Prognostic significance of postoperative complications for patients with hepatocellular carcinoma relative to alpha-feto protein and tumor burden score.

BACKGROUND: We sought to elucidate the impact of postoperative complications on patient outcomes relative to differences in alpha-fetoprotein-tumor burden score (ATS) among patients with hepatocellular carcinoma (HCC). METHODS: Patients who underwent resection of HCC between 2000 and 2020 were identified from an international database. Moderate/severe complications were defined using the optimal cut-off value of the comprehensive complication index (CCI) based on the log-rank test. RESULTS: A total of 1124 patients was included. CCI cut-off value of 16.6 was identified as the optimal prognostic threshold. Patients who experienced moderate/severe complications were more likely to have worse recurrence free survival [RFS] versus individuals who had no/mild complications (2-year RFS; no/mild complication: 55.9% vs. moderate/severe complication: 38.1% p < 0.001). Of note, low and medium ATS patients who experienced moderate/severe complications had a higher risk of recurrence (2-year RFS; no/mild complication: postoperative complications 70.0% vs. moderate/severe complication: 51.1%, p = 0.006; medium: no/mild complication: 50.8% vs moderate/severe complication: 56.7%, p = 0.01); however, postoperative complications were not associated with worse outcomes among patients with high ATS (no/mild complication: 39.1% vs. moderate/severe complication: 29.2%, p = 0.20). CONCLUSION: These data serve to emphasize how reduction in postoperative complications may be crucial to improve prognosis, particularly among patients with favorable HCC characteristics.

Association of county-level provider density and social vulnerability with colorectal cancer-related mortality.

BACKGROUND: Health care providers play a crucial role in increasing overall awareness, screening, and treatment of cancer, leading to reduced cancer mortality. We sought to characterize the impact of provider density on colorectal cancer population-level mortality. METHODS: County-level provider data, obtained from the Area Health Resource File between 2016 and 2018, were used to calculate provider density per county. These data were merged with county-level colorectal cancer mortality 2016-2020 data from the Centers for Disease Control and Prevention. Multivariable regression was performed to define the association between provider density and colorectal cancer mortality. RESULTS: Among 2,863 counties included in the analytic cohort, 1,132 (39.5%) and 1,731 (60.5%) counties were categorized as urban and rural, respectively. The colorectal cancer-related crude mortality rate was higher in counties with low provider density versus counties with moderate or high provider density (low = 22.9, moderate = 21.6, high = 19.3 per 100,000 individuals; P < .001). On multivariable analysis, the odds of colorectal cancer mortality were lower in counties with moderate and high provider density versus counties with low provider density (moderate odds ratio 0.97, 95% confidence interval 0.94-0.99; high odds ratio 0.88, 95% confidence interval 0.86-0.91). High provider density remained associated with a lower likelihood of colorectal cancer mortality independent of social vulnerability index (low social vulnerability index and high provider density: odds ratio 0.85, 95% confidence interval 0.81-0.89; high social vulnerability index and high provider density: odds ratio 0.93, 95% confidence interval 0.89-0.98). CONCLUSION: Regardless of social vulnerability index, high county-level provider density was associated with lower colorectal cancer-related mortality. Efforts to increase access to health care providers may improve health care equity, as well as long-term cancer outcomes.

Development and validation of nomograms to predict survival and recurrence after hepatectomy for intermediate/advanced (BCLC stage B/C) hepatocellular carcinoma.

BACKGROUND: Despite the Barcelona Clinic Liver Cancer system discouraging hepatectomy for intermediate/advanced hepatocellular carcinoma, the procedure is still performed worldwide, particularly in Asia. This study aimed to develop and validate nomograms for predicting survival and recurrence for these patients. METHODS: We analyzed patients who underwent curative-intent hepatectomy for intermediate/advanced hepatocellular carcinoma between 2010 and 2020 across 3 Chinese hospitals. The Eastern Hepatobiliary Surgery Hospital cohort was used as the training cohort for the nomogram construction, and the Jilin First Hospital and Fujian Mengchao Hepatobiliary Hospital cohorts served as the external validation cohorts. Independent preoperative predictors for survival and recurrence were identified through univariable and multivariable Cox regression analyses. Predictive accuracy was measured using the concordance index and calibration curves. The predictive performance between nomograms and conventional hepatocellular carcinoma staging systems was compared. RESULTS: A total of 1,328 patients met the inclusion criteria. The nomograms for predicting survival and recurrence were developed using 10 and 6 independent variables, respectively. Nomograms' concordance indices in the training cohort were 0.777 (95% confidence interval 0.759-0.800) and 0.719 (95% confidence interval 0.697-0.742) for survival and recurrence, outperforming 4 conventional staging systems (P < .001). Nomograms accurately stratified risk into low, intermediate, and high subgroups. These results were validated well by 2 external validation cohorts. CONCLUSION: We developed and validated nomograms predicting survival and recurrence for patients with intermediate/advanced hepatocellular carcinoma, contradicting Barcelona Clinic Liver Cancer surgical guidelines. These nomograms may facilitate clinicians to formulate personalized surgical decisions, estimate long-term prognosis, and strategize neoadjuvant/adjuvant anti-recurrence therapy.

