Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ in Males: An NCDB Analysis of the Surgical Approach to DCIS in Males.

BACKGROUND: Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS. METHODS: The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier. RESULTS: Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08). CONCLUSIONS: The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.

What Happens to Full Mouth Extraction Patients? A Retrospective Review of Patient Mortality at an Academic Medical Center.

PURPOSE: When providers are forced to address the growing oral healthcare needs of an aging and sick population, full mouth extractions (FMEs) are often sought as a solution. The purpose of this observational study was to evaluate mortality rates, mortality timeline, and to identify associated risk factors. METHODS: A single-center retrospective cohort study was conducted at the University of Cincinnati Medical Center. All patients who underwent FMEs at the Oral and Maxillofacial Surgery clinic from July 1, 2012 to December 31, 2019 due to caries or periodontal disease were included. Predictor variables recorded included a medical history, social history, and patient demographics. The main outcome variable was post-FME death, including the elapsed time from procedure to death. Deaths were identified using the National Death Index. Data were analyzed using simple descriptive statistics and Cox proportional hazard models. Deceased FME patients were compared to living FME patients to identify potential risk factors. Mortality risk index was derived from multivariable logistic regression. RESULTS: One thousand eight hundred twenty nine patients were included in the study. Nine hundred seventy six were female with a median age of 49 years (interquartile range 38-58). One thousand seven hundred nine were diagnosed with more than 1 comorbidity and 89% were on medicaid or medicare insurance. One hundred seventy patients (9.3%) were identified as deceased as of December 31, 2019. Of those who died, 87 patients were deceased within 2 years of the procedure and 147 within 5 years of the procedure. Statistically significant factors associated with mortality (P value < .01) included age (hazards ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.03), ASA score >3 (HR 3.12, 95% CI 2.2-4.42), nursing home residence (HR 2.66, 95% 1.67-4.28), hepatic disease (HR 1.81, 95% CI 1.18-2.78), and oncologic disease (HR 1.91, 95% 1.32-2.77). CONCLUSIONS: Approximately 1 in 10 patients died within 5 years of FME at our center. These patients may be medically and socially compromised. More research is needed to develop FME-specific mortality indices, which may serve useful for clinical decision-making and surgical palliative care.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

An analysis of applicant competitiveness to general surgery, surgical subspecialties, and integrated programs.

BACKGROUND: General surgery was once the gateway into a career in surgery. Over time, surgical subspecialties developed separate residency programs, and recently, integrated programs have emerged. It is unknown what impact the presence of surgical subspecialties and integrated programs have had on general surgery. Our objective was to evaluate match trends and quantify competitiveness of the general surgery, integrated programs, and surgical subspecialties matches. METHODS: National Residency Matching Program match data and applicant characteristics from 2010 through 2020 were analyzed for US senior allopathic applicants. Integrated programs were defined as plastic and vascular surgery, and surgical subspecialties were defined as otolaryngology, orthopedic surgery, and neurosurgery. Trends were evaluated using linear regression, programs were compared on 10 metrics by Wilcoxon rank-sum tests, and a logistic regression was used to rank each specialty match. RESULTS: The number of US senior applicants per position to integrated programs decreased and approached that of general surgery and surgical subspecialties, but the median number of applicants per position to general surgery was lower than to surgical subspecialties or integrated programs (1.21 interquartile range). Our logistic regression showed United States Medical Licensing Examination scores, research experience, Alpha Omega Alpha Honor Society membership, and graduation from a top medical school to be the most important factors in the match, and our weighted rank score found general surgery (2.85) to be less competitive than surgical subspecialties (1.92) or integrated programs (1.17). CONCLUSION: Throughout the last decade, integrated programs and surgical subspecialties have matched more competitive applicants based on the most significant predictors of the match. Moving forward, it is important that general surgery strives to attract the best and brightest out of medical school.

Opioid Dependence After Lung Cancer Resection: Institutional Analysis of State Prescription Drug Database.

