Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis.

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.

Colon cancer epidemiology, race and socioeconomic status: Comparing trends in counties served by an urban hospital in Newark, NJ with overall NJ-state and nation-wide patterns.

PURPOSE: Disparities in colorectal cancer (CRC) trends are linked with socioeconomic status (SES) and race. To better understand the colon cancer trends at our medical center, this study characterizes the racial and socioeconomic profile of the population served by our center to identify modifiable risk factors amenable to interventions. METHODS: Colon cancer data from our center as well as New Jersey (NJ) and United States (US) were obtained from National Cancer Database. Demographic data on race and SES for NJ counties were obtained from public databases that sourced data from the American Community Survey and the US census. We compared the odds of being diagnosed with early-onset and late-stage colon cancer (III or IV), respectively in NJ and US, across different racial groups. We also quantified the association between Social Vulnerability Index (SVI) and age-adjusted CRC mortality in NJ counties, with and without accounting for the racial composition of each county. RESULTS: In 2015, our center recorded higher proportions of late-stage and early-onset colon cancer diagnoses compared to all hospitals in NJ and US. Trends for stage and patient age at diagnosis of colon cancer for NJ and the US (2010-2019) showed that Black, Hispanic, and Asian/Pacific Islander individuals had greater odds of being diagnosed with early-onset (age<50) and late-stage colon cancer (Stage III/IV) when compared to White population. NJ counties served by our center showed an overrepresentation of either Black or Hispanic-Latino populations and reported significant disadvantage in SES. For NJ counties, each 25 percentile increase in social vulnerability was associated with 1.04 times the rate of age-adjusted colorectal cancer death (95 % CI: 1.00-1.07). CONCLUSION: Public data on race and SES of the target population can help identify areas of social disparities at the county-level to guide targeted interventions such as improving healthcare access and screening rates.

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair.

BACKGROUND: Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair. METHODS: A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well. RESULTS: Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios. CONCLUSIONS: Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods.

BACKGROUND: Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities. STUDY: The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001. RESULTS: A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB. CONCLUSIONS: Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.

Cost-effectiveness analysis of robotic cholecystectomy in the treatment of benign gallbladder disease.

BACKGROUND: Laparoscopic cholecystectomy is the current standard of care treatment for benign gallbladder disease. Robotic cholecystectomy is another approach for performing cholecystectomy that offers a surgeon better dexterity and visualization. However, robotic cholecystectomy may increase cost without sufficient evidence to suggest an improvement in clinical outcomes. The purpose of this study was to construct a decision tree model to compare cost-effectiveness of laparoscopic cholecystectomy and robotic cholecystectomy. METHODS: Complication rates and effectiveness associated with robotic cholecystectomy and laparoscopic cholecystectomy over a 1-year time frame were compared using a decision tree model populated with data from the published literature. Cost was calculated using Medicare data. Effectiveness was represented by quality-adjusted life-years. The primary outcome of the study was incremental cost-effectiveness ratio, which compares the cost per quality-adjusted life-year of the 2 interventions. The willingness-to-pay threshold was set at $100,000/quality-adjusted life-year. Results were confirmed with 1-way, 2-way, and probabilistic sensitivity analyses varying branch-point probabilities. RESULTS: The studies used in our analysis included 3,498 patients who underwent laparoscopic cholecystectomy, 1,833 patients who underwent robotic cholecystectomy, and 392 patients who required conversion to open cholecystectomy. Laparoscopic cholecystectomy produced 0.9722 quality-adjusted life-years, costing $9,370.06. Robotic cholecystectomy produced an additional 0.0017 quality-adjusted life-years at an additional $3,013.64. These results equate to an incremental cost-effectiveness ratio of $1,795,735.21/quality-adjusted life-year. This exceeds the willingness-to-pay threshold, making laparoscopic cholecystectomy the more cost-effective strategy. Sensitivity analyses did not alter results. CONCLUSION: Traditional laparoscopic cholecystectomy is the more cost-effective treatment modality for benign gallbladder disease. At present, robotic cholecystectomy is not able to improve clinical outcomes enough to justify its added cost.

Neoadjuvant Treatment Versus Upfront Surgery in Resectable Pancreatic Cancer: A Cost-Effectiveness Analysis.