Textbook Neoadjuvant Outcome-Novel Composite Measure of Oncological Outcomes among Gastric Cancer Patients Undergoing Multimodal Treatment.

The incidence of gastric cancer (GC) is expected to increase to 1.77 million cases by 2040. To improve treatment outcomes, GC patients are increasingly treated with neoadjuvant chemotherapy (NAC) prior to curative-intent resection. Although NAC enhances locoregional control and comprehensive patient care, survival rates remain poor, and further investigations should establish outcomes assessment of current clinical pathways. Individually assessed parameters have served as benchmarks for treatment quality in the past decades. The Outcome4Medicine Consensus Conference underscores the inadequacy of isolated metrics, leading to increased recognition and adoption of composite measures. One of the most simple and comprehensive is the "All or None" method, which refers to an approach where a specific set of criteria must be fulfilled for an individual to achieve the overall measure. This narrative review aims to present the rationale for the implementation of a novel composite measure, Textbook Neoadjuvant Outcome (TNO). TNO integrates five objective and well-established components: Treatment Toxicity, Laboratory Tests, Imaging, Time to Surgery, and Nutrition. It represents a desired, multidisciplinary care and hospitalization of GC patients undergoing NAC to identify the treatment- and patient-related data required to establish high-quality oncological care further. A key strength of this narrative review is the clinical feasibility and research background supporting the implementation of the first and novel composite measure representing the "ideal" and holistic care among patients with locally advanced esophago-gastric junction (EGJ) and GC in the preoperative period after NAC. Further analysis will correlate clinical outcomes with the prognostic factors evaluated within the TNO framework.

Comprehensive Review of Clinical Presentation, Diagnosis, Management, and Prognosis of Ruptured Hepatocellular Carcinoma.

INTRODUCTION: Spontaneous rupture of hepatocellular carcinoma (rHCC) is a life-threatening complication occurring in 3-15% of patients with HCC. This review discusses the most recent updates in the epidemiology, pathophysiology, risk factors, diagnosis and presentation, management, and prognostic factors of rHCC. METHODS: A comprehensive systematic review was performed using MEDLINE/PubMed and Web of Science databases, with the end of search date being December 1, 2023, regarding rHCC diagnosis, imaging, and management. RESULTS: Achieving adequate hemostasis and stabilization of the patient remains the primary objective in managing patients presenting with rHCC. In earlier studies, the mortality rate in the acute phase of rHCC has been reported to be 25-75%. However, more recent studies reviewed here have demonstrated that transcatheter arterial embolization/chemoembolization (TAE/TACE) followed by elective hepatectomy in select patients may offer significantly improved survival benefits and decrease perioperative complications compared to TAE/TACE alone or emergent/one-stage hepatectomy. CONCLUSION: Although prognosis for rHCC remains the lowest among causes of death related to HCC, more recent studies have demonstrated that improved short- and long-term patient outcomes may be achieved through active surveillance efforts for HCC combined with advanced multimodal diagnostic tools and multidisciplinary management strategies.

Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy.

BACKGROUND: This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS: Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS: Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION: Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.

Healthcare utilization and expenditures among patients with venous thromboembolism following gastrointestinal cancer surgery.