BACKGROUND: The national opioid epidemic is a public health crisis. Thoracic surgery has also been associated with high incidence of new persistent opioid use. Our purpose was to describe the incidence and predictors of opioid use after lung cancer resection. METHODS: Retrospective review of lung cancer resections from 2015 to 2018 was performed using the Ohio Automated Rx Reporting System. Opioid dosing was recorded as milligram morphine equivalents (MME). Patients were stratified by preoperative opioid use. Chronic preoperative opioid users (opioid dependent) filled > 120 days supply of opioid pain medication in the 12 months prior to surgery; intermittent opioid users filled < 120 days. Chronic postoperative opioid users continued monthly use after 180 days postoperatively. RESULTS: 137 patients underwent resection. 16.1% (n = 22) were opioid dependent preoperatively, 29.2% (n = 40) were intermittent opioid users, and 54.7% (n = 75) were opioid naïve. Opioid dependent patients had higher daily inpatient opioid use compared to intermittent users and opioid naïve (43[30.0-118.1] MME vs 17.9[3.5-48.8] MME vs 8.8[2.1-25.0] MME, p < 0.001). Twenty-six percent (n = 35) of all patients were opioid users beyond 180 days postoperatively. Variables associated with opioid use > 180 days were: chronic preoperative opioid use (OR 23.8, p < 0.01), daily inpatient opioid requirement (1.02, p < 0.01), and neoadjuvant chemotherapy (28.2, p < 0.01). CONCLUSIONS: A quarter of patients are opioid dependent after lung cancer resection. This is due to both preexisting and new persistent opioid use. Improved strategies are needed to prevent chronic pain and opioid dependence after lung cancer resection.

Swipe right for surgical residency: Exploring the unconscious bias in resident selection.

BACKGROUND: Applicants provide a photo with their application through the Electronic Residency Application Service, which may introduce appearance-based bias. We evaluated whether an unconscious appearance bias exists in surgical resident selection. METHODS: After the match, applicant data from the 2018 to 2019 and 2019 to 2020 application cycles were examined. Reviewers were not provided the applicant photo or self-identified race during the second cycle. Photos provided by candidates were then rated by 4 surgical subspecialty residents who had no prior exposure to applications or interview status. Photos were rated on perceived fitness level, visual appearance, and photo professionalism. An overall photo score was then calculated. RESULTS: In the study, 422 applications were reviewed and 164 received interview invitations during the 2018 to 2019 cycle. Alpha Omega Alpha membership (odds ratio, 2.31; 95% confidence interval, 1.18-4.51), overall photo score (odds ratio, 2.29, 95% confidence interval, 1.43-3.66), research (odds ratio, 5.61, 95% confidence interval, 2.84-11.20), age (odds ratio, 0.86, 95% confidence interval, 0.76-0.99), and step 2 (odds ratio, 1.06, 95% confidence interval, 1.03-1.09) were predictors for receiving an interview. For the 2019 to 2020 cycle, 398 applications were reviewed, and 75 applicants received an invitation. Step 2 (odds ratio, 1.07, 95% confidence interval, 1.02-1.12), research (odds ratio, 2.78, 95% confidence interval, 1.40-5.55), age (odds ratio, 0.82, 95% confidence interval, 0.71-0.95), and overall photo score (odds ratio, 2.27; 95% confidence interval, 1.14-4.52) remained predictors despite reviewers being blinded to the photo during this cycle. CONCLUSION: Although objective metrics remain critical in determining interview invitations, overall perceived applicant appearance may influence the selection process. Although visual appearance was associated with receiving an interview, the Electronic Residency Application Service photo does not ultimately affect selection. This may suggest that appearance may influence other objective and subjective aspects of the application.

Exploring the relationship between burnout and grit during general surgery residency: A longitudinal, single-institution analysis.