PURPOSE: Pancreatic cancer (PC) has an overall 5-year survival rate of 10%. The use of neoadjuvant chemoradiation is debated in resectable disease. The purpose of this study is to evaluate the cost-effectiveness of neoadjuvant chemoradiation followed by pancreaticoduodenectomy (NACRT) versus upfront pancreaticoduodenectomy and adjuvant chemotherapy (USR) in resectable PC. METHODS: A decision tree model was used to estimate the cost-effectiveness of NACRT versus USR. Values from the published literature populate the tree: costs from Medicare (FY2021) reimbursements, and morbidity and survival data for quality-adjusted life-years (QALYs). Patients with resectable pancreatic adenocarcinoma who qualified for resection were included. The ICER was the primary outcome. The model was validated using one-way and two-way deterministic, as well as probabilistic sensitivity analyses. RESULTS: The base case was modeled using a 65-year-old male. NACRT yielded 1.61 QALYs at $45,483.52 USD. USR yielded 1.47 QALYs at a discount of $6,840.96 USD. The ICER was $48,130 USD, which favors NACRT. One-way sensitivity analyses upheld these results except when ≤ 21.0% of NACRT patients proceeded to surgery and when ≤ 85.4% of NACRT patients were resectable at surgery. Two-way sensitivity analyses also favored NACRT except in cases when the proportion of resected disease after NACRT decreased. NACRT was favored in 94.3% of 100,000 random-sampling simulations. CONCLUSION: It is more cost-effective to administer NACRT before surgery for patients with resectable PC. On the basis of sensitivity analyses, USR with adjuvant therapy is only favored if rates of resection and eligibility for resection after NACRT decrease. NACRT should be considered in all patients unless there is an absolute contraindication.

Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study.

BACKGROUND: A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. METHODS: The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. RESULTS: Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02). CONCLUSIONS: Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Sentinel lymph node biopsy for head and neck cutaneous squamous cell carcinoma using the Brigham and Women's staging system: a cost analysis.

The objective is to determine the cost-effectiveness of sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (CSCC) according to the Brigham and Women's Hospital (BWH) Tumor Staging system. A decision analysis was utilized to examine costs and outcomes associated with the use of SLNB in patients with high-risk head and neck CSCC. Decision tree outcome probabilities were obtained from published literature. Costs were derived from Medicare reimbursement rates (US$) and effectiveness was represented by quality-adjusted life-years (QALYs). The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness-to-pay set at $100,000 per QALY gained. SLNB was found to be a cost-effective tool for patients with T3 tumors, with an ICER of $18,110.57. Withholding SLNB was the dominant strategy for both T2a and T2b lesions, with ICERs of - $2468.99 and - $16,694.00, respectively. Withholding SLNB remained the dominant strategy when examining immunosuppressed patients with T2a or T2b lesions. In patients with head and neck CSCC, those with T3 or T2b lesions with additional risk factors not accounted for in the staging system alone, may be considered for SLNB, while in other tumor stages it may be impractical. SLNB should only be offered on an individual patient basis.

Staging CT and Diagnostic Laparoscopy With Cytology Prior to the Treatment of Pancreatic Adenocarcinoma: A Case Series.

INTRODUCTION: Initial staging of pancreatic ductal adenocarcinoma (PDAC) is performed with computed tomography (CT). Laparoscopy with peritoneal cytology at staging can uncover occult disease undetected by CT. This case series assessed clinical course following staging laparoscopy with cytology in patients with PDAC. METHODS: This single-center study examined patients with non-metastatic PDAC diagnosed from 2017 to 2020. Patients underwent CT and subsequent laparoscopy with cytology prior to treatment. Demographics, clinicopathologic status, treatment course, and survival were compared. RESULTS: Eight patients were identified. All had negative laparoscopies. Five cytologies were negative, two were atypical, and one was positive. Two patients with negative cytology received neoadjuvant chemotherapy and underwent resection, with an average follow-up time of 32.9 months since diagnosis. Of the three remaining patients with negative cytology, none underwent resection. One received delayed chemotherapy, while the others could not due to medical contraindications. The average survival was 3.5 months (n=2). Of two patients with atypical cytology, neither underwent resection. One could not receive chemotherapy due to medical contraindication, while the other was lost to follow-up shortly after diagnosis. The average survival was 1.3 months (n=1). The patient with positive cytology received definitive chemotherapy without resection and survived for 21.6 months. CONCLUSIONS: The patient with positive cytology may have been spared non-therapeutic surgery. Remaining unresected patients showed poor survival, though the lack of immediate chemotherapy may contribute to this finding. Further research is needed to determine optimal candidates for invasive staging and implications of atypical cytology.

Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting.

BACKGROUND AND AIMS: Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. METHODS: A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. RESULTS: Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. CONCLUSIONS: In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Novel Long Noncoding RNA miR205HG Functions as an Esophageal Tumor-Suppressive Hedgehog Inhibitor.