BACKGROUND: We sought to assess healthcare utilization and expenditures among patients who developed venous thromboembolism (VTE) after gastrointestinal cancer surgery. METHODS: Patients who underwent surgery for esophageal, gastric, hepatic, biliary duct, pancreatic, and colorectal cancer between 2013 and 2020 were identified using the MarketScan database. Entropy balancing was performed to obtain a cohort that was well balanced relative to different clinical covariates. Generalized linear models were used to compare 1-year postdischarge costs among patients who did and did not develop a postoperative VTE. RESULTS: Among 20,253 individuals in the analytical cohort (esophagus [n = 518 {2.6%}], stomach [n = 970 {4.8%}], liver [n = 608 {3.0%}], bile duct [n = 294 {1.5%}], pancreas [n = 1511 {7.5%}], colon [n = 12,222 {60.3%}], and rectum [n = 4130 {20.4%}]), 894 (4.4%) developed VTE. Overall, most patients were male (n = 10,656 [52.6%]), aged between 55 and 64 years (n = 10,372 [51.2%]), and were employed full time (n = 11,408 [56.3%]). On multivariable analysis, VTE was associated with higher inpatient (mean difference [MD], $17,547; 95% CI, $15,141-$19,952), outpatient (MD, $8769; 95% CI, $7045-$10,491), and pharmacy (MD, $2811; 95% CI, $2509-$3113) expenditures (all P < .001). Furthermore, patients who developed VTE had higher out-of-pocket costs for inpatient (MD, $159; 95% CI, $66-$253) and pharmacy (MD, $122; 95% CI, $109-$136) services (all P < .001). CONCLUSION: Among privately insured patients aged <65 years, VTE was associated with increased healthcare utilization and expenditures during the first year after discharge.

Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery.

BACKGROUND: New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS: Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION: Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.

Practice Patterns and Outcomes Among Surgical Oncology Fellowship Graduates Performing Complex Cancer Surgery in the United States Across Different Career Stages.

BACKGROUND: Practice patterns and potential quality differences among surgical oncology fellowship graduates relative to years of independent practice have not been defined. METHODS: Medicare claims were used to identify patients who underwent esophagectomy, pancreatectomy, hepatectomy, or rectal resection for cancer between 2016 and 2021. Surgical oncology fellowship graduates were identified, and the association between years of independent practice, serious complications, and 90-day mortality was examined. RESULTS: Overall, 11,746 cancer operations (pancreatectomy [61.2%], hepatectomy [19.5%], rectal resection [13.7%], esophagectomy [5.6%]) were performed by 676 surgical oncology fellowship graduates (females: 17.7%). The operations were performed for 4147 patients (35.3%) by early-career surgeons (1-7 years), for 4104 patients (34.9%) by mid-career surgeons (8-14 years), and for 3495 patients (29.8%) by late-career surgeons (>15 years). The patients who had surgery by early-career surgeons were treated more frequently at a Midwestern (24.9% vs. 14.2%) than at a Northeastern institution (20.6% vs. 26.9%) compared with individuals treated by late-career surgeons (p < 0.05). Surgical oncologists had comparable risk-adjusted serious complications and 90-day mortality rates irrespective of career stage (early career [13.0% and 7.2%], mid-career [12.6% and 6.3%], late career [12.8% and 6.5%], respectively; all p > 0.05). Surgeon case-specific volume independently predicted serious complications across all career stages (high vs. low volume: early career [odds ratio {OR}, 0.80; 95% confidence interval {CI}, 0.65-0.98]; mid-career [OR, 0.81; 95% CI, 0.66-0.99]; late career [OR, 0.78; 95% CI, 0.62-0.97]). CONCLUSION: Among surgical oncology fellowship graduates performing complex cancer surgery, rates of serious complications and 90-day mortality were comparable between the early-career and mid/late-career stages. Individual surgeon case-specific volume was strongly associated with postoperative outcomes irrespective of years of independent practice or career stage.

Inflammatory bowel disease-associated colorectal cancer negatively affects surgery outcomes and health care costs.

