Renovating the Commission on Cancer's Quality Measure Portfolio.

IMPORTANCE: Nearly 75% of newly diagnosed cancer patients in the United States will receive care from a hospital that is accredited by the Commission on Cancer (CoC). To support hospitals in their quality assurance efforts, the CoC maintains a portfolio of quality measures to give hospitals compliance data with select best practices for cancer care. As the CoC quality measures have evolved over recent years, many clinicians may lack awareness of the intent and content of the measure portfolio, as well as the mechanism by which new measures originate. OBSERVATIONS: The CoC quality measures are based on data that hospitals submit to the National Cancer Database, allowing the CoC to track compliance with a subset of consensus best practices. Each year, new measures are designed by diverse teams of specialists in the different treatment modalities for the tumor types covered by the portfolio. These proposed measures are then subjected to a range of vetting, refinement, and prioritization steps before being voted into the portfolio by the Quality Assurance and Data Committee of the CoC. Over the past 4 years, the CoC has worked to renovate not only the portfolio but also the process used to create and launch new measures, revise existing measures, and retire obsolete measures. CONCLUSION AND RELEVANCE: In the following overview, we outline the current measure process, highlight important changes to the portfolio, and share opportunities to further increase the impact.

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.

Expanded Indications for Neoadjuvant Endocrine Therapy in Early-Stage Breast Cancer During the COVID-19 Pandemic.

BACKGROUND: In response to the COVID-19 pandemic, the Pandemic Breast Cancer Consortium (PBCC) published recommendations for triage of breast cancer patients. The recommendations included neoadjuvant treatment of early-stage breast cancer patients experiencing delays in surgery. This study evaluated national patterns of neoadjuvant treatment according to triage guidelines. METHODS: Patients treated with surgery (upfront or post-neoadjuvant) in 2018-2020 were collected from the National Cancer Database. The proportions of patients treated according to the PBCC triage guidelines were calculated in 2020 and compared with similar cohorts in 2018-2019. Patient and hospital factors were evaluated for association with treatment. RESULTS: Among cT1N0 ER+/PR+/HER2- patients, those treated in 2020 were more likely to receive neoadjuvant endocrine therapy (NET) compared with those before that time (odds ratio [OR], 3.08; range, 2.93-3.24). Among the patients with cT2N0 or cT1N1 disease, NET was more common in 2020 (OR, 1.76; range, 1.65-1.88). Academic facility, black or Asian race, more comorbidities, and the New England/Middle Atlantic region were associated with NET use. CONCLUSIONS: During the COVID-19 pandemic, expanded utilization of neoadjuvant therapy for surgical breast cancer patients was observed. Health care system limitations during the pandemic contributed to expanded adoption of neoadjuvant therapy for early breast cancer, contrary to usual practice. Long-term outcomes for patients treated according to PBCC recommendations should be closely monitored.

Addressing Data Aggregation and Data Inequity in Race and Ethnicity Reporting and the Impact on Breast Cancer Disparities.

Collecting and reporting data on race and ethnicity is vital to understanding and addressing health disparities in the United States. These health disparities can include increased prevalence and severity of disease, poorer health outcomes, decreased access to healthcare, etc., in disadvantaged populations compared with advantaged groups. Without these data, researchers, administrators, public health practitioners, and policymakers are unable to identify the need for targeted interventions and assistance. When researching or reporting on race and ethnicity, typically broad racial categories are used. These include White or Caucasian, Black or African American, Asian American, Native Hawaiian or Other Pacific Islander, or American Indian and Alaska Native, as well as categories for ethnicity such as Latino or Hispanic or not Latino or Hispanic. These categories, defined by the Office of Management and Budget, are the minimum standards for collecting and reporting race and ethnicity data across federal agencies. Of note, these categories have not been updated since 1997. The lack of accurate and comprehensive data on marginalized racial and ethnic groups limits our understanding of and ability to address health disparities. This has implications for breast cancer outcomes in various populations in this country. In this paper, we examine the impact data inequity and the lack of data equity centered processes have in providing appropriate prevention and intervention efforts and resource allocations.

