Disparities in esophageal cancer care based on race: a National Cancer Database analysis.

Esophageal cancer is one of the most common cancer killers in our country. The effects of racial disparities on care for esophageal cancer patients are incompletely understood. Using the National Cancer Database, we investigated racial disparities in treatment and outcome of esophageal cancer patients. The National Cancer Database was queried from 2004 to 2017. Logistic regression and survival analysis were used to determine racial differences in access, treatment and outcome. A total of 127,098 patients were included. All minority groups were more likely to be diagnosed at advanced stages versus Caucasians after adjusting for covariates (African American OR-1.64 [95% confidence interval 1.53-1.76], Hispanic OR-1.19 [1.08-1.32], Asian OR-1.78 [1.55-2.06]). After adjustment, all minorities were less likely at every stage to receive surgery. Despite these disparities, Hispanics and Asians had improved survival compared with Caucasians. African Americans had worse survival. Racial disparities for receiving surgery were present in both academic and community institutions, and at high-volume and low-volume institutions. Surgery partially mediated the survival difference between African Americans and Caucasians (HR-1.13 [1.10-1.16] and HR-1.04 [1.02-1.07], without and with adjustment of surgery).There are racial disparities in the treatment of esophageal cancer. Despite these disparities, Hispanics and Asians have improved overall survival versus Caucasians. African Americans have the worst overall survival. Racial disparities likely affect outcome in esophageal cancer. But other factors, such as epigenetics and tumor biology, may correlate more strongly with outcome for patients with esophageal cancer.

COVID-19 Pandemic and Surgical Oncology: Preserving the Academic Mission.

BACKGROUND: The global pandemic of respiratory disease cause by the novel human coronavirus (SARS-CoV-2) has caused untold suffering, loss of life and upheaval in society. The pandemic has lead to massive redirection of health care resources to treat the surge of COVID-19 patients, and enforcement of social distancing to reduce the rate of transmission. METHODS: Editorial Board members provided observations of the implications of the pandemic on academic surgical oncology. RESULTS: Delivery of health care to other populations including cancer patients has been significantly disrupted. The implications both short term and long term threaten preservation of the academic mission in medicine at large, and certainly in the field of surgical oncology. CONCLUSIONS: The effects on surgical oncology training, research and clinical trials are major.

Effects of proton pump inhibitor use on the esophageal microbial community.

BACKGROUND: Changes in the esophageal microbiome correlate with esophageal disease, but the effects of proton pump inhibitor (PPI) drugs are incompletely characterized. Our objective was to identify the effects of PPI use on the microbial community of the esophagus. METHODS: Mucosal biopsies of the distal esophagus were analyzed using a customized esophageal microbiome qPCR panel array (EMB). Patient demographics, use of PPIs, duration of use and dose were recorded. RESULTS: Fifty-eight patients were included. Mean age was 60.5 years. Ninety percent (52/58) of patients were on PPIs. Mean dose was 42.7 mg. Mean duration of use was 2.5 years. The use of PPIs led to a significant difference in absolute levels of only one organism, Actinomyces, in the entire array (p < 0.01). Among patients who used proton pump inhibitors, there was no significant association between dose and absolute levels of any organism. Similarly, there was no association between duration of use and absolute levels of any organism. CONCLUSIONS: PPI use does not seem to cause significant changes in the distal esophageal microbial community. Future studies with larger sample sizes and esophageal pH testing should be performed to determine the level of acidity and its relationship to the microbial community.

Treatment of clinical T2N0M0 esophageal cancer.

BACKGROUND: Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990-2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population. METHODS: Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan-Meier plots were used for statistical survival analysis. RESULTS: A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival. CONCLUSIONS: EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.

Well-being Through the Synergy of Community Engagement, Health Equity, and Advocacy.