BACKGROUND: Inflammatory bowel disease may affect the pathogenesis and clinicopathologic course of colorectal cancer. We sought to characterize the impact of inflammatory bowel disease on outcomes after colectomy and/or proctectomy for a malignant indication. METHODS: Patients diagnosed with colorectal cancer as well as a pre-existing comorbid diagnosis of Crohn's disease or ulcerative colitis between 2018 and 2021 were identified from Medicare claims data. The postoperative textbook outcome was defined as the absence of complications, as well as no extended hospital stay, 90-day readmission, or mortality. Postdischarge disposition and expenditures were also examined. RESULTS: Among 191,684 patients with colorectal cancer, 4,770 (2.5%) had a pre-existing diagnosis of inflammatory bowel disease. Patients with inflammatory bowel disease-associated colorectal cancer were less likely to undergo surgical resection (no inflammatory bowel disease: 47.6% vs inflammatory bowel disease: 42.1%; P < .001). Among patients who did undergo colorectal surgery, individuals with inflammatory bowel disease were less likely to achieve a textbook outcome (odds ratio 0.64 [95% confidence interval 0.58-0.70]). In particular, patients with inflammatory bowel disease had higher odds of postoperative complications (odds ratio 1.24 [1.12-1.38]), extended hospital stay (odds ratio 1.41 [1.27-1.58]), and readmission within 90 days (odds ratio 1.56 [1.42-1.72]) (all P < .05). Patients with inflammatory bowel disease-associated colorectal cancer were less likely to be discharged to their home under independent care (odds ratio 0.77 [0.68-0.87]) and had 12.2% higher expenditures, which correlated with whether the patient had a postoperative textbook outcome. CONCLUSION: One in 40 patients with colorectal cancer had concomitant inflammatory bowel disease. Inflammatory bowel disease was associated with a lower probability of achieving ideal postoperative outcomes, higher postdischarge expenditure, as well as worse long-term survival after colorectal cancer resection.

Textbook outcome in liver surgery: open vs minimally invasive hepatectomy among patients with hepatocellular carcinoma.

BACKGROUND: We sought to investigate whether minimally invasive hepatectomy (MIH) was superior to open hepatectomy (OH) in terms of achieving textbook outcome in liver surgery (TOLS) after resection of hepatocellular carcinoma (HCC). METHODS: Patients who underwent resection of HCC between 2000 and 2020 were identified from an international database. TOLS was defined by the absence of intraoperative grade ≥2 events, R1 resection margin, posthepatectomy liver failure, bile leakage, major complications, in-hospital mortality, and readmission. RESULTS: A total of 1039 patients who underwent HCC resection were included in the analysis. Although most patients underwent OH (n = 724 [69.7%]), 30.3% (n = 315) underwent MIH. Patients who underwent MIH had a lower tumor burden score (3.6 [IQR, 2.6-5.2] for MIH vs 6.1 [IQR, 3.9-10.1] for OH) and were more likely to undergo minor hepatectomy (84.1% [MIH] vs 53.6% [OH]) than patients who had an OH (both P < .001). After propensity score matching to control for baseline differences between the 2 cohorts, the incidence of TOLS was comparable among patients who had undergone MIH (56.6%) versus OH (64.8%) (P = .06). However, MIH was associated with a shorter length of hospital stay (6.0 days [IQR, 4.0-8.0] for MIH vs 9.0 days [IQR, 6.0-12.0] for OH). Among patients who had MIH, the odds ratio of achieving TOLS remained stable up to a tumor burden score of 4; after which the chance of TOLS with MIH markedly decreased. CONCLUSION: Patients with HCC who underwent resection with MIH versus OH had a comparable likelihood of TOLS, although MIH was associated with a short length of stay.

Medicaid expansion and palliative care for advanced-stage liver cancer.

BACKGROUND: Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer. METHODS: Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states. RESULTS: Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333). CONCLUSION: The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.

Association of county-level food deserts and food swamps on postoperative outcomes among patients undergoing colorectal surgery.

BACKGROUND: Although malnutrition has been linked to worse healthcare outcomes, the broader context of food environments has not been examined relative to surgical outcomes. We sought to define the impact of food environment on postoperative outcomes of patients undergoing resection for colorectal cancer (CRC). METHODS: Patients who underwent surgery for CRC between 2014 and 2020 were identified from the Medicare database. Patient-level data were linked to the United States Department of Agriculture data on food environment. Multivariable regression was used to examine the association between food environment and the likelihood of achieving a textbook outcome (TO). TO was defined as the absence of an extended length of stay (≥75th percentile), postoperative complications, readmission, and mortality within 90 days. RESULTS: A total of 260,813 patients from 3017 counties were included in the study. Patients from unhealthy food environments were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with higher social vulnerability (all P < .01). Patients residing in unhealthy food environments were less likely to achieve a TO than that of patients residing in the healthiest food environments (food swamp: 48.8% vs 52.4%; food desert: 47.9% vs 53.7%; P < .05). On multivariable analysis, individuals residing in the unhealthy food environments had lower odds of achieving a TO than those of patients living in the healthiest food environments (food swamp: OR, 0.86; 95% CI, 0.83-0.90; food desert: OR, 0.79; 95% CI, 0.76-0.82); P < .05). CONCLUSION: The surrounding food environment of patients may serve as a modifiable sociodemographic risk factor that contributes to disparities in postoperative CRC outcomes.

