Cost-Effectiveness Analysis of Total Neoadjuvant Therapy Followed by Radical Resection Versus Conventional Therapy for Locally Advanced Rectal Cancer.

BACKGROUND: Definitive surgery with total mesorectal excision is the mainstay of treatment for locally advanced rectal cancer. Multimodality therapy improves long-term survival. Current standards advise neoadjuvant chemoradiation followed by radical surgery and adjuvant chemotherapy. Nationally, compliance with adjuvant chemotherapy is only 32%. New research evaluates the effectiveness of total neoadjuvant therapy: complete chemotherapy and chemoradiation before surgery. OBJECTIVE: The aim of this study is to determine the favored treatment for locally advanced rectal cancer by comparing the cost-effectiveness of total neoadjuvant therapy and the current standard of care. DESIGN: Decision analytical modeling using long-term costs and 5-year disease-free survival was performed to determine the cost-effectiveness after total neoadjuvant therapy and the current standard of care. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters. SETTINGS: Centers for Medicare & Medicaid Services billing data perspective was adopted and outcomes modeled according to local and national databases and literature consensus. PATIENTS: Adult patients with stage II or III rectal cancer were selected. MAIN OUTCOME MEASURES: Cost-effectiveness in disease-free life-years, incremental cost-effectiveness ratio, and net monetary benefit were determined over a 5-year posttreatment period. The favored strategy was determined based on cost-effectiveness and sensitivity analyses. RESULTS: Cost-effectiveness for total neoadjuvant therapy was 40,708 $/life-year, and, for conventional therapy, cost-effectiveness was 44,248 $/life-year. Sensitivity analysis showed that, for an estimated total neoadjuvant therapy completion rate of 90%, total neoadjuvant therapy would remain the dominant strategy for any adjuvant chemotherapy completion rate of less than 93%. LIMITATIONS: The samples used to calculate completion rates are small, and survival probabilities are based on existing literature, local database values, and consensus estimates. The model encompasses a 5-year time period from diagnosis. CONCLUSIONS: Cost-effectiveness analysis shows that a strategy of total neoadjuvant therapy followed by radical surgery is favored over the current standard of care for locally advanced rectal cancer. Sensitivity analysis shows that a low rate of adjuvant chemotherapy administration plays a key role in decreasing the cost-effectiveness of the current standard of care. See Video Abstract at http://links.lww.com/DCR/A942.

Open in Case of SOAP Emergency: Preparation for and Recovery after Failing to Match.

Failing to secure an internship is an extremely stressful event. In this manuscript we describe a process to prepare students for success, should they fail to match. This process involves an assessment of individual vulnerability, implementing mitigation strategies, developing a comprehensive plan in the event of failing to match, that is executed if the student needs to enter the Supplemental Offer Acceptance Program (SOAP) or the "scramble".

Empowering the Resident Learner.

Surgical resident autonomy is an essential element of the transition from supervised training to independent practice. However, in an age of duty hour restrictions, legislative constraints, increased litigation, and heightened societal expectations, training an autonomous resident proves increasingly difficult. To tackle these barriers to training successful surgeons, the American College of Surgeons Committee on Resident Education initiated the Resident Mentored Autonomy Project. As a subdivision of this project, the Empowered Learner research team here presents a framework for training the self-directed and empowered surgical resident learner. There are many strategies by which surgical faculty, program directors and chairs, and residents themselves may engage to improve resident operative autonomy.

Medical Student Selection.

Medical school admissions committees are tasked with fulfilling the values of their institutions through careful recruitment. Making accurate predictions regarding the enrollment behavior of admitted students is critical to intentionally formulating class composition and impacts long-term physician representation.

Surveillance Colonoscopy Revealing Asymptomatic Low-Grade Appendiceal Mucinous Neoplasm.

Appendicular mucinous neoplasms are a collection of rare tumors with diverse clinical presentations and pathologic potential, which can cause diagnostic and therapeutic challenges. Traditionally, they are diagnosed by radiologic imaging or identified intraoperatively; however, rarely, they may be diagnosed during an endoscopic procedure. In this unusual case, we present the case of a 62-year-old Caucasian male undergoing routine surveillance colonoscopy due to a history of colonic neoplasia. During the colonoscopy, a submucosal, non-bleeding 1cm mass of benign appearance was found in the appendix. Further workup determined the mass was likely a mucocele, and surgical consultation was recommended. The patient denied any symptoms suggestive of a mucinous neoplasm prior to and during evaluation. A laparoscopic appendectomy was subsequently performed, and the histopathology report confirmed the diagnosis of a low-grade appendiceal mucinous neoplasm. The patient recovered without complications and continued to deny any symptoms during his postoperative course and follow-up care. Given their rare incidence and unpredictable nature, appendiceal mucinous neoplasms remain difficult to identify. Discovering a low-grade mucinous neoplasm in an asymptomatic patient via colonoscopy illustrates the spectrum of unique presentations and modalities for diagnosis.

Promoting Access of Osteopathic Medical Students to Surgical Residency Training Programs.

The COVID-19 pandemic has uncovered disparities for allopathic and osteopathic surgical applicants for the upcoming 2021 residency application cycle. It has provided an opportunity for change to the current paradigm in surgical resident selection. This study seeks to quantify the disproportionality of opportunities between allopathic and osteopathic students and provides solutions to level the playing field for all applicants.

Virtual interviews - Utilizing technological affordances as a predictor of applicant confidence.

PURPOSE: In the midst of a pandemic, residency interviews transitioned to a virtual format for the first time. Little is known about the effect this will have on the match process. The study aim is to evaluate resident application processes and perceived outcomes. METHODS: An electronic survey was distributed to 142 colon and rectal surgery residency applicants (95% of total). RESULTS: A total of 77 applicants responded to the survey (54% response rate). Applicants reported high levels of satisfaction with virtual interviews but less comfort. Utilizing the mute button and using notes in a different way from face-to-face interviews were significantly associated with applicant confidence that they ranked the right program highest. A majority of applicants (73%) would recommend virtual interviews next year even if COVID-19 is not a factor. CONCLUSION: While applicants appear generally satisfied with virtual interviews, they also reported less comfort. Applicant confidence was predicted by utilizing the unique technological affordances offered by the virtual platform.