Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

BACKGROUND: Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows. METHODS: This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate. RESULTS: A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015. DISCUSSION: From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Sentinel Lymph Node Identification in Post Neoadjuvant Chemotherapy Breast Cancer Patients Undergoing Surgical Excision Using Lymphosonography.

OBJECTIVES: This study evaluated the efficacy of lymphosonography in the identification of sentinel lymph nodes (SLNs) in post neoadjuvant chemotherapy patients with breast cancer scheduled to undergo surgical excision. METHODS: Seventy-nine subjects scheduled for breast cancer surgery with SLN excision completed this IRB-approved study, out of which 18 (23%) underwent neoadjuvant chemotherapy before surgery. Subjects underwent percutaneous Sonazoid (GE Healthcare) injections around the tumor area for a total of 1.0 mL. Lymphosonography was performed using CPS on an S3000 HELX scanner (Siemens Healthineers) with a linear probe. Subjects received blue dye and radioactive tracer as part of their standard of care. Excised SLNs were classified as positive or negative for the presence of blue dye, radioactive tracer and Sonazoid. The results were compared between methods and pathology findings. RESULTS: Seventy-two SLNs were surgically excised from 18 subjects, 29 were positive for blue dye, 63 were positive for radioactive tracer and 57 were positive for Sonazoid. Comparison with blue dye showed that both radioactive tracer and lymphosonography achieved an accuracy of 53% (P > .50). Comparison with radioactive tracer showed that blue dye had an accuracy of 53%, while lymphosonography achieved an accuracy of 67% (P < .01). Of the 72 SLNs, 15 were determined malignant by pathology; the detection rate was 47% for blue dye (7/15), 67% for radioactive tracer (10/15) and 100% for lymphosonography (15/15) (P < .001). CONCLUSIONS: Lymphosonography achieved similar accuracy as radioactive tracer and higher accuracy than blue dye for identifying SLNs. The 15 SLNs positive for malignancy were all identified by lymphosonography.

Advanced-Stage Melanoma at Presentation Following the Peak of the Pandemic: A COVID-19 Cancer Canary in a Coal Mine.

BACKGROUND: For melanoma patients, timely identification and tumor thickness are directly correlated with outcomes. COVID-19 impacted both patients' ability and desire to see physicians. We sought to identify whether the pandemic correlated with changes in melanoma thickness at presentation and subsequent treatment timeline. METHODS: Retrospective chart review was performed on patients who underwent surgery for melanoma in an academic center surgical oncology practice from May 2019 to September 2021. Patients were split into two cohorts: "pre-pandemic" from May 2019 to May 2020 and "pandemic," after May 2020, representing when these patients received their initial diagnostic biopsy. Demographic and melanoma-specific variables were recorded and analyzed. RESULTS: A total of 112 patients were identified: 51 patients from the "pre-pandemic" and 61 from the "pandemic" time period. The pandemic cohort more frequently presented with lesions greater than 1 mm thickness compared to pre-pandemic (68.8% v 49%, p = 0.033) and were found to have significantly more advanced T stage (p = 0.02) and overall stage disease (p = 0.022). Additionally, trends show that for pandemic patients more time passed from patient-reported lesion appearance/change to diagnostic biopsy (5.7 ± 2.0 v 7.1 ± 1.5 months, p = 0.581), but less time from biopsy to operation (42.9 ± 2.4 v 52.9 ± 5.0 days, p = 0.06). CONCLUSIONS: "Pandemic" patients presented with thicker melanoma lesions and more advanced-stage disease. These results may portend a dangerous trend toward later stage at presentation, for melanoma and other cancers with rapid growth patterns, that will emerge as the prolonged effects of the pandemic continue to impact patients' presentation for medical care.

Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial.

OBJECTIVE: Single-center studies have demonstrated that resection of cavity shave margins (CSM) halves the rate of positive margins and re-excision in breast cancer patients undergoing partial mastectomy (PM). We sought to determine if these findings were externally generalizable across practice settings. METHODS: In this multicenter randomized controlled trial occurring in 9 centers across the United States, stage 0-III breast cancer patients undergoing PM were randomly assigned to either have resection of CSM ("shave" group) or not ("no shave" group). Randomization occurred intraoperatively, after the surgeon had completed their standard PM. Primary outcome measures were positive margin and re-excision rates. RESULTS: Between July 28, 2016 and April 13, 2018, 400 patients were enrolled in this trial. Four patients (2 in each arm) did not meet inclusion criteria after randomization, leaving 396 patients for analysis: 196 in the "shave" group and 200 to the "no shave" group. Median patient age was 65 years (range; 29-94). Groups were well matched at baseline for demographic and clinicopathologic factors. Prior to randomization, positive margin rates were similar in the "shave" and "no shave" groups (76/196 (38.8%) vs. 72/200 (36.0%), respectively, P = 0.604). After randomization, those in the "shave" group were significantly less likely than those in the "no shave" group to have positive margins (19/196 (9.7%) vs. 72/200 (36.0%), P < 0.001), and to require re-excision or mastectomy for margin clearance (17/196 (8.7%) vs. 47/200 (23.5%), P < 0.001). CONCLUSION: Resection of CSM significantly reduces positive margin and re-excision rates in patients undergoing PM.

Study protocol: a randomized control trial of African American families fighting parental cancer together.