Facets of well-being for cardiothoracic surgeons include interconnectivity, or a sense of belonging within a community, and social relatedness. Striving for health equity achieves a sense of belonging and meaning to one's work. In "Elevating Health Equity: The Synergy of Community Engagement and Advocacy," the imperative for mentorship and diversification within health care is expounded, establishing a multitiered blueprint for equity. Integral to this framework is the nurturing of a heterogeneous health care workforce, ameliorating racial and gender disparities in patient care. This article puts forth an intricate, empirically substantiated roadmap toward a more empathic and efficacious health care system.

Transdiaphragmatic sarcomatoid carcinoma of the lung: A case report.

INTRODUCTION: Pulmonary sarcomatoid carcinoma is a very rare primary tumor of the lung. Although usually aggressive, these tumors have not been described previously to invade through the diaphragm into the liver. We present a patient with a pulmonary sarcomatoid carcinoma with transdiaphragmatic spread into the dome of the liver. PRESENTATION OF CASE: An 82-year-old female with a lifetime non-smoking history presented with generalized fatigue, fever, night sweats, cough, and pleuritic chest pain. She had recently traveled to the western United States. Additionally, she had recently undergone periodontal deep cleaning with no peri-procedural antibiotics. Laboratory testing was significant for a leukocytosis of 13.5 white blood cells per microliter and a negative viral panel. Computed tomography and magnetic resonance imaging revealed a large heterogeneous mass extending from the right pulmonary hilum through the diaphragm. Although initial radiology reports suggested hepatic abscess, percutaneous fine needle aspiration was performed. Biopsy revealed pulmonary sarcomatoid carcinoma. She was begun on systemic treatment. DISCUSSION: Pulmonary sarcomatoid carcinoma can exhibit transdiaphragmatic invasion into the liver. This clinical situation can easily be confused with a hepatic abscess, but suspicion should remain for abscess. Clinical suspicion for neoplasm should warrant biopsy when technically possible. CONCLUSION: Although hepatic abscesses can exhibit transdiaphragmatic spread into the chest, pulmonary sarcomatoid carcinoma can also invade the abdomen. Biopsy should be performed during the evaluation and workup of the patient.

Influence of Air Quality on Lung Cancer in People Who Have Never Smoked.

OBJECTIVE: Lung cancer is the leading cause of cancer-related death. The percentage of people who have never smoked with lung cancer has risen recently, but alternative risk factors require further study. Our goal was to determine the impact of air quality on incidence of lung cancer in people who have smoked or never smoked. METHODS: The Cancer Registry from a large urban medical center was queried to include every new diagnosis of lung cancer from 2013 to 2021. Air quality and pollution data for the county were obtained from the United States Environmental Protection Agency from 1980 to 2018. Patient demographics, location of residence, smoking history and tumor stage were recorded. Bivariate comparison analyses were conducted in R. RESULTS: A total of 2,223 new cases of lung cancer were identified. Mean age was 69.2 years. There was a nonsmoking rate of 8.1 percent. A total of 37 percent of patients identified as a racial minority. People who have never smoked were more likely to be diagnosed at an advanced stage. When analyzing geographic distribution, incidence of lung cancer among people who have never smoked was more closely associated with highly polluted areas. People who have never smoked with lung cancer had significantly higher exposure levels of multiple pollutants. CONCLUSIONS: Newly diagnosed lung cancer appears to be more related to poor air quality among people who have never smoked than people who have smoked. Future studies are needed to examine the associations of specific pollutants with lung cancer incidence.

Non-IgG4-Related Fibrosing Mediastinitis Diagnosed on Core Needle Biopsy and Treated with Steroids: A Case Study and Review of the Differential Diagnoses.