BACKGROUND: How burnout changes during general surgery residency remains unknown. METHODS: From 2015 to 2018, general surgery residents completed the Maslach Burnout Inventory and Grit Scale. Statistical analyses were adjusted for repeated measures and compared to the incoming intern level. RESULTS: Fifty-five residents participated in this study. Burnout rates varied by program level, with an increased risk occuring in the third clinical year (OR = 11.7, p = 0.03). Emotional exhaustion (EE) peaked during the first and third clinical years, depersonalization (DP) peaked during the first and second clinical years, and personal achievement (PA) reached a nadir during the third clinical year (all p < 0.05). Residents with burnout had lower grit scores compared to those without burnout (3.71 vs 4.02, p < 0.01). Increasing grit was linearly associated with decreasing EE, decreasing DP, and increasing PA (all p < 0.05). CONCLUSIONS: Burnout varies throughout surgical residency, and grit is inversely related to burnout.

Predicting Weight Loss Using Psychological and Behavioral Factors: The POUNDS LOST Trial.

CONTEXT: Eating habits and food craving are strongly correlated with weight status. It is currently not well understood how psychological and behavioral factors influence both weight loss and weight regain. OBJECTIVE: To examine the associations between psychological and behavioral predictors with weight changes and energy intake in a randomized controlled trial on weight loss. DESIGN AND SETTING: The Prevention of Obesity Using Novel Dietary Strategies is a dietary intervention trial that examined the efficacy of 4 diets on weight loss over 2 years. Participants were 811 overweight (body mass index, 25-40.9 kg/m2; age, 30-70 years) otherwise healthy adults. RESULTS: Every 1-point increase in craving score for high-fat foods at baseline was associated with greater weight loss (-1.62 kg, P = .0004) and a decrease in energy intake (r = -0.10, P = .01) and fat intake (r = -0.16, P < .0001) during the weight loss period. In contrast, craving for carbohydrates/starches was associated with both less weight loss (P < .0001) and more weight regain (P = .04). Greater cognitive restraint of eating at baseline was associated with both less weight loss (0.23 kg, P < .0001) and more weight regain (0.14 kg, P = .0027), whereas greater disinhibition of eating was only associated with more weight regain (0.12 kg, P = .01). CONCLUSIONS: Craving for high-fat foods is predictive of greater weight loss, whereas craving for carbohydrates is predictive of less weight loss. Cognitive restraint is predictive of less weight loss and more weight regain. Interventions targeting different psychological and behavioral factors can lead to greater success in weight loss.

Does Geographical Bias Impact the Match for General Surgery Residents?

OBJECTIVE: As the competitiveness of applicants for general surgery residency grows, it is becoming challenging for programs to differentiate qualified candidates with a genuine interest in matching at their institution. The purpose of this study was to examine geographic trends in the general surgery match in order to elicit regional biases and optimize applicant interview selection strategies. DESIGN: In this single-center retrospective study, geographical information regarding birth place, college, medical school, and final match institution for general surgery residency applicants was examined. SETTING: This study was set at the University of Cincinnati College of Medicine. PARTICIPANTS: All general surgery residency applicants interviewing at our institution between 2015-2017 were included. METHODS: Academic variables and geographical information were collected for all applicants in the cohort. Statistical analyses were performed using chi-square and logistic regression techniques to determine any association between geography and match outcomes. RESULTS: Of 198 applicants included in the analysis, approximately 25% matched at an institution located in the same state as their medical school. Total 75% of applicants matched at a residency program located less than 640 miles away from either their birth place, college, or medical school, while only 15% matched at an institution located over 1000 miles away and 4% matched over 2000 miles away. When examining applicant characteristics, there were no significant differences in gender, clerkship grade, United States Medical Licensing Exam scores, Alpha Omega Alpha Honor Society membership, or quality of recommendation letters between applicants who matched in the lowest and highest quartiles of distance to final residency program location. CONCLUSIONS: A significant proportion of general surgery applicants matched at institutions located in a region near either their birth place, college, or medical school. Given the limited number of interviews able to be offered by institutions and the associated opportunity costs, general surgery programs should consider regional biases when evaluating residency applicants.

See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon.

OBJECTIVE: The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA). DESIGN, SETTING, AND PARTICIPANTS: This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05. RESULTS: 30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05). CONCLUSIONS: Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.

Predictors of medical student success on the surgery clerkship.

