Surgery in combination with systemic chemotherapy is associated with improved survival in stage IV gallbladder cancer.

BACKGROUND: Gallbladder cancer (GBC) is the most common biliary malignancy frequently metastatic at diagnosis with poor prognosis. While surgery remains the standard for early-stage GBC, the role of surgery in patients with metastatic gastrointestinal cancers is expanding due to improvements in systemic therapies. We sought to evaluate the survival of patients with stage IV GBC undergoing surgery in an era of improved multi-agent systemic therapy. METHODS: A retrospective review of the National Cancer Database was performed. Patients with stage IV GBC who underwent systemic therapy were included. Patients who received radiation therapy, palliative therapy or had missing survival data were excluded. Univariable and multivariable analysis was performed. RESULTS: 4,145 patients were identified between 2004 and 2016. Mean age was 69. Surgery combined with systemic therapy predicted improved median survival compared with chemotherapy alone (11.1mo versus 6.8mo, HR 0.65, p < 0.001). Additionally, receipt of treatment after 2011 predicted improved survival (HR 0.86, p < 0.001). Patients treated with multi-agent chemotherapy in combination with surgery were associated with the greatest hazard ratio benefit (0.40, p < 0.001) versus single agent therapy alone. CONCLUSION: Patients with stage IV gallbladder cancer treated with a combination of surgery and chemotherapy are associated with an improved overall survival compared to chemotherapy alone. Patients receiving care during the more recent era demonstrated improved survival. These results support a role for surgery in selected patients with stage IV gallbladder cancer receiving chemotherapy.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study.

OBJECTIVE: A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions. METHODS: We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome. RESULTS: Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care. CONCLUSIONS: Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.