OBJECTIVES: This study aimed to investigate the histological characteristics and treatment efficacy of non-immunoglobulin G4-related fibrosing mediastinitis and discuss differential diagnoses for this rare entity. METHODS: We present a case study of non-immunoglobulin G4-related fibrosing mediastinitis diagnosed on core biopsy and treated with steroids. A total of four 18-gauge core needle biopsy specimens were obtained for surgical pathology. Analysis of the patient's medical history, radiological characteristics of fibrosing mediastinitis, histological features, immunohistochemistry results, the differential diagnosis and treatment efficacy of different types of fibrosing mediastinitis was performed. RESULTS: This report describes a unique presentation of fibrosing mediastinitis (syncope and weight loss) that was concerning for malignancy. Histological, laboratory and radiographical studies confirmed the diagnosis of non-immunoglobulin G4-related fibrosing mediastinitis. The patient received corticosteroid treatment which showed marked improvement after 1 month of treatment. CONCLUSIONS: Fibrosing mediastinitis is an extremely uncommon entity with unknown pathogenesis, and it is more important to rule out malignancy and infection than to delineate between fibrosing mediastinitis and IgG4-related disease. In doing this, we may reasonably initiate a trial of corticosteroids which may prove beneficial, as in this patient. More studies on the pathogenesis of fibrosing mediastinitis are necessary to guide better directed treatments.

Trauma pneumonectomy followed by extracorporeal membrane oxygenation cannulation: a case report.

Background: Trauma pneumonectomy remains an incredibly morbid procedure, reserved for the most critical cases where it is the only surgical option to stop massive ongoing hemorrhage. There are only few cases reported in the literature of survivors of trauma pneumonectomy complicated by acute respiratory distress syndrome (ARDS). We present our case of long-term survival in this circumstance. Given the limited published research on survival after prolonged veno-venous extracorporeal membrane oxygenation (VV-ECMO), it is important to share our experiences using VV-ECMO as an adjunct for pulmonary recovery. Case Description: We present a case of a 35-year-old male patient who survived a gunshot wound to the right lung following trauma pneumonectomy with the assistance of VV-ECMO. He developed postoperative hemodynamic instability and required 38 days of VV-ECMO. He ultimately survived discharge from the hospital. One year after his gunshot injury, the patient was living at home with assistance. Urgent VV-ECMO cannulation and a multi-disciplinary approach was lifesaving in the treatment of this patient's post-pneumonectomy ARDS. Conclusions: In review of the literature, ECMO has been used in a few other cases of ARDS following trauma pneumonectomy to allow for full pulmonary recovery. This case highlights the challenges following this morbid procedure, however with a multidisciplinary approach and urgent use of ECMO, a favorable outcome can be achieved.

Spatial and spatio-temporal clusters of lung cancer incidence by stage of disease in Michigan, United States 1985-2018.

Lung cancer is the most common cause of cancer-related death in Michigan. Most patients are diagnosed at advanced stages of the disease. There is a need to detect clusters of lung cancer incidence over time, to generate new hypotheses about causation and identify high-risk areas for screening and treatment. The Michigan Cancer Surveillance database of individual lung cancer cases, 1985 to 2018 was used for this study. Spatial and spatiotemporal clusters of lung cancer and level of disease (localized, regional and distant) were detected using discrete Poisson spatial scan statistics at the zip code level over the study time period. The approach detected cancer clusters in cities such as Battle Creek, Sterling Heights and St. Clair County that occurred prior to year 2000 but not afterwards. In the northern area of the lower peninsula and the upper peninsula clusters of late-stage lung cancer emerged after year 2000. In Otter Lake Township and southwest Detroit, late-stage lung cancer clusters persisted. Public and patient education about lung cancer screening programs must remain a health priority in order to optimize lung cancer surveillance. Interventions should also involve programs such as telemedicine to reduce advanced stage disease in remote areas. In cities such as Detroit, residents often live near industry that emits air pollutants. Future research should therefore, continue to focus on the geography of lung cancer to uncover place-based risks and in response, the need for screening and health care services.

Regional trends in diagnosis of advanced lung cancer in Michigan over 33 years.