A Medium-Term Comparison of Quality of Life and Pain After Robotic or Laparoscopic Cholecystectomy.

INTRODUCTION: We sought to compare medium-term outcomes between robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC) using validated quality of life (QoL) and pain assessments. MATERIALS AND METHODS: Patients who underwent RC or LC between 2012 and 2017 at a single academic institution were examined. Cases converted to open were excluded. Patients were contacted by telephone in 2019 and completed two standardized surveys to rate their QoL and pain. RESULTS: Of those screened, 122 (35.8%) completed both surveys. Ninety three (76.2%) underwent RC and 29 (23.8%) underwent LC. The groups (RC versus LC) were similar based on mean age (47.9 versus 45.5 y, P = 0.48), gender (66.7% versus 72.4% female, P = 0.56), race (86.0% White/5.4% Black versus 72.4% White/13.8% Black, P = 0.2), insurance status (98.9% versus 100.0% insured, P = 0.58), median body mass index (31.8 versus 31.3, P = 0.43), and median Charlson Comorbidity Index (1 versus 0, P = 0.14). Fewer RC patients had a history of steroid use compared to LC (16.1% versus 34.5%, P = 0.03). No overall significant difference in QoL was demonstrated. LC group had higher severity of "tiring-exhausting pain" (P = 0.04), "electric-shock pain" (P = 0.003), and "shooting pain" (P = 0.05). The "overall intensity" of pain in the "gallbladder region" between the groups was similar at the time of follow-up (P = 0.31). CONCLUSIONS: QoL over 2-7 y following time of surgery is comparable for robotic-assisted versus conventional laparoscopic cholecystectomies. The laparoscopic approach may be associated with a higher severity of subset categories of pain, but overall pain between the two approaches is comparable.

Women speaker representation at SAGES annual meetings: a cross-sectional analysis.

BACKGROUND: Gender representation trends at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Annual Meetings and the effect of the 2018 'We R SAGES' initiatives are unknown. We assessed gender trends in oral presentations at the SAGES Annual Meeting between 2012 and 2022 with a focus on assessing the impact of the 2018 initiatives. METHODS: Abstracts selected for oral presentations from 2012 to 2022 were reviewed for presenter and first, second, and senior author gender. Gender was categorized as woman, man, or unknown using public professional profiles. Subsequent publications were identified using search engines. The primary outcome was the temporal trend of proportion of women in each role using interrupted time series analysis. Secondary outcomes included publication rates based on first and senior author genders in 2012-2018 versus 2019-2022. RESULTS: 1605 abstracts were reviewed. The proportion of women increased linearly in all categories: presenter (2.4%/year, R2 = 0.91), first author (2.4%/year, R2 = 0.90), senior author (2%/year, R2 = 0.65), and overall (2.2%, R2 = 0.91), (p < 0.01 for all). Prior to 2018, the proportion of women increased annually for presenters (coefficient: 0.026, 95% CI [0.016, 0.037], p = 0.002) and first authors (coefficient: 0.026, 95% CI [0.016, 0.037], p = 0.002), but there was no significant increase after 2018 (p > 0.05). Female second author proportion increased annually prior to 2018 (coefficient: 0.012, 95% CI [0.003, 0.021], p = 0.042) and increased by 0.139 (95% CI [0.070, 0.208], p = 0.006) in 2018. Annual female senior author proportion did not significantly change after 2018 (p > 0.05). 1198 (75.2%) abstracts led to publications. Women were as likely as men to be first (79% vs 77%, p = 0.284) or senior author (79% vs 77%, p = 0.702) in abstracts culminating in publications. There was no difference in woman first author publication rate before and after 2018 (80% vs 79%, p = 1.000), but woman senior author publication rate increased after 2018 (71% vs 83%, p = 0.032). CONCLUSION: There was an upward trend in women surgeons' presentations and associated publications in the SAGES Annual Meetings over the last decade.

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.

Evaluation of the Impact of the COVID-19 Pandemic on Reliability of Cancer Surveillance Data in the National Cancer Database.