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Recently, long noncoding RNAs (lncRNAs) have been identified as key regulators of biological pathways. However, involvement of lncRNAs in the development of BE and EAC has not been well-studied. The aims of the current study were: (1) to study involvement of the lncRNA, miR205HG, in the development of BE and EAC; (2) to clarify the role of miR205HG in in vitro and in vivo experiments; and (3) to investigate the mechanism of miR205HG involving the Hedgehog (Hh) signaling pathway. These experiments revealed that miR205HG was downregulated in EAC vs. normal esophageal epithelia (NE) as well as in EAC cell lines, and its forced overexpression inhibited EAC cell proliferation and cell cycle progression in vitro. Similarly, overexpression of miR205HG inhibited xenograft tumor growth in mice In vivo. Finally, we show that one mechanism of action of miR205HG involves the Hh signaling pathway: miR205HG and Hh expression levels were inversely correlated in both EAC (r = -0.73) and BE (r = -0.83) tissues, and in vitro studies revealed details of Hh signaling inhibition induced by miR205HG. In conclusion, these findings establish that lncRNA miR205HG functions as a tumor suppressor in the development of BE and EAC, at least in part through its effect on the Hh signaling pathway.

Comparison of mastectomy and breast reconstruction outcomes using low thermal dissection versus traditional electrocautery: a blinded randomized trial.

INTRODUCTION: PlasmaBlade® is a thermal dissection device that may allow for improved perfusion of the mastectomy flap by limiting thermal injury. In this study we aim to compare the mastectomy flap perfusion using PlasmaBlade® versus traditional electrocautery. METHODS: Patients undergoing bilateral mastectomy with immediate breast reconstruction were recruited. The right and left breasts of each patient were randomized to dissection with PlasmaBlade® or standard electrocautery. Randomization was performed using random sequences on the day of surgery and was blinded to the plastic surgeon. Mastectomy flap perfusion was assessed following completion of the mastectomy using intra-operative fluoroscopy and plastic surgeon review. Surgical site drainage and pain score were measured. Sign tests were employed to assess differences in perfusion and Wilcoxon paired test for the secondary outcomes. RESULTS: Twenty patients were enrolled in the study with median age of 40.5 years and median BMI of 26 kg/m2. In 18 patients (90%), perfusion was assessed to be better on the side of the PlasmaBlade® dissection. Median daily drainage over a 7-day period was 51 cc (IQR 35-61) on the PlasmaBlade® side and 44 cc (IQR 31-61) on the control side. Median pain score on the PlasmaBlade® side was 4.0 (IQR 2.3-5.9) and 4.4 (IQR 2.9-6) on the control side. No skin necrosis was noted in either groups. CONCLUSION: Use of PlasmaBlade® appears to be a safe and reliable technique to perform mastectomy and breast reconstruction with equivalent outcomes to traditional electrocautery. Although, mastectomy skin flap perfusion was rated better intra-operatively for the PlasmaBlade® group, both cohorts had comparable outcomes. ClinicalTrials.gov Identifier: NCT03711916 Level of Evidence: I (Randomized trial).

Pure fat grafting for breast reconstruction: An alternative autologous breast reconstruction.

Plastic surgeons offer various options for breast reconstruction based on patient preference, underlying disease, and comorbidities. An alternative form of breast reconstruction exists, which includes tissue expansion with tissue expander and subsequent fat grafting without the use of implant or flap. We retrospectively reviewed the breast cancer patients who underwent breast reconstruction at our institution to identify those with pure fat grafting. Demographic information, complications, operative details, and BREAST-Q scores were abstracted. From 2010-2015, 10 patients were identified. Patients with unilateral or bilateral mastectomy followed by pure fat grafting had a median of 3.5 or 4 sessions and a total median fat grafting volume of 380 or 974.5 cc, respectively. Patients were followed for 12 months, and no complications or breast cancer recurrences were noted. Finally, BREAST-Q scores at the 12-month follow-up were comparable to the preoperative values.

Concerns of Hereditary Breast Cancer in Pregnancy and Lactation.

Genetic testing should be offered to all women less than 40 years of age who are diagnosed with breast cancer, and patients with PABC are generally among them. However, there is no specific study about these cases, and whether genetic testing should be carried out during or after pregnancy is not known. Generally, testing before delivery should only be performed if positive results change management plans, such as undergoing fetal testing and choosing mastectomy instead of breast conserving surgery.

Paget Disease of the Breast in Pregnancy and Lactation.

Paget's disease of the breast (PDB) is a rare breast carcinoma believed to arise from an underlying in situ or invasive ductal cancer that migrates through the epidermis causing characteristic skin changes including scaling, redness, and itching of the nipple, areola, and sometimes the surrounding skin. Although Paget's may mimic benign conditions such as contact or allergic eczema and mastitis, it should remain a strong consideration in the differential diagnosis , especially in peripartum women for whom benign conditions such as bacterial mastitis from breastfeeding are common. The workup of Paget's should focus on both making the diagnosis with nipple/skin scrape cytology or punch biopsy as well as evaluating any underlying mass with mammogram, breast ultrasound , and also a core needle biopsy , if required. Treatment focuses on management of the underlying breast cancer as usual. The purpose of this chapter is to describe the presentation of PDB as well as outline an approach to its diagnosis and management, especially in the setting of pregnancy and lactation.