Background: Lung cancer is the most common cancer killer worldwide. Nearly 80 percent of lung cancers are diagnosed at advanced stages. Lack of access to medical care and undwerutilized lung cancer screening are key reasons for advanced diagnoses. We sought to understand the regional differences in presentation of lung cancer across Michigan. Utilizing a comprehensive cancer registry over 33 years, our goal was to examine associations between sociodemographic patient factors and diagnoses at advanced stages. Methods: The Michigan Cancer Registry was queried from 1985 to 2018 to include all new diagnoses of non-small cell lung cancer (NSCLC) using International Classification of Diseases for Oncology (ICD-O) version 3 codes. NSCLC was categorized as early, regional and distant disease. Advanced disease was considered to be any disease that was regional or distant. NSCLC rates were calculated and mapped at the zip code level using the 2010 population as the denominator and spatial empirical Bayes methodology. Regional hospital service areas were constructed using travel time to treatment from the patient's zip code centroid. Logistic regression models were estimated to investigate the significance of rural vs. urban and travel time on level of disease at presentation. Kaplan-Meier and multivariate survival analysis was performed to evaluate the association between distance from the nearest medical center and length of survival controlling for known risk factors for lung cancer. Results: From 1985 to 2018, there were 141,977 patients in Michigan diagnosed with NSCLC. In 1985, men were 2.2 times more likely than women to be diagnosed but by 2018 women and men developed disease at equal rates. Mean age was 67.8 years. Among all patients with known stage of disease, 72.5% of patients were diagnosed with advanced disease. Regional and distant NSCLC rates were both higher in the northern parts of the state. Longer drive times in rural regions also significantly increased the likelihood of advanced NSCLC diagnoses, in particular regional lung cancer. Patients with longer drive times also experienced overall worse survival after controlling for other factors. Conclusions: Regional disparities exist in Michigan for diagnoses of NSCLC at advanced stages. Factors such as lack of screening in urban regions and distances to treating institutions in rural areas likely contribute to the increased likelihood of advanced NSCLC. Future interventions should target the specific needs of residents to detect disease at earlier stages and improve overall outcomes.

Association of Social Determinants with Patient-Reported Outcomes in Patients with Cancer.

Patient-reported outcome (PRO) scores have been utilized more frequently, but the relationship of PRO scores to determinants of health and social inequities has not been widely studied. Our goal was to determine the association of PRO scores with social determinants. All patients with a new cancer diagnosis who completed a PRO survey from 2020 to 2022 were included. The PRO survey recorded scores for depression, fatigue, pain interference and physical function. Higher depression, fatigue and pain scores indicated more distress. Higher physical condition scores indicated improved functionality. A total of 1090 patients were included. Married patients had significantly better individual PRO scores for each domain. Patients who were able to use the online portal to complete their survey also had better individual scores. Male patients and non-White patients had worse pain scores than female and White patients, respectively. Patients with prostate cancer had the best scores while patients with head and neck and lung cancer had the worst scores. PRO scores varied by cancer disease site and stage. Social support may act in combination with specific patient/tumor factors to influence PRO scores. These findings present opportunities to address patient support at institutional levels.

Lung Cancer and Air Quality in a Large Urban County in the United States.

Lung cancer is the leading cancer-related killer in the United States. The incidence varies geographically and may be affected by environmental pollutants. Our goal was to determine associations within time series for specific air pollutants and lung cancer cases over a 33-year period in Wayne County, Michigan, controlling for population change. Lung cancer data for Wayne County were queried from the Michigan Cancer Registry from 1985 to 2018. Air pollutant data were obtained from the United States Environmental Protection Agency from 1980 to 2018. Autoregressive distributed lag (ARDL) models were estimated to investigate time lags in years between specific air pollution levels and lung cancer development. A total of 58,866 cases of lung cancer were identified. The mean age was 67.8 years. Females accounted for 53 percent of all cases in 2018 compared to 44 percent in 1985. Three major clusters of lung cancer incidence were detected with the most intense clusters in downtown Detroit and the heavily industrialized downriver area. Sulfur dioxide (SO2) had the strongest statistically significant relationship with lung cancer, showing both short- and long-term effects (lag range, 1-15 years). Particulate matter (PM2.5) (lag range, 1-3 years) and nitrogen dioxide (NO2) (lag range, 2-4 years) had more immediate effects on lung cancer development compared to carbon monoxide (CO) (lag range, 5-6 years), hazardous air pollutants (HAPs) (lag range, 9 years) and lead (Pb) (lag range, 10-12 years), which had more long-term effects on lung cancer development. Areas with poor air quality may benefit from targeted interventions for lung cancer screening and reductions in environmental pollution.

