 74% of respondents (95% CI, 72%-77%), most commonly financial (costs/insurance). However, 94% of respondents (95% CI, 92%-96%) with barriers would travel if provided facilitators, many of which were relatively low cost (transportation, parking, and hotel). Conclusions and Relevance: It appears that most of the US public could be motivated to travel to safer hospitals for complex cancer surgery, yet most would require some support to move. Further efforts to ensure that benefits from regionalization are equitable across sociodemographic strata are indicated.