Simultaneous resection for colorectal cancer with synchronous liver metastases: current state-of-the-art.

BACKGROUND: A large proportion of patients with colorectal cancer (CRC) presents with synchronous colorectal liver metastases (sCRLM) at diagnosis. Surgical approaches for patients with sCRLM have evolved over the past decades. Simultaneous resection (SR) of CRC and sCRLM for selected patients has emerged as a safe and efficient alternative approach to traditional staged resections. METHODS: A comprehensive review of the literature was performed using MEDLINE/PubMed and Web of Science databases with the end of search date October 30, 2023. The MeSH terms "simultaneous resections" and "combined resections" in combination with "colorectal liver metastases," "colorectal cancer," "liver resection," and "hepatectomy" were searched in the title and/or abstract. RESULTS: SRs aim to achieve maximal tumor clearance, minimizing the risk of disease progression and optimizing the potential for long-term survival. Improvements in perioperative care, advances in surgical techniques, and a better understanding of patient selection criteria have collectively contributed to reducing morbidity and mortality associated with these complex procedures. Several studies have demonstrated that SR are associated with reduced overall length of stay and lower costs with comparable morbidity and long-term outcomes. In light of these outcomes, the proportion of patients undergoing SR for CRC and sCRLM has increased substantially over the past 2 decades. CONCLUSION: For patients with sCRLM, SR represents an attractive alternative to the traditional staged approach and should be selectively used; however, the decision on whether to proceed with a simultaneous versus staged approach should be individualized based on several patient- and disease-related factors.

Cannabis use disorder and perioperative outcomes following complex cancer surgery.

INTRODUCTION: Cannabis usage is increasing in the United States, especially among patients with cancer. We sought to evaluate whether cannabis use disorder (CUD) was associated with higher morbidity and mortality among patients undergoing complex cancer surgery. METHODS: Patients who underwent complex cancer surgery between January 2016 and December 2019 were identified in the National Inpatient Sample database. CUD was defined according to ICD-10 codes. Propensity score matching was performed to create a 1:1 matched cohort that was well balanced with respect to covariates, which included patient comorbidities, sociodemographic factors, and procedure type. The primary composite outcome was in-hospital mortality and seven major perioperative complications (myocardial ischemia, acute kidney injury, stroke, respiratory failure, venous thromboembolism, hospital-acquired infection, and surgical procedure-related complications). RESULTS: Among 15 014 patients who underwent a high-risk surgical procedure, a cohort of 7507 patients with CUD (median age; 43 years [IQR: 30-56 years]; n = 3078 [41.0%] female) were matched with 7507 patients who were not cannabis users (median age; 44 years [IQR: 30-58 years); n = 2997 [39.9%] female). CUD was associated with slight increased risk relative to postoperative kidney injury (CUD, 7.8% vs. no CUD, 6.1%); however, in-hospital mortality was slightly lower (CUD, 0.9% vs. no CUD, 1.6%) (both p < 0.001). On multivariable analysis, after controlling for other risk factors, CUD was not associated with higher morbidity and mortality (adjusted odds ratio: 1.06, 95% CI: 0.98-1.15; p = 0.158). CONCLUSION: CUD was not associated with a higher risk of postoperative morbidity and mortality following complex cancer surgery.

Association of Hospital Market Competition with Outcomes of Complex Cancer Surgery.

