Reexamining Time From Breast Cancer Diagnosis to Primary Breast Surgery.

Importance: Although longer times from breast cancer diagnosis to primary surgery have been associated with worse survival outcomes, the specific time point after which it is disadvantageous to have surgery is unknown. Identifying an acceptable time to surgery would help inform patients, clinicians, and the health care system. Objective: To examine the association between time from breast cancer diagnosis to surgery (in weeks) and overall survival and to describe factors associated with surgical delay. The hypothesis that there is an association between time to surgery and overall survival was tested. Design, Setting, and Participants: This was a case series study that used National Cancer Database (NCDB) data from female individuals diagnosed with breast cancer from 2010 to 2014 (with 5-year follow-up to 2019). The NCDB uses hospital registry data from greater than 1500 Commission on Cancer-accredited facilities, accounting for 70% of all cancers diagnosed in the US. Included participants were females 18 years or older with stage I to III ductal or lobular breast cancer who underwent surgery as the first course of treatment. Patients with prior breast cancer, missing receptor information, neoadjuvant or experimental therapy, or who were diagnosed with breast cancer on the date of their primary surgery were excluded. Multivariable Cox regression was used to evaluate factors associated with overall survival. Patients were censored at death or last follow-up. Covariates included age and tumor characteristics. Multinomial regression was performed to identify factors associated with longer time to surgery, using surgery 30 days or less from diagnosis as the reference group. Data were analyzed from March 15 to July 7, 2022. Exposures: Time to receipt of primary breast surgery. Measures: The primary outcome measure was overall survival. Results: The final cohort included 373 334 patients (median [IQR] age, 61 [51-70] years). On multivariable Cox regression analysis, time to surgery 9 weeks (57-63 days) or later after diagnosis was associated with worse overall survival (hazard ratio, 1.15; 95% CI, 1.08-1.23; P < .001) compared with surgery between 0 to 4 weeks (1-28 days). By multinomial regression, factors associated with longer times to surgery (using surgery 1-30 days from diagnosis as a reference) included the following: (1) younger age, eg, the adjusted odds ratio (OR) for patients 45 years or younger undergoing surgery 31 to 60 days from diagnosis was 1.32 (95% CI, 1.28-1.38); 61 to 74 days, 1.64 (95% CI, 1.52-1.78); and greater than 74 days, 1.58 (95% CI, 1.46-1.71); (2) uninsured or Medicaid status, eg, the adjusted OR for patients with Medicaid undergoing surgery 31 to 60 days from diagnosis was 1.35 (95% CI, 1.30-1.39); 61 to 74 days, 2.13 (95% CI, 2.01-2.26); and greater than 74 days, 3.42 (95% CI, 3.25-3.61); and (3) lower neighborhood household income, eg, the adjusted OR for patients with household income less than $38,000 undergoing surgery 31 to 60 days from diagnosis was 1.35 (95% CI, 1.02-1.07); 61 to 74 days, 1.21 (95% CI, 1.15-1.27); and greater than 74 days, 1.53 (95% CI, 1.46-1.61). Conclusions and Relevance: Findings of this case series study suggest the use of 8 weeks or less as a quality metric for time to surgery. Time to surgery of greater than 8 weeks may partly be associated with disadvantageous social determinants of health.

What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?

INTRODUCTION: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC. METHODS: An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS). RESULTS: In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395-25,240). Median length of stay (LOS) was 8 (7-11.5) days and ICU stay was 1 (1-1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS. DISCUSSION: Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.

Development and Assessment of the Wisconsin Surgical Coaching Rubric.

Importance: Surgical coaching continues to gain momentum as an innovative method for continuous professional development. A tool to measure the performance of a surgical coach is needed to provide formative feedback to coaches for continued skill development and to assess the fidelity of a coaching intervention for future research and dissemination. Objective: To evaluate the validity of the Wisconsin Surgical Coaching Rubric (WiSCoR), a novel tool to assess the performance of a peer surgical coach. Design, Setting, and Participants: Surgical coaching sessions from November 2014 through February 2018 conducted by 2 statewide peer surgical coaching programs were audio recorded and transcribed. Twelve raters used WiSCoR to rate the performance of the surgical coach for each session. The study included peer surgical coaches in the Wisconsin Surgical Coaching Program (n = 8) and the Michigan Bariatric Surgery Collaborative coaching program (n = 15). The data were analyzed in 2019. Interventions or Exposures: Use of WiSCoR to rate peer surgical coaching sessions. Main Outcomes and Measures: There were 282 WiSCoR ratings from the 106 coaching sessions included in the study. WiSCoR was evaluated using a framework, including inter-rater reliability assessed with Gwet weighted agreement coefficent. Descriptive statistics of WiSCoR were calculated. Results: Eight coaches (35%) and 11 coachees (29%) were from the Wisconsin Surgical Program and 15 coaches (65%) and 27 coachees (71%) were from the Michigan Bariatric Surgery Collaborative. The validity of WiSCoR is supported by high interrater reliability (Gwet weighted agreement coefficient, 0.87) as well as a weakly positive correlation of WiSCoR to coachee ratings of coaches (r = 0.22; P = .04), rigorous content development, consistent rater training, and the association of WiSCoR with coach and coaching program development. The mean (SD) overall coach performance rating using WiSCoR was 3.23 (0.82; range, 1-5). Conclusions and Relevance: WiSCoR is a reliable measure that can assess the performance of a surgical coach, inform fidelity to coaching principles, and provide formative feedback to surgical coaches. While coachee ratings may reflect coachee satisfaction, they are not able to determine the quality of a coach.