PURPOSE: This study evaluated the reliability of cancer cases reported to the National Cancer Database (NCDB) during 2020, the first year of the COVID-19 pandemic. METHODS: Total number of cancer cases reported to the NCDB between January 2018 and December 2020 were calculated for all cancers and 21 selected cancer sites. The additive outlier method was used to identify structural breaks in trends compared with previous years. The difference between expected (estimated using the vector autoregressive method) and observed number of cases diagnosed in 2020 was estimated using generalized estimating equation under assumptions of the Poisson distribution for count data. Interrupted time series analysis was used to compare changes in the number of records processed by registrars each month of 2020. All models accounted for seasonality, regional variation, and random error. RESULTS: There was a statistically significant decrease (structural break) in the number of cases diagnosed in April 2020, with no recovery in number of cases during subsequent months, leading to a 12.4% deficit in the number of cases diagnosed during the first year of the pandemic. While the number of cancer records initiated by cancer registrars also decreased, the number of records marked completed increased during the first months of the pandemic. CONCLUSION: There was a significant deficit in the number of cancer diagnoses in 2020 that was not due to cancer registrars' inability to extract data during the pandemic. Future studies can use NCDB data to evaluate the impact of the pandemic on cancer care and outcomes.

Lessons in Cultural Adaptations: Translation of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Cervical Cancer Module From English to Chichewa in Malawi.

INTRODUCTION: To complete a culturally appropriate translation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Cervical Cancer module (QLQ-CX24) from English to Chichewa (one of the official languages of Malawi) in preparation for postsurgical outcomes research in rural Malawian cervical cancer patients. METHODS: Following the EORTC translation procedure manual, two distinct forward translations from English were reconciled into a preliminary Chichewa translation, followed by two distinct back-translations to English. The English back-translation was reconciled and the translation report sent for discussion and proofreading by EORTC; this was followed by pilot testing. All translators were physicians fluent in English and Chichewa. RESULTS: Of 24 questions in QLQ-CX24, three had prior translations available; all three required revision to clarify tense or wording. Three discussion exchanges with EORTC refined the translation and ensured faithfulness to the original English meaning; proofreaders contributed minor changes. Pilot testing was completed on 10 female patients (three with cervical cancer, four suspicious cervical lesions, and three screening only). Three patients were illiterate. During pilot testing, translation of question 46 (Q46) was misunderstood as referring to vaginal discharge instead of feeling "feminine". The remaining questions were understood, with minor feedback for six questions. Final revision of Q46 yielded a phrase describing "feminine" as "appearance or activities as a woman". Concepts comparable to "feminine" were absent in the Chichewa language/regional Malawian culture. The final revision of Q46 was pilot-tested on five patients (three illiterate) and found acceptable. CONCLUSIONS: Translation of the QLQ-CX24 module was completed successfully and revealed absence of the modern concept of femininity in Chichewa language and regional Malawian culture. Care should be taken when creating and translating healthcare-related documents for surgical research to ensure broad applicability across cultures.

Timeliness of Multimodal Care for At-Risk Breast Cancer Patients at a Safety Net Institution.

INTRODUCTION: Because limited data exist, we sought to evaluate timeliness of multimodal treatments in a safety net breast cancer population. METHODS: Breast cancer patients treated at a safety net hospital from 2016 to 2020 were analyzed retrospectively. Time intervals were defined as primary time (PT) from diagnosis to initiation of primary intervention, secondary time (ST) from completion of primary to initiation of secondary intervention, and tertiary time (TT) from completion of secondary to initiation of tertiary intervention. Variables included primary language, insurance type, and race. RESULTS: Of 223 patients, 99 (44.4%) primarily spoke Spanish, 29 (13.0%) were of Black race, and 184 (82.5%) had Medicaid or uninsured status. Median (IQR) age at diagnosis was 55 (48-62) years. Primary intervention was surgical in 127/216 (58.8%); secondary intervention was systemic in 38/169 (22.5%); and tertiary intervention was radiation in 67/80 (83.8%). Overall, median days (IQR) for PT were 69 (53, 98), ST were 65 (42, 95), and TT were 69 (43, 88). PT was significantly longer in Black [105 (76, 142) days] patients compared to non-Hispanic White patients [68 (51, 107) days, P = 0.031)] and White Hispanic patients [65 (53,91) days, P = 0.014]. There were no significant differences in PT, ST, or TT by spoken language or insurance type. CONCLUSIONS: Black patients remain at risk due to prolonged time to intervention. Spanish-speaking status was not associated with inferior timeliness or completion of multimodal care at a safety net hospital. Identifying safety net hospital barriers to achieving benchmarks for timely completion of all phases of multimodal care warrants further attention.