INTRODUCTION: Predictors of student performance on clerkship rotations are limited. In this study, we aim to identify predictors of success on the surgery clerkship. METHODS: 62 third-year medical students completed an institution-specific clerkship survey. Students were grouped according to clerkship grade of honors (HG) versus high-pass or pass (PG). Statistical analyses were performed using Student's t-test, Pearson's Chi-square/Fisher's exact test, and linear regression analysis. Multivariate logistic regression was performed to identify predictors of achieving an honors on the clerkship. RESULTS: HG students were more likely to be individual-based learners with higher grit and USMLE Step 1 scores compared with PG students. Moreover, USMLE Step 1 score was associated with quiz, shelf examination, and final clerkship grades, but not clinical evaluations. There were few differences with regard to preferred learning modalities, but overall, medical students favored active learning activities. CONCLUSIONS: We found that higher USMLE Step 1 score, higher grit score, and an individual-based learning style were associated with a higher grade on the surgery clerkship. However, these factors may not fully capture the less objective components of high performance. Additional methods by which educators can measure students' clinical competency are needed.

Characteristics and diagnosis of pregnancy and lactation associated breast cancer: Analysis of a self-reported regional registry.

BACKGROUND: Pregnancy-associated breast cancer (PABC) is the most common malignancy in pregnancy. However due to its infrequent occurrence, PABC continues to be poorly understood. METHODS: We performed a retrospective study using self-reported data from 1079 eligible women in a regional breast cancer registry. RESULTS: The PABC cases were more likely than non-PABCs to be younger than age 35 and have nodal involvement at diagnosis. Despite diagnosis at a young age, there was not an association between PABC and family history. For method of diagnosis, PABC was found on self-exam, while non-PABCs were found on mammography. CONCLUSION: In conclusion, PABC is rarely detected by mammography and diagnosis is highly dependent on detection during self-breast exam. Women who are or recently were pregnant should be encouraged to perform regular self-breast exams to report any changes for further evaluation. Patient and clinician education regarding risk and realities of PABC is essential.

What matters after sleeve gastrectomy: patient characteristics or surgical technique?

BACKGROUND: The impact of operative technique on outcomes in laparoscopic sleeve gastrectomy has been explored previously; however, the relative importance of patient characteristics remains unknown. Our aim was to characterize national variability in operative technique for laparoscopic sleeve gastrectomy and determine whether patient-specific factors are more critical to predicting outcomes. METHODS: We queried the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for laparoscopic sleeve gastrostomies performed in 2015 (n = 88,845). Logistic regression models were used to determine predictors of postoperative outcomes. RESULTS: In 2015, >460 variations of laparoscopic sleeve gastrectomy were performed based on combinations of bougie size, distance from the pylorus, use of staple line reinforcement, and oversewing of the staple line. Despite such substantial variability, technique variants were not predictive of outcomes, including perioperative morbidity, leak, or bleeding (all P ≥ .05). Instead, preoperative patient characteristics were found to be more predictive of these outcomes after laparoscopic sleeve gastrectomy. Only history of gastroesophageal disease (odds ratio 1.44, 95% confidence interval 1.08-1.91, P < .01) was associated with leak. CONCLUSION: Considerable variability exists in technique among surgeons nationally, but patient characteristics are more predictive of adverse outcomes after laparoscopic sleeve gastrectomy. Bundled payments and reimbursement policies should account for patient-specific factors in addition to current accreditation and volume thresholds when deciding risk-adjustment strategies.

Understanding the "Weekend Effect" for Emergency General Surgery.

