Trends in Racial and Ethnic Differences in Declined Surgery for Resectable Malignancies in the United States.

OBJECTIVE: To assess trends in patients' decisions to decline cancer surgery in the United States by race and ethnicity. BACKGROUND: Racial and ethnic differences in declining potentially curative cancer surgery are suggested to be due to systemic inequities in healthcare access and mistrust of healthcare systems, among other factors. Despite ongoing national efforts to address these inequities, it is unknown whether differences in rates of declined cancer surgery have improved. METHODS: Using population-based data from the US Surveillance, Epidemiology, and End Results Program from 2000 to 2019, we studied individuals with non-metastatic cancer who were recommended surgery. Racial and ethnic differences in risk-adjusted rates of declined surgery were evaluated by year and cancer site using mixed-effects logistic regression. RESULTS: Of 2,740,129 patients with resectable, non-metastatic cancer, Black patients had the highest rates of declined surgery (2.10% [95% CI, 1.91-2.31%]) while White patients had the lowest (1.04% [95% CI, 0.95-1.14%]). From 2000 to 2019, racial and ethnic differences in declined surgery did not change significantly, except for a decrease in the difference between Hispanic and White patients (difference-in-difference, -0.4% [95% CI, -0.71% to -0.09%]). When stratified by cancer site, Black-White differences in rates of declined surgery decreased significantly (but were not eliminated) for four of fifteen sites (esophageal, pancreatic, lung, and kidney) ( P <0.001). CONCLUSIONS: Patients from racial and ethnic minority groups were more likely to decline surgical intervention for potentially curable malignancies and these differences have persisted over time. Further work is needed to understand the causes of these differences and identify opportunities for improvement.

Perceptions of Mobile Health Technology in Elective Surgery: A Qualitative Study of North American Surgeons.

OBJECTIVES: To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth. BACKGROUND: Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited. METHODS: This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed. RESULTS: Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care. CONCLUSIONS: These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.

Association of Receipt of Systemic Treatment for Melanoma With Insurance Type in North Carolina.

BACKGROUND: Previous studies of hospital-based patients with metastatic melanoma suggest sociodemographic factors, including insurance type, may be associated with the receipt of systemic treatments. OBJECTIVES: To examine whether insurance type is associated with the receipt of systemic treatment among patients with melanoma in a broad cohort of patients in North Carolina. METHODS: We conducted a retrospective cohort study between 2011 and 2017 of patients with stages III-IV melanoma using data from the North Carolina Central Cancer Registry linked to Medicare, Medicaid, and private health insurance claims across the state. The primary outcome was the receipt of any systemic treatment, and the secondary outcome was the receipt of immunotherapy. RESULTS: A total of 372 patients met the inclusion criteria. The average age was 68 years old (interquartile range: 56-76) and 61% were male. Within the cohort 48% had Medicare only, 29% had private insurance, 12% had both Medicare and Medicaid, and 11% had Medicaid only. A total of 186 (50%) patients received systemic treatment for melanoma, 125 (67%) of whom received immunotherapy. The use of systemic therapy, including immunotherapy, increased significantly over time. Having Medicaid-only insurance was independently associated with a 45% lower likelihood of receiving any systemic treatment [0.55 (95% CI: 0.35, 0.85)] and a 43% lower likelihood of receipt of immunotherapy [0.57 (95% CI: 0.34, 0.95)] compared with private insurance. CONCLUSIONS: Stage III-IV melanoma patients with Medicaid-only insurance were less likely to receive systemic therapy or immunotherapy than patients with private insurance or Medicare insurance. This finding raises concerns about insurance-based disparities in treatment access.

Examining Public Communication About Surgical Cancer Care on Twitter.