Twenty-Five Years of Cancer Follow-Up; Is the Data Worth the Effort?

BACKGROUND: Substantial resources are dedicated to long-term follow-up within cancer registries; however, the completeness of these data is poorly characterized. Our objectives were to quantify long-term cancer follow-up data completeness and the effort required to collect these data using the National Cancer Database (NCDB). METHODS: To quantify data completeness, patients diagnosed with cancer in 1989 were identified in the NCDB and loss to follow-up rates were assessed for 25 years after diagnosis. To quantify data collection effort, patients diagnosed from 1989 to 2014 who were alive and eligible for follow-up in 2014 were identified and the effort to perform patient follow-up was obtained via a survey of tumor registrars. The effort to perform follow-up beyond various intervals after diagnosis was calculated. RESULTS: In total, 484,201 patients at 958 hospitals were diagnosed with cancer in 1989. After 5 years, 6.5% of patients were lost to follow-up (13.1% of living patients), 50.3% were deceased, and 43.2% had ongoing follow-up. After 15 years, 22.9% were lost to follow-up (68.7% of living patients), 66.7% were deceased, and 10.5% had ongoing follow-up. By 25 years, loss to follow-up increased to 28.6% (93.7% of living patients), 69.5% were deceased, and 1.9% had ongoing follow-up. In 2014, 522,838 h were spent performing follow-up for 2,091,353 patients at 1456 hospitals who were >15 years from their initial cancer diagnosis. CONCLUSIONS: While 5-year follow-up is excellent in the NCDB, loss to follow-up increases over time. The impact of curtailing data collection is under investigation and follow-up duration requirements will be re-evaluated.

Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital.

INTRODUCTION: Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively. METHODS: We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language. RESULTS: Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046). CONCLUSIONS: Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.

Omission of Radiation in Conservative Treatment for Breast Cancer: Opportunity for De-escalation of Care.

INTRODUCTION: De-escalation of breast cancer treatment aims to reduce patient and financial toxicity without compromising outcomes. Level I evidence and National Comprehensive Cancer Network guidelines support omission of adjuvant radiation in patients aged >70 y with hormone-sensitive, pT1N0M0 invasive breast cancer treated with endocrine therapy. We evaluated radiation use in patients eligible for guideline concordant omission of radiation. METHODS: Subgroup analysis of patients eligible for radiation omission from two pooled randomized controlled trials, which included stage 0-III breast cancer patients undergoing breast conserving surgery, was performed to evaluate factors associated with radiation use. RESULTS: Of 631 patients, 47 (7.4%) met radiation omission criteria and were treated by 14 surgeons at eight institutions. The mean age was 75.3 (standard deviation + 4.4) y. Majority of patients identified as White (n = 46; 97.9%) and non-Hispanic (n = 44; 93.6%). The mean tumor size was 1.0 cm; 37 patients (88.1%) had ductal, 4 patients (9.5%) had lobular, and 17 patients (40.5%) had low-grade disease. Among patients eligible for radiation omission, 34 (72.3%) patients received adjuvant radiation. Those who received radiation were significantly younger than those who did not (74 y, interquartile range = 4 y, versus 78 y, interquartile range = 11 y, P = 0.03). There was no difference in radiation use based on size (P = 0.4), histology (P = 0.5), grade (P = 0.7), race (P = 1), ethnicity (P = 0.6), institution (P = 0.1), gender of the surgeon (P = 0.7), or surgeon (P = 0.1). CONCLUSIONS: Fewer than 10% of patients undergoing breast conservation met criteria for radiation omission. Nearly three-quarters received radiation therapy with younger age being a driver of radiation use, suggesting ample opportunity for de-escalation, particularly among younger eligible patients.