The effect of 1-day multidisciplinary clinic on breast cancer treatment.

PURPOSE: A delay in breast cancer treatment is associated with inferior survival outcomes; however, no clear guidelines exist defining the appropriate time frame from diagnosis to definitive treatment of breast cancer. A multidisciplinary approach for breast cancer treatment can minimize the time from diagnosis to first treatment. We hypothesized single-day multidisciplinary clinic (MDC) may accelerate the time to first treatment on complex breast cancer cases at our institution. METHODS: We identified patients who were treated at Johns Hopkins for stage II or III breast cancer, who were at least 18 years of age, and were seen in a new single-day MDC with coordination between two or three specialties or by specialists from varying disciplines on different days (IDC). Patients who initiated treatment between May 2015 (initiation of MDC clinic) and December 2017 were included in our study. RESULTS: A total of 296 patient records were reviewed independently. The mean (SD) patient age was 55 (13) years. The median time to first neoadjuvant chemotherapy (NACT) was significantly reduced for patients seen in the MDC (12.7 days), compared to those seen at the IDC (24.4 days, logrank p < 0.001). The median time to definitive surgery was similar between groups (31 and 32 days for the MDC and IDC cohorts, respectively). CONCLUSIONS: A single-day MDC visit is associated with a reduced time from diagnosis to NACT. Further studies are needed to determine if a shorter interval can improve the management and the outcome of complex breast cancer cases.

Analysis of Breast Cancer Patients with T1-2 Tumors and 1-3 Positive Lymph Nodes Treated with or without Postmastectomy Radiation Therapy.

The use of postmastectomy radiation therapy (PMRT) has been recommended for patients with 4 or more positive lymph nodes, however, its role in patients with 1-3 positive lymph nodes remains unclear. The purpose of this study is to evaluate oncological outcomes for breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes after undergoing PMRT. We performed a single-institution retrospective investigation that evaluated the association between PMRT and outcomes in breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes, who underwent mastectomy from 2004 to 2015. Multivariable Cox proportional hazards regression was used to evaluate the association of PMRT with disease-free survival and overall survival. A total of 379 patients met inclusion criteria, of which 204 (54%) received PMRT while 175 (46%) did not receive PMRT following mastectomy and were followed over a median of 5.2 years (25th-75th percentile: 2.8-8.4 years). Recurrence was similar in patients receiving PMRT compared to those that did not: locoregional (0 vs 3, P = 0.061), distant (9 vs 3, P = 0.135) and any recurrence (11 vs 7, P = 0.525). After adjustment for potential confounding variables, PMRT was not associated with a statistically significant difference in disease-free survival (HR: 0.93; 95% CI: 0.48, 1.79) or overall survival (HR: 0.91; 95% CI: 0.45, 1.85). PMRT was not associated with improved oncological outcomes in patients with T1-2 breast cancer and 1-3 positive lymph nodes at our institution.

Estrogen Receptor Positive and Progesterone Receptor Negative Breast Cancer: the Role of Hormone Therapy.

ER+/PR- (estrogen receptor positive and progesterone receptor negative) tumors constitute only a small portion of the breast cancer population. Patients with ER+/PR- tumors, however, are characterized by worse survival compared to patients with ER+/PR+ (estrogen receptor positive and progesterone receptor positive) tumors. Controversy exists regarding the efficacy of hormone blocking therapy for patients with ER+/PR- tumors. The NCDB was queried between 2004 and 2015, and patients with invasive ER+/PR- tumors were identified. We employed univariate Cox proportional hazards to compare outcomes among patients that did or did not receive hormone blocking therapy. We identified 138,398 patients with invasive ER+/PR- tumors, 32,044 (23%) of whom did not receive hormone blocking therapy. The reasons for not receiving hormone blocking therapy included contraindications to treatment, death, patient refusal, and unknown. There were no significant differences in race, income quartile, or education quartile between patients who did and did not receive hormone blocking therapy. Patients who did not receive hormone blocking therapy underwent surgical assessment of the axilla more frequently than those who did receive hormone therapy. Our analysis demonstrated that hormone blocking therapy administration was associated with increased overall survival for up to 10 years of follow up (HR: 0.58; 95% CI: 0.56-0.59, p < 0.001). Hormone blocking therapy may be associated with increased survival for breast cancer patients with ER+/PR- tumors. Although this benefit may last for years after completion of the course, up to 25% of patients do not receive this treatment. Strategies to increase the utilization and adherence to hormone blocking therapy regimens may improve patient survival outcomes.