BACKGROUND: The association of hospital market competition, financial costs, and quality of oncologic care has not been well-defined. This study sought to evaluate variations in patient outcomes and financial expenditures after complex cancer surgery across high- and low-competition markets. METHODS: Medicare 100% Standard Analytic Files were used to identify patients with lung, esophageal, gastric, hepatopancreaticobiliary, or colorectal cancer who underwent surgical resection between 2018 and 2021. Data were merged with the annual hospital survey database, and the hospital market Herfindahl-Hirschman index was used to categorize hospitals into low- and high-concentration markets. Multi-level, multivariable regression models adjusting for patient characteristics (i.e., age, sex, comorbidities, and social vulnerability), year of procedure, and hospital factors (i.e., case volume, nurse-bed ratio, and teaching status) were used to assess the association between hospital market competition and outcomes. RESULTS: Among 117,641 beneficiaries who underwent complex oncologic surgery, the mean age was 73.8 ± 6.1 years, and approximately one-half of the cohort was male (n = 56,243, 47.8%). Overall, 63.8% (n = 75,041) of the patients underwent care within a high-competition market. Notably, there was marked geographic variation relative to market competition. High versus low market-competition hospitals were more likely to be in high social vulnerability areas (35.1 vs 27.5%; p < 0.001), as well as care for racial/ethnic minority individuals (13.8 vs 7.7%; p < 0.001), and patients with more comorbidities (≥ 2 Elixhauser comorbidities: 63.1 vs 61.1%; p < 0.001). In the multivariable analysis, treatment at hospitals in high- versus low-competition markets was associated with lower odds of achieving a textbook outcome (odds ratio, 0.95; 95% confidence interval, 0.91-0.99; p = 0.009). Patients at high-competition hospitals had greater mean index hospitalization costs ($19,462.2 [16211.9] vs $18,844.7 [14994.7]) and 90-day post-discharge costs ($7807.8 [15431.3] vs $7332.8 [14038.2]) (both p < 0.001) than individuals at low-competition hospitals. CONCLUSIONS: Hospital market competition was associated with poor achievement of an optimal postoperative outcome and greater hospitalization costs.

The associations of food environment with gastrointestinal cancer outcomes in the United States.

BACKGROUND: Social conditions and dietary behaviors have been implicated in the rising burden of gastrointestinal cancers (GIC). The "food environment" reflects influences on a community level relative to food availability, nutritional assistance, and social determinants of health. Using the US Department of Agriculture-Food Environment Atlas (FEA), we sought to characterize the association of food environment on GIC presenting stage and long-term survival. METHODS: Patients diagnosed with GIC between 2013 and 2017 were identified using the SEER database. FEA-scores were based on 282 county-level food security variables, store-restaurant availability, SNAP/WIC enrollment, pricing/taxes, and producer vicinity adjusted-for factors of socioeconomic status, race-ethnicity, transportation access, and comorbidities. Relative FEA rankings across US counties were averaged into a composite score and assigned to patients by county-of-residence. The association of FEA, cancer stage, and survival were analyzed using multiple logistic regression and cox-proportional hazard models relative to White/non-White race/ethnicity. RESULTS: Among 287,148 patients, the most common GIC-sites were colon (n = 97,942, 34%), pancreas (n = 49,785, 17.3%), liver (n = 31,098, 11.0%) and esophagus (n = 16,271, 5.7%). A worse food environment was independently associated with increased odds of late-stage diagnosis (esophageal odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05; hepatic OR: 1.06, 95% CI: 1.03-1.08; pancreatic OR: 1.04, 95% CI: 1.01-1.06) among all patients; in contrast, food environment was associated with colorectal cancer stage among non-White patients only (OR: 1.04, 95% CI: 1.03-1.06). Worse food environment was associated with worse 3-year survival (colon OR: 1.03, 95% CI: 1.01-1.04; hepatic OR: 1.12, 95% CI: 1.08-1.17; gastric OR: 1.07, 95% CI: 1.01-1.13). Similar associations were noted relative to overall survival among the entire cohort (biliary tract hazard ratio [HR]: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.02, 95% CI: 1.01-1.04; hepatic HR: 1.07, 95% CI: 1.06-1.09; pancreatic HR: 1.04, 95% CI: 1.02-1.05; rectum HR: 1.03, 95% CI: 1.01-1.04; gastric HR: 1.05, 95% CI: 1.03-1.07), as well as among non-White patients (biliary HR: 1.04, 95% CI: 1.01-1.07; colon HR: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.05, 95% CI: 1.02-1.08; hepatic HR: 1.08, 95% CI: 1.06-1.10) (all p < 0.003). CONCLUSIONS: Food environment was independently associated with late-stage tumor presentation and worse 3-year and overall survival among GIC patients. Interventions to address inequities across communities relative to food environments are needed to alleviate disparities in cancer care.