Evaluating information loss in the National Cancer Database from cases lost to follow-up.

BACKGROUND AND OBJECTIVES: Cancer registries must focus on data capture which returns value while reducing resource burden with minimal loss of data. Identifying the optimum length of follow-up data collection for patients with cancer achieves this goal. METHODS: A two-step analysis using entropy calculations to assess information gain for each follow-up year, and second-order differences to compare survival outcomes between the defined follow-up periods and lifetime follow-up. A total of 391 567 adult cases, deidentified in the National Cancer Database and diagnosed in 1989. Comparisons examined a subset of 61 908 lung cancer cases, 48 387 colon and rectal cancer cases, and 64 134 breast cancer cases in adults. A total of 4133 pediatric cases were diagnosed in 1989 examining 1065 leukemia cases and 494 lymphoma cases. RESULTS: Annual increases in information gain fell below 1% after 16 years of follow-up for adult cases and 9 years for pediatric cases. Comparison of second-order differences showed 62% of the comparisons were similar between 15 years and lifetime follow-up when examining restricted mean survival time. In addition, 90% of the comparisons were statistically similar when comparing hazard ratios. CONCLUSIONS: Survival analysis using 15 years postdiagnosis follow-up showed minimal differences in information gain compared to lifetime follow-up.

Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial.

OBJECTIVE: Single-center studies have demonstrated that resection of cavity shave margins (CSM) halves the rate of positive margins and re-excision in breast cancer patients undergoing partial mastectomy (PM). We sought to determine if these findings were externally generalizable across practice settings. METHODS: In this multicenter randomized controlled trial occurring in 9 centers across the United States, stage 0-III breast cancer patients undergoing PM were randomly assigned to either have resection of CSM ("shave" group) or not ("no shave" group). Randomization occurred intraoperatively, after the surgeon had completed their standard PM. Primary outcome measures were positive margin and re-excision rates. RESULTS: Between July 28, 2016 and April 13, 2018, 400 patients were enrolled in this trial. Four patients (2 in each arm) did not meet inclusion criteria after randomization, leaving 396 patients for analysis: 196 in the "shave" group and 200 to the "no shave" group. Median patient age was 65 years (range; 29-94). Groups were well matched at baseline for demographic and clinicopathologic factors. Prior to randomization, positive margin rates were similar in the "shave" and "no shave" groups (76/196 (38.8%) vs. 72/200 (36.0%), respectively, P = 0.604). After randomization, those in the "shave" group were significantly less likely than those in the "no shave" group to have positive margins (19/196 (9.7%) vs. 72/200 (36.0%), P < 0.001), and to require re-excision or mastectomy for margin clearance (17/196 (8.7%) vs. 47/200 (23.5%), P < 0.001). CONCLUSION: Resection of CSM significantly reduces positive margin and re-excision rates in patients undergoing PM.

Improvement in Breast Reconstruction Disparities following Medicaid Expansion under the Affordable Care Act.