BACKGROUND: Several studies have identified a "weekend effect" for surgical outcomes, but definitions vary and the cause is unclear. Our aim was to better characterize the weekend effect for emergency general surgery using mortality as a primary endpoint. METHODS: Using data from the University HealthSystem Consortium from 2009 to 2013, we identified urgent/emergent hospital admissions for seven procedures representing 80% of the national burden of emergency general surgery. Patient characteristics and surgical outcomes were compared between cases that were performed on weekdays vs weekends. RESULTS: Hospitals varied widely in the proportion of procedures performed on the weekend. Of the procedures examined, four had higher mortality for weekend cases (laparotomy, lysis of adhesions, partial colectomy, and small bowel resection; p < 0.01), while three did not (appendectomy, cholecystectomy, and peptic ulcer disease repair). Among the four procedures with increased weekend mortality, patients undergoing weekend procedures also had increased severity of illness and shorter time from admission to surgery (p < 0.01). Multivariate analysis adjusting for patient characteristics demonstrated independently higher mortality on weekends for these same four procedures (p < 0.01). CONCLUSIONS: For the first time, we have identified specific emergency general surgery procedures that incur higher mortality when performed on weekends. This may be due to acute changes in patient status that require weekend surgery or indications for urgent procedures (ischemia, obstruction) compared to those without a weekend mortality difference (infection). Hospitals that perform weekend surgery must acknowledge and identify ways to manage this increased risk.

Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals.

BACKGROUND: Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS: The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS: Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION: For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.

Combination oral and mechanical bowel preparations decreases complications in both right and left colectomy.

BACKGROUND: Before elective colectomy, many advocate mechanical bowel preparation with oral antibiotics, whereas enhanced recovery pathways avoid mechanical bowel preparations. The optimal preparation for right versus left colectomy is also unclear. We sought to determine which strategy for bowel preparation decreases surgical site infection (SSI) and anastomotic leak (AL). METHODS: Elective colectomies from the National Surgical Quality Improvement Program colectomy database (2012-2015) were divided by (1) type of bowel preparation: no preparation (NP), mechanical preparation (MP), oral antibiotics (PO), or mechanical and oral antibiotics (PO/MP); and (2) type of colonic resection: right, left, or segmental colectomy. Univariate and multivariate analyses identified predictors of SSI and AL, and their risk-adjusted incidence was determined by logistic regression. RESULTS: When analyzed as the odds ratio compared with NP, the PO and PO/MP groups were associated with a decrease in SSI (PO = 0.70 [0.55-0.88] and PO/MP = 0.47 [0.42-0.53]; P < .01). Use of PO/MP was associated with a decrease in SSI across all types of resections (right colectomy = 0.40 [0.33-0.50], left colectomy = 0.57 [0.47-0.68], and segmental colectomy = 0.43 (0.34-0.54); P < .01). Similarly, use of PO/MP was associated with a decrease in AL in left colectomy = 0.50 ([0.37-0.69]; P < .01) and segmental colectomy = 0.53 ([0.36-0.80]; P < .01). CONCLUSION: Mechanical bowel preparation with oral antibiotics is the preferred preoperative preparation strategy in elective colectomy because of decreased incidence of SSI and AL.

Hospital safety-net burden does not predict differences in rectal cancer treatment and outcomes.

BACKGROUND: Safety-net hospitals have been shown to have inferior short-term surgical outcomes. The aim of this study was to compare rectal cancer management and survival across hospitals stratified by payer mix. MATERIALS AND METHODS: Rectal cancer patients (n = 296,068) were identified using the 1998-2010 National Cancer Data Base. Hospitals were grouped into safety-net burden categories, according to the proportion of patients with Medicaid or no health insurance, as follows: low-, medium-, and high-burden hospitals (HBHs). Patient and tumor characteristics, processes of care, and outcomes were evaluated, and regression analysis was used to investigate correlations between hospital safety-net burden on patient survival. RESULTS: HBH encountered patients with more advanced disease (P < 0.001). Despite this, stage I-III patients at HBH had equal likelihood of receiving surgery and guideline-appropriate radiation and chemotherapy (all P > 0.05). The 30-day readmissions and mortality were also similar across safety-net groups (all P > 0.05). Multivariate analysis showed no difference in survival between HBH and low-burden hospital (P = 0.164). CONCLUSIONS: Hospital payer mix may not adversely influence management of rectal cancer. This study highlights potential areas to improve cancer care for vulnerable patient populations.

Time to Initiation of Adjuvant Chemotherapy in Pancreas Cancer: A Multi-Institutional Experience.