INTRODUCTION: Social media platforms like Twitter are highly utilized for communicating about cancer care. Although surgery is the primary curative treatment for solid malignancies, little is known about online communication behaviors regarding this treatment modality. This study tracked online discussions and characterized participants to better characterize the content of public communication about surgical cancer care. METHODS: Tweets referencing cancer surgery were collected from 2018 to 2021 using Twitter's Application Programming Interface. Metadata (e.g., profile biography, follower count) was used to predict user demographic information. Natural language processing was performed using Latent Dirichlet Allocation to identify common themes of conversation and mentioned cancer sites. RESULTS: There were 442,840 tweets about cancer surgery by 262,168 users, including individuals (65%), influencers (1.5%), surgeons (1%), and oncologists (0.5%). Following the onset of the COVID-19 pandemic, tweets mentioning delays in care increased by 21.7% (1971-57,846 tweets). Individuals commonly mentioned surgical costs (20.3%) and postoperative recovery (21.6%). Surgeons and oncologists frequently mentioned research (52.7%), but infrequently mentioned community support (7.8%) or survivorship (9.3%). Relative to their prevalence, neurologic cancers were most discussed (231 tweets per 1000 operations) while thoracic (29 tweets per 1000 operations) and urologic cancers were least discussed (12 tweets per 1000 operations). CONCLUSIONS: Twitter was utilized by patients to discuss real-time issues such as COVID-19-related surgical delays and the financial burden of cancer surgery. Further efforts to improve community outreach may be optimized by targeting greater discussion of undermentioned cancer types and encouraging clinicians to participate in discussions about community-centered themes.

Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain.

BACKGROUND: Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear. QUESTIONS/PURPOSES: (1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life? METHODS: We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors. RESULTS: After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [ß] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (ß = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (ß = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (ß = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (ß = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively. CONCLUSION: There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes. LEVEL OF EVIDENCE: Level II, prognostic study.

Smartphone-based Assessment of Preoperative Decision Conflict and Postoperative Physical Activity Among Patients Undergoing Cancer Surgery: A Prospective Cohort Study.

OBJECTIVE: To determine the prevalence of clinically significant decision conflict (CSDC) among patients undergoing cancer surgery and associations with postoperative physical activity, as measured through smartphone accelerometer data. BACKGROUND: Patients with cancer face challenging treatment decisions, which may lead to CSDC. CSDC negatively affects patient-provider relationships, psychosocial functioning, and health-related quality of life; however, physical manifestations of CSDC remain poorly characterized. METHODS: Adult smartphone-owners undergoing surgery for breast, skin-soft-tissue, head-and-neck, or abdominal cancer (July 2017-2019) were approached. Patients downloaded the Beiwe application that delivered the Decision Conflict Scale (DCS) preoperatively and collected smartphone accelerometer data continuously from enrollment through 6 months postop-eratively. Restricted-cubic-spline regression, adjusting for a priori potential confounders (age, type of surgery, support status, and postoperative complications) was used to determine trends in postoperative daily physical activity among patients with and without CSDC (DCS score >25/100). RESULTS: Among 99 patients who downloaded the application, 85 completed the DCS (86% participation rate). Twenty-three (27%) reported CSDC. These patients were younger (mean age 48.3 years [standard deviation 14.2]-vs-55.0 [13.3], P = 0.047) and more frequently lived alone (22%-vs-6%, P = 0.042). There were no differences in preoperative physical activity (115.4 minutes [95%CI 90.9, 139.9]-vs-110.8 [95%CI 95.7, 126.0], P = 0.753). Adjusted postoperative physical activity was lower among patients reporting CSDC at 30 days (difference 33.1 minutes [95%CI 5.93,60.2], P = 0.017), 60 days 35.5 [95%CI 8.50, 62.5], P = 0.010 and 90 days 31.8 [95%CI 5.44, 58.1], P = 0.018 postoperatively. CONCLUSIONS: CSDC was prevalent among patients who underwent cancer surgery and associated with lower postoperatively daily physical activity. These data highlight the importance of addressing modifiable decisional needs of patients through enhanced shared decision-making.

Enhancing Patient-Centered Surgical Care With Mobile Health Technology.

From smartphones or wearables to portable physiologic sensors and apps, healthcare is witnessing an exponential growth in mHealth-digital health tools used to support medical and surgical care, as well as public health. In surgery, there is interest in harnessing the capabilities of mHealth to improve the quality of patient-centered care delivery. Digitally delivered surveys have enhanced patient-reported outcome measurement and patient engagement throughout care. Wearable devices and sensors have allowed for the assessment of physical fitness before surgery and during recovery. Smartphone-based digital phenotyping has introduced novel methods of integrating multiple data streams (accelerometer, global positioning system, call and text logs) to create multidimensional digital health footprints for patients following surgery. Yet, with all the technological sophistication and 'big data' mHealth provides, widespread implementation has been elusive. Do clinicians and patients find these data valuable or clinically actionable? How can mHealth become integrated into the day-to-day workflows of surgical systems? Do these data represent opportunities to address disparities of care or worsen them? In this review, we discuss experiences and future opportunities to use mHealth to enhance patient-centered surgical care.