BACKGROUND:  Under the Affordable Care Act, Medicaid expansion effective 1 January 2014 aimed to increase access to health care. We sought to determine the association of Medicaid expansion with disparities in utilization of breast reconstruction. METHODS: Non-Hispanic Black (NHB) and White (NHW) breast cancer patients undergoing mastectomy +/- reconstruction between 2010 and 2017 were selected from the National Cancer Database. Annual trends for utilization of breast reconstruction by race, income, and education were evaluated by Medicaid expansion status using difference-in-differences regression analyses. Medicaid expansion was categorized by expansion date as early (2010-2013), 2014 (1/2014), late (after 1/2014), or no expansion. RESULTS: Of 443,607 patients, 36.3% (n = 161,128) underwent reconstruction, 13.1% (n = 58,249) were NHB, 16.8% (n = 74,430) had median income < $40,227, and 17.1% (n = 75,718) were in the lowest education quartile. In non-expansion states, lower proportions of NHB patients underwent reconstruction than NHW patients in all years, with the smallest disparity (NHB% - NHW%) (- 6.4%) in 2017. Decreases in disparities between NHB and NHW patients were seen with the smallest difference observed in 2014 (- 2.5%) in early-expansion states, in 2017 (- 0.7%) in 1/2014 expansion states, and in 2017 (- 4.5%) in late-expansion states. Similar findings for convergence of reconstruction utilization rates for the lowest two education levels and lowest two income quartiles were found with Medicaid expansion, with no convergence seen in non-expansion states over the study period. CONCLUSIONS: Some improvement in breast reconstruction disparities followed Medicaid expansion. Failure to improve parity without Medicaid expansion should be a consideration with any modifications to Medicaid access.

The Impact of Primary Tumor Surgery on Survival in HER2 Positive Stage IV Breast Cancer Patients in the Current Era of Targeted Therapy.

OBJECTIVE: We sought to examine the impact of primary tumor resection on survival in HER2+ stage IV breast cancer patients in the era of HER2 targeted therapy. METHODS: We conducted a retrospective cohort study of women with HER2+ stage IV breast cancer in the National Cancer Database from 2010 to 2012 comparing those who did and did not undergo definitive breast surgery. RESULTS: Of 3231 patients, treatment included primary site surgery in 35.0%; chemo/targeted therapy in 89.4%; endocrine therapy in 37.7%; and radiation in 31.8%. Surgery was associated with Medicare/other government (OR 1.36, 95% CI 1.03-1.81) or private insurance (OR 1.93, 95% CI 1.53-2.42) versus none/Medicaid, radiation (OR 2.10, 95% CI 1.76-2.51), chemo/targeted therapy (OR 1.99, 95% CI 1.47-2.70), and endocrine therapy (OR 1.73, 95% CI 1.40-2.14). Non-Hispanic Black versus White patients (OR 0.68, 95% CI 0.53-0.87) were less likely to have surgery. Overall mortality was associated with insurance (Medicare/other government versus none/Medicaid, HR 0.36, p < 0.0001), receipt of chemo/targeted therapy (HR 0.76, p = 0.008), endocrine therapy (HR 0.70, p = 0.0006), and radiation therapy (HR 1.33, p = 0.0009), NH Black versus White race/ethnicity (HR 1.39, p = 0.002), visceral versus bone-only metastases (HR 1.44, p = 0.0003), and lowest versus highest income quartile (HR 1.36, p = 0.01). Propensity score analysis showed surgery was associated with improved survival versus no surgery (HR 0.56, 95% CI 0.40-0.77). CONCLUSIONS: Surgery of the primary site for metastatic HER2+ breast cancer is associated with improved overall survival in selected patients.

Has Breast Surgery Shattered the Glass Ceiling? Trends in Female Representation at The American Society of Breast Surgeons Annual Meeting 2009-2019.

BACKGROUND: Our study sought to evaluate gender representation and the impact of gender on the large volume of research presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, the largest breast surgery meeting in the United States. METHODS: Publicly available ASBrS meeting programs and proceedings from 2009 to 2019 were reviewed to ascertain proportions of female engagement in society positions, contributions to scientific sessions, and subsequent manuscript publications. Trend analyses for temporal changes in gender representation and univariate tests of associations between authorship gender and publication success were performed. RESULTS: Women comprised 44.8% of members of the board of directors, 41.7% of committee chairs, and 54.8% of committee members. There were significant annual increased proportions of female committee members (3.2% per year, p = 0.01) and chairs (6.0% per year, p = 0.03). Women represented > 50% of all speakership positions, except keynote (42.2%). For oral, quickshot, and poster scientific presentations, > 70% of first authors and > 60% of senior authors were women. The meeting-related publication rate with female senior authorship was higher than that with male senior authorship (41.0% vs. 36.3%, p = 0.04). CONCLUSIONS: Although female surgeons remain a minority at most conferences, women have represented the majority of participants in committees, speakership, and scientific presentations at the ASBrS Annual Meeting over the past 10 years. The glass ceiling in breast surgery has been shattered, but efforts to improve gender equity must continue, not only in breast surgery, but all surgical specialties.

