Propensity Score Matching Analysis of the Effect of Payer Status on the Survival of Colon Cancer Patients.

Background and objective Colon cancer is one of the most common types of cancer globally. The factors that could affect colon cancer survival include age, stage, treatment, and other socioeconomic aspects. Payer status has been shown to be a significant predictor of cancer patient survival in retrospective studies. However, due to the limitations of retrospective studies, patient baseline characteristics between payer statuses are not comparable. Few studies have addressed the effect of payer status on the overall survival (OS) of patients using propensity score matching (PSM). In light of this, we conducted a study to examine the effect of payer status on the survival of colon cancer patients based on PSM. Materials and methods  About 66,493 stage II/III colon cancer patients aged 40-90 years and diagnosed between 2004 and 2015 were analyzed from a de-identified National Cancer Database (NCDB) file. All patients had undergone surgery, and patients who had received radiation therapy, hormone therapy, immunotherapy, palliative care, or therapies other than chemotherapy were excluded. Only private or Medicaid payer status was included. The propensity score was calculated by computing the probability of patients being in the Medicaid group using logistic regression. The PSMATCH procedure in the SAS software (SAS Inc., Gary, NC) was used to perform PSM on patients with Medicaid and private insurance. The greedy nearest neighbor matching method was used to match one Medicaid to one privately insured patient with a caliper of 0.2. At the same time, an exact match was done for gender, age group, race, and stage at diagnosis. Multivariate Cox regression was then used to estimate the effect of payer status on survival before and after PSM. Results Among the 66,493 patients, 90.3% were privately insured and 9.7% had Medicaid. In univariate analysis, payer status was found to be a significant predictor of OS. Prior to PSM, the median overall survival (MOS) for patients with private insurance was 12.75 years, while those with Medicaid had a MOS of 9.02 years. After PSM, 6,167 paired patients were matched, and patients with private insurance had a MOS of >12.82 years and Medicaid patients had a MOS of 8.88 years. After PSM, patients with Medicaid had a 50% increased risk of death, and payer status proved to be a statistically significant predictor of OS of colon cancer. Conclusion Based on our findings, as per the PSM method, payer status can be a significant predictor of survival among colon cancer patients. Also, chemotherapy, race, age, and other socioeconomic factors were also found to be significant predictors of OS. Further research should be conducted to investigate other covariates not studied here and the mediation effect of payer on the survival of cancer patients.

Advanced metastatic gastric adenocarcinoma identified within the placenta: a case report with literature review.

We present an extremely rare case of a multiparous women age 32 in her 35th week of gestation who was admitted to our hospital for evaluation of back pain and was incidentally found to have metastatic gastric adenocarcinoma, diagnosed from a routine placental specimen. The coexistence of gastric carcinoma with pregnancy is a rare event, accounting for 0.026% to 0.1% of all pregnancies. To the best of our knowledge, the world literature contains only eight known cases of metastatic gastric cancer to the placenta-the present case is the ninth. An uncommon finding, in this case, was the extensive spread of cancer to bone marrow and leptomeninges.

Cancer-Related Pneumopericardium: A Case Report and Literature Review.

Pneumopericardium is a relatively rare entity mostly described in the literature as a result of causes such as penetrating/blunt trauma and iatrogenic causes during cardiothoracic procedures. We are presenting a case of pneumopericardium as a complication of progressed gastroesophageal junction tumor along with a literature review of all cancer-related pneumopericardium cases reported in the last decade. We present the case of a 65-year-old male with a past medical history significant for locally advanced gastroesophageal junction adenocarcinoma who presented to the hospital with complaints of shortness of breath and fever. A chest X-ray showed an intact esophageal stent along with radiolucency around the cardiac silhouette which suggested pneumopericardium. Computed tomography scan of the chest confirmed the presence of pneumopericardium in posterior pericardium with foci of gas above the esophageal stent likely to be communicating with the pericardium. An echocardiogram was obtained which showed no signs of tamponade. Given the advanced nature of the disease we applied a conservative management given that the pneumopericardium was deemed to be small with no tamponade. Goals of care were discussed with the patient and his family and the patient opted for comfort care measures. This case report prompted us to perform an extensive literature review of cancer-related pneumopericardium from 2008 to 2019. We found 11 cases where it was reported secondary to malignancies of different kinds. Our aim is to compile a review for clinicians to view varied presentations and better direct therapy dependent on the individual case and clinical presentation in patients with cancer-related pneumopericardium. Moreover, although pneumopericardium is rare, it should be considered in differential diagnosis in patients presenting with shortness of breath or chest pain especially with cancers involving the cardiothoracic region.

