'CROSS'-ing into the 'Real World': a retrospective cohort study of patients receiving trimodality and bimodality therapy for esophageal cancer.

Background: A standard of care for nonmetastatic esophageal cancer is trimodality therapy consisting of neoadjuvant chemoradiation and esophagectomy, with evidence for improved overall survival versus surgery alone in the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial. Patients who receive treatment with curative intent but are poor candidates for or decline surgery receive definitive bimodality therapy. Literature characterizing patients who receive bimodality therapy compared to trimodality therapy, and their relative outcomes, is sparse, especially among patients who are too old or too frail to qualify for clinical trials. In this study, we assess a single-institution real-world dataset of patients receiving bimodality and trimodality management. Methods: Patients treated for clinically resectable, nonmetastatic esophageal cancer between 2009 and 2019 who received bimodality or trimodality therapy were reviewed, generating a dataset of 95 patients. Clinical variables and patient characteristics were assessed for association with modality on multivariable logistic regression. Overall, relapse-free, and disease-free survival were assessed with Kaplan-Meier analyses and Cox proportional modeling. For patients nonadherent to planned esophagectomy, reasons for nonadherence were recorded. Results: Bimodality therapy was associated with greater age-adjusted comorbidity index, worse performance status, higher N-stage, presenting symptom other than dysphagia, and held chemotherapy cycles on multivariable analysis. Compared to bimodality therapy, trimodality therapy was associated with higher overall (3-year: 62% vs. 18%, P<0.001), relapse-free (3-year: 71% vs. 18%, P<0.001), and disease-free (3-year: 58% vs. 12%, P<0.001) survival. Similar results were observed among patients who did not meet CROSS trial qualifying criteria. Only treatment modality was associated with overall survival after adjusting for covariates (HR 0.37, P<0.001, reference group: bimodality). Patient choice accounted for 40% of surgery nonadherence in our population. Conclusions: Patients receiving trimodality therapy were observed to have superior overall survival compared to bimodality therapy. Patient preference for organ-preserving therapies appears to impact resection rate; further characterization of patient decision-making may be helpful. Our results suggest patients who wish to prioritize overall survival should be encouraged to pursue trimodality therapy and obtain early consultation with surgery. Development of evidence-based interventions to physiologically prepare patients before and during neoadjuvant therapy as well as efforts to optimize the tolerability of the chemoradiation plan are warranted.

Social Media and the Quest for Equity and Diversity in Oncology: On Safe Spaces and the Concept of the Public Physician.

Despite their increased enrollment into medical school, women still face systemic barriers in medicine, whether in an academic or nonacademic setting. Those from Under-Represented Minority (URM) groups face similar issues, which may affect their desire to enter, pursue, and/or maintain a career in medicine. Social media provides unique opportunities for peer-to-peer support among members of URM communities and for amplification of their voices calling for social justice-here defined as a redistribution of power and the quest for equity in access to opportunities, including access to mentorship, professional development, and timely promotion in academic rank. These issues are relevant to oncologists especially as we strive for diversity, equity, and inclusion and to ensure that our patients have equal access to care, regardless of their circumstances. In this article, we review current literature that highlights issues faced by women and historically URM groups in medicine, particularly in oncology. We also discuss the physician's role as a social justice advocate and the concept of the public physician.

Social Media and Professional Development for Oncology Professionals.

The use of social media continues to increase in health care and academia. Health care practice, particularly the oncologic field, is constantly changing because of new knowledge, evidence-based research, clinical trials, and government policies. Therefore, oncology trainees and professionals continue to strive to stay up-to-date with practice guidelines, research, and skills. Although social media as an educational and professional development tool is no longer completely new to medicine and has been embraced, it is still under-researched in terms of various outcomes. Social media plays several key roles in professional development and academic advancement. We reviewed the literature to evaluate how social media can be used for professional development and academic promotion of oncology professionals.

NKX2.2, PDX-1 and CDX-2 as potential biomarkers to differentiate well-differentiated neuroendocrine tumors.

BACKGROUND: Well-differentiated neuroendocrine tumors (NET) most frequently arise from the gastrointestinal tract (GI), pancreas, and lung. Patients often present as metastasis with an unknown primary, and the clinical management and outcome depend on multiple factors, including the accurate diagnosis with the tumor primary site. Determining the site of the NET with unknown primary remains challenging. Many biomarkers have been investigated in primary NETs and metastatic NETs, with heterogeneous sensitivity and specificity observed. METHODS: We used high-throughput tissue microarray (TMA) and immunohistochemistry (IHC) with antibodies against a panel of transcriptional factors including NKX2.2, PDX-1, PTF1A, and CDX-2 on archived formalin-fixed paraffin-embedded NETs, and investigated the protein expression pattern of these transcription factors in 109 primary GI (N = 81), pancreatic (N = 17), and lung (N = 11) NETs. RESULTS: Differential expression pattern of these markers was observed. In the GI and pancreatic NETs (N = 98), NKX2.2, PDX-1, and CDX-2 were immunoreactive in 82 (84%), 14 (14%), and 52 (52%) cases, respectively. PDX-1 was expressed mainly in the small intestinal and appendiceal NETs, occasionally in the pancreatic NETs, and not in the colorectal NETs. All three biomarkers including NKX2.2, PDX-1, and CDX-2 were completely negative in lung NETs. PTF1A was expressed in all normal and neuroendocrine tumor cells. CONCLUSIONS: Our findings suggest that NKX2.2 was a sensitive and specific biomarker for the GI and pancreatic neuroendocrine tumors. We proposed that a panel of immunostains including NKX2.2, PDX-1, and CDX-2 may show diagnostic utility for the most common NETs.

Teams and Teamwork in Cancer Care Delivery: Shared Mental Models to Improve Planning for Discharge and Coordination of Follow-Up Care.

This article discusses the potential for shared mental models to improve teamwork during discharge planning and follow-up care. A 58-year-old inpatient on the hematology care unit of an academic medical center was discharged to his community after initial treatment of acute myeloid leukemia, without a clear plan for either discharge or follow-up. This case highlights the challenges faced by the primary oncology care team, the patient's community health-care team, the patient, and his caregiver, because a formal plan for follow-up care after discharge was not in place. The lack of communication within the oncology care team and between the medical center and community care teams that leads to the gap in continuity of care between inpatient and outpatient oncology settings could be addressed at least in part by establishing a shared mental model. This model would require all individuals involved in patient care to recognize they are part of a team. Furthermore, all members of the interdisciplinary discharge team need to understand their own roles and responsibilities as well as those of the other team members, including the need for communication and how their roles and activities affect those of other team members. Tools such as huddles, checklists, and patient education could be used to help the team recognize and achieve its goals. Ideally, this shared mental model could be extended to include the community health-care team, leading to a more fluid transition between inpatient and outpatient care, improving patient satisfaction, and likely improving patient outcomes.