Support service use and interest in support services among distressed family caregivers of lung cancer patients.

OBJECTIVE: This study examined support service use and interest in support services among distressed family caregivers of patients recently entering comprehensive cancer care facilities. METHODS: Primary family caregivers of lung cancer patients (N=83) were recruited from three medical centers within 12 weeks of the patient's new visit to the oncology clinic. All family caregivers were screened for psychological distress, and those reporting significant anxiety or depressive symptoms were eligible for this study. Caregivers completed a baseline assessment of support service use (i.e., use of mental health services and complementary and alternative medicine [CAM]) and interest in support services. Support service use was also assessed 3 months later. RESULTS: Although all caregivers reported clinically meaningful distress, only 26% used mental health and 39% used CAM services during the 3-month study period. Patients' receipt of chemotherapy was positively associated with caregivers' mental health service use, whereas greater education and receiving assistance with caregiving tasks were associated with CAM use. Forty percent of caregivers who did not use CAM at baseline were interested in CAM. In addition, 29% of caregivers who did not receive mental health services at baseline were interested in professional psychosocial support, and 29% of caregivers who did not receive staff assistance with practical needs at baseline were interested in this service. CONCLUSIONS: Findings suggest that distressed family caregivers of lung cancer patients underuse mental health services and that a sizable minority are interested in professional help with psychosocial and practical needs.

Economic and social changes among distressed family caregivers of lung cancer patients.

PURPOSE: Although costs of lung cancer care have been documented, economic and social changes among lung cancer patients' family caregivers have yet to be fully examined. In addition, research has not focused on caregivers with greater need for support services. This study examined various economic and social changes among distressed family caregivers of lung cancer patients during the initial months of cancer care in the USA. METHODS: Lung cancer patients' primary family caregivers with significant anxiety or depressive symptoms were recruited from three medical centers within 12 weeks of the patient's new oncology visit. Caregivers (N = 83) reported demographic and medical information and caregiving burden at baseline. Seventy-four caregivers reported anxiety and depressive symptoms and economic and social changes 3 months later. RESULTS: Seventy-four percent of distressed caregivers experienced one or more adverse economic or social changes since the patient's illness. Common changes included caregivers' disengagement from most social and leisure activities (56%) and, among employed caregivers (n = 49), reduced hours of work (45%). In 18% of cases, a family member quit work or made another major lifestyle change due to caregiving. Additionally, 28% of caregivers reported losing the main source of family income, and 18% reported losing most or all of the family savings. Loss of the main source of family income and disengagement from most social and leisure activities predicted greater caregiver distress. CONCLUSIONS: Findings suggest that distressed caregivers of lung cancer patients experience high rates of adverse economic and social changes that warrant clinical and research attention.

The Role of Sublobar Resection for the Surgical Treatment of Non-Small Cell Lung Cancer.

Lung cancer is the most common cancer killer in the world. The standard of care for surgical treatment of non-small cell lung cancer has been lobectomy. Recent studies have identified that sublobar resection has non-inferior survival rates compared to lobectomy, however. Sublobar resection may increase the number of patients who can tolerate surgery and reduce postoperative pulmonary decline. Sublobar resection appears to have equivalent results to surgery in patients with small, peripheral tumors and no lymph node disease. As the utilization of segmentectomy increases, there may be some centers that perform this operation more than other centers. Care must be taken to ensure that all patients have access to this modality. Future investigations should focus on examining the outcomes from segmentectomy as it is applied more widely. When employed on a broad scale, morbidity and survival rates should be monitored. As segmentectomy is performed more frequently, patients may experience improved postoperative quality of life while maintaining the same oncologic benefit.