Laparoscopic colectomy for cancer: Improved compliance with guidelines for chemotherapy and survival.

BACKGROUND: Laparoscopic surgery for colon cancer has been demonstrated in clinical trials to have short-term benefits when compared to the open surgical approach. Guidelines of the National Comprehensive Cancer Network recommend that patients with stage III or high-risk stage II colon cancer undergo adjuvant chemotherapy. We hypothesized that laparoscopic colectomy is associated with increased compliance to recommendations for chemotherapy, a lesser time to start of chemotherapy, and increased overall survival. METHODS: The National Cancer Data Base was queried to identify patients with stage III or high-risk stage II colon cancer (T4, positive margins, <12 lymph nodes, or high tumor grade) diagnosed 2010-2012. Patients were divided into laparoscopic colectomy and open colectomy groups. Intent-to-treat analysis was used with converted cases included in the laparoscopic colectomy group. Rates of receiving adjuvant chemotherapy, time from diagnosis and date of operation to start of chemotherapy, and overall survival were compared. RESULTS: A total of 48,257 patients were included for analysis; 18,801 patients underwent laparoscopic colectomy and 29,456 underwent open colectomy. Laparoscopic colectomy patients received adjuvant chemotherapy at a somewhat greater rate than open colectomy (66.2% vs 59.4%, P < .01). Among patients who received chemotherapy, mean time to start of chemotherapy after definitive resection was somewhat less for laparoscopic colectomy than open colectomy (48.7 vs 52.7 days, P < .01). Two-year overall survival was greater for laparoscopic colectomy than open colectomy (81.9% vs 73.2%, P < .01). CONCLUSION: Compared to open colectomy, laparoscopic colectomy is associated with somewhat greater rates of compliance with guidelines for adjuvant chemotherapy for stage III and high-risk stage II colon cancer, as well as a slightly lesser time to start of chemotherapy and improved overall survival.

Poor survival in stage IIB/C (T4N0) compared to stage IIIA (T1-2 N1, T1N2a) colon cancer persists even after adjusting for adequate lymph nodes retrieved and receipt of adjuvant chemotherapy.

BACKGROUND: A survival paradox between Stage IIB/C and Stage IIIA colon cancers exists. It is unclear how adequate lymph nodes dissection (LN) and post-surgery chemotherapy contribute to the survival paradox. We intended to assess the impact of these two factors on the survival paradox. RESULTS: We evaluated 34,999 patients diagnosed with stage IIIA or stage IIB/C colon cancer in 2003-2012 from the National Cancer Data Base. The 5-year overall survival (OS) was 73.5 % for stage IIIA and 51.1 % for stage IIB/C (P < 0.0001). The 5-year OS was 84.1 % for stage IIIA with post-surgery chemotherapy, 70.8 % for stage IIB/C with ≥ 12 LNs retrieved with chemotherapy, 53.9 % for stage IIB/C < 12 LNs with chemotherapy, 49.5 % for stage IIIA without chemotherapy, 43.7 % for stage IIB/C ≥ 12 LNs retrieved without chemotherapy, to 27.7 % for stage IIB/C < 12 LNs without chemotherapy. Even among stage IIB/C who had optimal treatment (≥12 LNs retrieved, received chemotherapy), OS remains lower than stage IIIA with chemotherapy. After adjusting LN dissection and chemotherapy in addition to the adjustment of other clinical factors, the survival paradox was reduced from HR = 1.76 (95 % CI: 1.68-1.85) to HR 1.51 (95 % CI: 1.44-1.59). CONCLUSIONS: LN dissection and post-surgery chemotherapy partially explained the survival paradox. More research is warranted to identify other factors that contribute to this paradox. Future iteration of TNM staging system should take this into consideration.