Gastric Cancer Peritoneal Carcinomatosis Risk Score.

BACKGROUND: Gastric cancer (GC) peritoneal carcinomatosis (PC) is associated with a poor prognosis. Although grade, histology, and stage are associated with PC, the cumulative risk of PC when multiple risk factors are present is unknown. This study aimed to develop a cumulative GCPC risk score based on individual demographic/tumor characteristics. METHODS: Patient-level data (2004-2014) from the California Cancer Registry were reviewed by creating a keyword search algorithm to identify patients with gastric PC. Multivariable logistic regression was used to assess demographic/tumor characteristics associated with PC in a randomly selected testing cohort. Scores were assigned to risk factors based on beta coefficients from the logistic regression result, and these scores were applied to the remainder of the subjects (validation cohort). The summed scores of each risk factor formed the total risk score. These were grouped, showing the percentages of patients with PC. RESULTS: The study identified 4285 patients with gastric adenocarcinoma (2757 males, 64.3%). The median age of the patients was 67 years (interquartile range [IQR], 20 years). Most of the patients were non-Hispanic white (n = 1748, 40.8%), with proximal (n = 1675, 39.1%) and poorly differentiated (n = 2908, 67.9%) tumors. The characteristics most highly associated with PC were T4 (odds ratio [OR], 3.12; 95% confidence interval [CI], 2.19-4.44), overlapping location (OR 2.27; 95% CI 1.52-3.39), age of 20-40 years (OR 3.42; 95% CI 2.24-5.21), and Hispanic ethnicity (OR 1.86; 95% CI 1.36-2.54). The demographic/tumor characteristics used in the risk score included age, race/ethnicity, T stage, histology, tumor grade, and location. Increasing GCPC score was associated with increasing percentage of patients with PC. CONCLUSION: Based on demographic/tumor characteristics in GC, it is possible to distinguish groups with varying odds for PC. Understanding the risk for PC based on the cumulative effect of high-risk features can help clinicians to customize surveillance strategies and can aid in early identification of PC.

Reporting and Abstracting Variability in Technical Standards for Breast Cancer Operations.

BACKGROUND: The American College of Surgeons Commission on Cancer has incorporated documentation of critical elements outlined in Operative Standards for Cancer Surgery into revised standards for cancer center accreditation. This study assessed the current documentation of critical elements in partial mastectomy (PM) and sentinel lymph node biopsy (SLNB) operative reports. MATERIALS AND METHODS: Operative reports for PM + SLNB at a single academic institution from 2013 to 2018 were reviewed for compliance and surveyor interobserver reliability with the Oncologic Elements of Operative Record defined in Operative Standards and compared with a nonredundant American Society of Breast Surgeons Mastery of Breast Surgery (MBS) quality measure for specimen orientation. RESULTS: Ten reviewers each evaluated 66 PM + SLNB operative reports for 13 Oncologic Elements and one MBS measure. No operative records reported all critical elements for PM + SLNB or PM alone. Residents completed 36.4% of operative reports: Element documentation was similar for PM but varied significantly for SLNB between resident and attending authorship. Combined reporting performance and interrater reliability varied across all elements and was highest for the use of SLNB tracer (97.1% and κ = 0.95, respectively) and lowest for intraoperative assessment of SLNB (30.6%, κ = 0.43). MBS specimen orientation had both high proportion reported (87.0%) and interrater reliability (κ = 0.84). CONCLUSIONS: Adherence to reporting critical elements for PM and SLNB varied. Whether differential compliance was tied to discrepancies in documentation or reviewer abstraction, clarification of synoptic choices may improve reporting consistency. Evolving techniques or technologies will require continuous appraisal of mandated reporting for breast surgery.