Fragmentation of care in breast cancer: greater than the sum of its parts.

INTRODUCTION: Fragmentation of care (FC, the receipt of care at > 1 institution) has been shown to negatively impact cancer outcomes. Given the multimodal nature of breast cancer treatment, we sought to identify factors associated with FC and its effects on survival of breast cancer patients. METHODS: A retrospective analysis was performed of surgically treated, stage I-III breast cancer patients in the 2004-2020 National Cancer Database, excluding neoadjuvant therapy recipients. Patients were stratified into two groups: FC or non-FC care. Treatment delay was defined as definitive surgery > 60 days after diagnosis. Multivariable logistic regression was performed to identify factors predictive of FC, and survival was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS: Of the 531,644 patients identified, 340,297 (64.0%) received FC. After adjustment, FC (OR 1.27, 95% CI 1.25-1.29) was independently associated with treatment delay. Factors predictive of FC included Hispanic ethnicity (OR 1.04, 95% CI: 1.01-1.07), treatment at comprehensive community cancer programs (OR 1.06, 95% CI: 1.03-1.08) and integrated network cancer programs (OR 1.55, 95% CI: 1.51-1.59), AJCC stage II (OR 1.06, 95% CI 1.05-1.07) and stage III tumors (OR 1.06, 95% CI: 1.02-1.10), and HR + /HER2 + tumors (OR 1.05, 95% CI: 1.02-1.07). Treatment delay was independently associated with increased risk of mortality (HR 1.23, 95% CI 1.20-1.26), whereas FC (HR 0.87, 95% CI 0.86-0.88) showed survival benefit. CONCLUSIONS: While treatment delay negatively impacts survival in breast cancer patients, our findings suggest FC could be a marker for multispecialty care that may mitigate some of these effects.

Oncologic outcomes and survival of modern surgical approaches for gastric gastrointestinal stromal tumor (GIST).

BACKGROUND: Studies have demonstrated comparable outcomes between laparoscopic and open resection of gastrointestinal stromal tumor (GIST). We sought to compare outcomes among robotic, laparoscopic, and open resection of gastric GIST in the era of expanding minimally invasive surgery. METHODS: A retrospective analysis was performed of adult patients with gastric GIST undergoing definitive surgery using the National Cancer Database from 2010 to 2020, excluding cases converted to open. Patients were stratified into minimally invasive surgery (MIS), (combined robotic (R) and laparoscopic (L)), and open (O). Hospital length of stay (LOS), 30-day mortality, 90-day mortality, and margin status were assessed. Subgroup analysis was performed to evaluate outcomes between R and L cohorts. Entropy balancing was used to adjust for intergroup differences. Kaplan-Meier survival estimates were used to compare unadjusted 5-year survival. RESULTS: Of the 15,022 patients (R = 10.4%, L = 44.3%, O = 45.3%), 63.2% were stage I and 70.6% underwent partial gastrectomy. MIS approach was associated with shorter hospital LOS (ß: - 2.58; 95% CI: - 2.82 to - 2.33) and lower odds of 30-day (OR 0.45; 95% CI: 0.30-0.68) and 90-day mortality (OR 0.54; 95% CI: 0.39-0.74) compared to O. Likelihood of R0 resection similar between groups (OR 1.00; 95% CI: 0.88-1.14). Hospital LOS (ß: + 0.25; 95% CI: - 0.14-0.64), odds of 30-day (OR 0.99; 95% CI: 0.40-2.46) and 90-day mortality (OR 0.89; 95% CI: 0.47-1.70), and rate of R0 resection (OR 1.02; 95% CI: 0.82-1.27) were comparable between R and L cohorts. Compared to O, MIS approach was associated with improved 5-year OS (log rank p < 0.001). Overall survival was not significantly different between R and L (log rank p = 0.44). CONCLUSION: These findings suggest that MIS approach may be considered for resection of gastric GIST in select patients. Among patients receiving an MIS approach, the robotic technique can be considered an oncologically safe alternative to laparoscopic surgery.

Robotic major and minor hepatectomy: critical appraisal of learning curve and its impact on outcomes.

BACKGROUND: Robotic hepatectomy has gained increasing acceptance across the US. Although the robotic approach offers significant technical advantages, it is still bound by the individual surgeon's learning curve. Proficiency in this approach should theoretically lead to improved peri-operative outcomes. METHODS: Between 2017 and 2020, data on 148 consecutive robotic hepatectomies performed by a single surgeon was retrospectively analyzed. Using cumulative sum (CUSUM) method, intraoperative blood loss (EBL) and operative time were used to assess learning curves for robotic major (n = 58) and minor (n = 90) hepatectomy patients. Perioperative outcomes were compared in regards with proficiency. RESULTS: Proficiency for robotic major and minor hepatectomy was achieved after 22 cases and 34 cases, respectively. No significant differences were observed in patient demographics or tumor characteristics. For robotic major hepatectomy, when compared to early experience, proficiency was associated with a significant improvement in mean EBL (242 mL vs 118 mL, p = 0.0004), operative time (330 min vs 247 min, p = 0.0002), decreased overall complication rate (23% vs 3%, p = 0.039), and length of hospital stay (5.7 days vs 4.1 days, p = 0.004). No difference in conversion rate, mortality or 30 day readmission was seen. For robotic minor hepatectomy, proficiency was associated with significantly decreased mean EBL (115 mL vs 54 mL, p = 0.005), operative time (168 vs 125 min, p = 0.014), and length of hospital stay (2.8 days vs 2.1 days, p = 0.021). No difference was observed in conversion rate, overall complications, mortality or 30 day readmission. CONCLUSION: In the modern era, robotic hepatectomy offers a safe approach with excellent perioperative outcomes. Post learning curve proficiency is associated with significant improvements in perioperative outcomes in both major and minor hepatectomy. Results from our study can serve as a guide to surgeons and programs looking to adopt this technique.