BACKGROUND: Despite randomized trials addressing adjuvant therapy (AT) for pancreas cancer, the ideal time to initiate therapy remains undefined. Retrospective analyses of the ESPAC-3 trial demonstrated that time to initiation of AT did not impact overall survival (OS). Given the absence of confirmatory data outside of a clinical trial, we sought to determine if AT timing in routine clinical practice is associated with OS differences. METHODS: Perioperative data of pancreatectomies for ductal adenocarcinoma from five institutions (2005-2015) were assessed. Delay in AT was defined as initiation >12 weeks after surgery. Multivariate analysis was performed to identify predictors of mortality. RESULTS: Of 867 patients, 172 (19.8%) experienced omission of AT. Improved OS was observed in patients who received AT compared with patients who did not (24.8 vs. 19.1 months, p < 0.01). Information on time to initiation of AT was available in 488 patients, of whom 407 (83.4%) and 81 (16.6%) received chemotherapy ≤12 and >12 weeks after surgery, respectively. There were no differences in recurrence-free survival or OS (all p > 0.05) between the timely and delayed AT groups. After controlling for perioperative characteristics and tumor pathology, patients who initiated AT ≤ 12 or > 12 weeks after surgery had a 50% lower odds of mortality than patients who only underwent resection (p < 0.01). CONCLUSIONS: In a multi-institutional experience of resected pancreas cancer, delayed initiation of AT was not associated with poorer survival. Patients who do not receive AT within 12 weeks after surgery are still appropriate candidates for multimodal therapy and its associated survival benefit.

Cancer Center Volume and Type Impact Stage-Specific Utilization of Neoadjuvant Therapy in Rectal Cancer.

BACKGROUND: Neoadjuvant chemoradiation reduces local recurrence in locally advanced rectal cancer, and adherence to national and societal recommendations remains unknown. OBJECTIVE: To determine variability in guideline adherence in rectal cancer treatment and investigate whether hospital volume correlated with variability seen. DESIGN: We performed a retrospective analysis using the National Cancer Database rectal cancer participant user files from 2005 to 2010. Stage-specific predictors of neoadjuvant chemotherapy and radiation use were determined, and variation in use across hospitals analyzed. Hospitals were ranked based on likelihood of preoperative therapy use by stage, and observed-to-expected ratios for neoadjuvant therapy use calculated. Hospital outliers were identified, and their center characteristics compared. RESULTS: A total of 23,488 patients were identified at 1183 hospitals. There was substantial variability in the use of neoadjuvant chemoradiation across hospitals. Patients managed outside clinical guidelines for both stage 1 and stage 3 disease tended to receive treatment at lower-volume, community cancer centers. CONCLUSIONS: There is substantial variability in adherence to national guidelines in the use of neoadjuvant chemoradiation for rectal cancer across all stages. Both hospital volume and center type are associated with over-treatment of early-stage tumors and under-treatment of more invasive tumors. These findings identify a clear need for national quality improvement efforts in the treatment of rectal cancer.

Surviving rectal cancer: examination of racial disparities surrounding access to care.

BACKGROUND: The aim of this study was to evaluate whether survival differences are attributable to disproportionate access to stage-specific rectal cancer treatment recommended by the National Comprehensive Care Network. METHODS: A retrospective analysis of the National Cancer Data Base between 1998 and 2006 was performed. A series of Kaplan-Meier survival analyses were used to compare 5-y survival among race cohorts. Propensity score matching was used to compare Caucasian and African American patients who received the same treatment by accounting for covariates. RESULTS: 5-y overall survival in African Americans was 50.7% versus 56.2% in Caucasians (P < 0.001). In patients with stage I-III disease, 5-y survival was 58.7% in African Americans versus 63.1% in Caucasians (P < 0.001). Analysis of patients receiving surgery for stage I-III disease, revealed a 61.1% 5-y survival in African Americans versus 65.8% in Caucasians (P < 0.001). Propensity score matching did not eliminate the racial disparity. The median survival for Caucasian patients was 109.6 mo as compared to 85.8 mo for African Americans (P < 0.001). CONCLUSIONS: These data show that access to standard care appears to decrease but not eliminate the survival differences between African Americans and Caucasians with rectal cancer.