Merkel cell carcinoma in a young man with AIDS-related Kaposi sarcoma.

Merkel cell carcinoma (MCC) is a rare, aggressive primary neuroendocrine carcinoma of the skin that can present in immunocompromised patients. Kaposi sarcoma (KS) is an indolent angioproliferative tumor associated with human herpesvirus 8 (HHV8). The concurrence of both MCC and KS is rare, and there have been limited cases reported in the literature. We present a rare case of concurrent MCC and KS in an immunocompromised patient. To our knowledge, this is the first report of MCC and KS described in the same histopathological specimen. A 37-year-old Black male with a history of recurrent AIDS-related KS involving bilateral lower extremities was evaluated for a tender nodule on the left posterior leg. A punch biopsy was consistent with MCC. Magnetic resonance imaging brain and full-body positron emission tomography/computed tomography (PET/CT) scan were without evidence of distant metastasis. The patient underwent wide local excision with negative margins and completed postoperative radiation therapy. However, he later developed cutaneous metastasis of MCC to the left medial thigh and excision revealed residual MCC with adjacent KS. Treatment is still ongoing with pembrolizumab for both KS and MCC.

Feasibility and performance of smartphone-based daily micro-surveys among patients recovering from cancer surgery.

AIMS: Daily micro-surveys, or the high-frequency administration of patient-reported outcome measures (PROMs), may provide real-time, unbiased assessments of health-related quality of life (HRQoL). We evaluated the feasibility and accuracy of daily micro-surveys using a smartphone platform among patients recovering from cancer surgery. METHODS: In a prospective study (2017-2019), patients undergoing cancer surgery downloaded a smartphone application that administered daily micro-surveys comprising five randomly selected items from the Short Form-36 (SF-36). Micro-surveys were administered without replacement until the entire SF-36 was administered weekly. The full-length SF-36 was also administered preoperatively and 4, 12, and 24 weeks postoperatively. We assessed response and completion rates between the micro-surveys and full-length SF-36, as well as agreement of responses using Bland-Altman (B&A) analyses. RESULTS: Ninety-five patients downloaded the application and were followed for a mean of 131 days [SD ± 85]. Response rates for the full-length SF-36 and micro-surveys was 76% [95%CI 69, 83], and 34% [95%CI 26, 39]. Despite lower response rates, more SF-36 surveys were collected using the daily micro-surveys compared to the intermittent full-length SF-36 (9.9 [95%CI 8.4, 12.6] vs. 3.0 [95%CI 2.8, 3.3], respectively). B&A analyses demonstrated lack of agreement between micro-surveys and SF-36. However, agreement improved with higher micro-survey completion rate. Eighty-five percent of participants reported that daily micro-surveys were not burdensome. CONCLUSION: This study suggests that collection of daily micro-surveys among patients recovering from cancer surgery is feasible using smartphones in the early postoperative period. Future implementation of daily micro-surveys may more granularly describe momentary HRQoL changes through a greater volume of self-reported survey data.

The Evidence Behind Robot-Assisted Abdominopelvic Surgery : A Systematic Review.

BACKGROUND: Use of robot-assisted surgery has increased dramatically since its advent in the 1980s, and nearly all surgical subspecialties have adopted it. However, whether it has advantages compared with laparoscopy or open surgery is unknown. PURPOSE: To assess the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults. DATA SOURCES: PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2021. STUDY SELECTION: Randomized controlled trials that compared robot-assisted abdominopelvic surgery with laparoscopy, open surgery, or both. DATA EXTRACTION: Two reviewers independently extracted study data and risk of bias. DATA SYNTHESIS: A total of 50 studies with 4898 patients were included. Of the 39 studies that reported incidence of Clavien-Dindo complications, 4 (10%) showed fewer complications with robot-assisted surgery. The majority of studies showed no difference in intraoperative complications, conversion rates, and long-term outcomes. Overall, robot-assisted surgery had longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery. LIMITATIONS: Heterogeneity was present among and within the included surgical subspecialties, which precluded meta-analysis. Several trials may not have been powered to assess relevant differences in outcomes. CONCLUSION: There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes without the existing disadvantages. PRIMARY FUNDING SOURCE: None. (PROSPERO: CRD42020182027).