BACKGROUND: African American adults experience a disproportionate burden and increased mortality for most solid tumor cancers and their adolescent children are negatively impacted by the illness experience. The purpose of this randomized clinical trial is to evaluate the efficacy of a culturally sensitive family-based intervention program developed for African American families coping with solid tumor parental cancer using an intention-to-treat approach. Primary outcome is adolescent depressive symptoms at end of treatment. METHODS: A sample of 172 African American families will be enrolled from two diverse oncology centers (Helen Graham Cancer Center in Newark, DE, and Kimmel Cancer Center in Philadelphia, PA). Eligible families will be randomized either to a 5-session intervention Families Fighting Cancer Together (FFCT) or a 5-session parent-only psycho-educational (PED) program. Assessments will occur at weeks 0 (baseline), 8 (end-of-treatment), 24, and 52. DISCUSSION: Treatments to help African American adolescents cope with the impact of parental cancer are scarce and urgently needed. If successful, this proposed research will change the nature of intervention support options available to African Americans, who are overrepresented and underserved by existing services or programs. TRIAL REGISTRATION: This project is registered with ClinicalTrials.gov (Protocol #: NCT03567330).

African American Patients' Psychosocial Support Needs and Barriers to Treatment: Patient Needs Assessment.

This study assessed adult patient's psychosocial support needs and treatment barriers in an urban diverse cancer center. A needs assessment was conducted with a convenience sample of adult oncology patients (n = 113; 71.7 % African American). Most patients were parenting school-age children and worried about them (96 %); 86.7 % would attend a family support program. Among patients who were married or partnered (68 %), 63.7 % were concerned about communication, coping, and emotional support; 53.9 % would attend a couple support program. Patients identified similar treatment barriers: transportation, babysitting for younger children, convenience of time/place, and refreshments. Findings suggest that behavioral health care providers should be available to screen cancer patients and improve access to appropriate psychosocial oncology support programs.

Cancer and the family: Variations by sex and race/ethnicity.

BACKGROUND: Cancer affects patients and their families, but few data are available on factors associated with diversity of family structures among patients with cancer. Family is a source of both support and responsibility that must be understood to support patients and their families. METHODS: Pooled data (2004-2015) from the National Health Interview Study were used to compare characteristics of cancer survivors with and without minor children and differences by sex and race/ethnicity among survivors with minor children. RESULTS: 13.9% of cancer survivors have minor children in the household, and this experience is more likely for women and people who identify as other than non-Hispanic White. CONCLUSION: There are considerable differences by sex and race/ethnicity in the characteristics of cancer survivors with minor children. Clinicians should make consideration of family circumstances a routine part of their history. Doing so will help to identify potential sources of support and responsibility that may affect adherence.

Characterizing Sentinel Lymph Node Status in Breast Cancer Patients Using a Deep-Learning Model Compared With Radiologists' Analysis of Grayscale Ultrasound and Lymphosonography.

ABSTRACT: The objective of the study was to use a deep learning model to differentiate between benign and malignant sentinel lymph nodes (SLNs) in patients with breast cancer compared to radiologists' assessments.Seventy-nine women with breast cancer were enrolled and underwent lymphosonography and contrast-enhanced ultrasound (CEUS) examination after subcutaneous injection of ultrasound contrast agent around their tumor to identify SLNs. Google AutoML was used to develop image classification model. Grayscale and CEUS images acquired during the ultrasound examination were uploaded with a data distribution of 80% for training/20% for testing. The performance metric used was area under precision/recall curve (AuPRC). In addition, 3 radiologists assessed SLNs as normal or abnormal based on a clinical established classification. Two-hundred seventeen SLNs were divided in 2 for model development; model 1 included all SLNs and model 2 had an equal number of benign and malignant SLNs. Validation results model 1 AuPRC 0.84 (grayscale)/0.91 (CEUS) and model 2 AuPRC 0.91 (grayscale)/0.87 (CEUS). The comparison between artificial intelligence (AI) and readers' showed statistical significant differences between all models and ultrasound modes; model 1 grayscale AI versus readers, P = 0.047, and model 1 CEUS AI versus readers, P < 0.001. Model 2 r grayscale AI versus readers, P = 0.032, and model 2 CEUS AI versus readers, P = 0.041.The interreader agreement overall result showed κ values of 0.20 for grayscale and 0.17 for CEUS.In conclusion, AutoML showed improved diagnostic performance in balance volume datasets. Radiologist performance was not influenced by the dataset's distribution.

Association of race and socioeconomic status and outcomes of patients with rectal cancer.

BACKGROUND: Few studies have evaluated disparities of race and socioeconomic status (SES) with outcomes in patients with rectal cancer. We hypothesize that disparities exist in the treatment and outcomes among patients with rectal cancer. METHODS: Medical records of all patients with rectal cancer treated from 2000 to 2009 at an NCI cancer center (Fox Chase Cancer Center) and an urban academic center (Temple University Hospital) were retrospectively reviewed from a prospectively maintained tumor registry database. SES was estimated using census data. Quartiles of income and education based on zip codes were calculated. Lowest vs other quartiles were compared. Clinicopathologic variables included: initial stage, chemotherapy refusal, sphincter preservation, and overall survival (OS). RESULTS: A total of 748 patients were included in the analysis (581 white, 135 black, 6 other, 26 unknown). No difference in race, SES, or insurance status was seen with regard to stage at presentation. Chemotherapy and radiation refusal was rare. After excluding stage IV patients; sphincter preservation was more common among those with higher income. Median OS for all stages was worse for nonwhite patients (31 vs 50 months, p < .001), and those with low income and education. OS disparities were most pronounced among nonwhite patients with advanced disease. Insurance was not associated with a survival difference. Age, stage, and race were independent predictors of survival. CONCLUSIONS: Disparity exists in outcomes of patients with rectal cancer. Nonwhite race is associated with worse OS, and lower SES is associated with lower OS and sphincter preservation among patients with rectal cancer.

Examining rectal carcinoids in the era of screening colonoscopy: a surveillance, epidemiology, and end results analysis.

BACKGROUND: Little is known about the epidemiology of rectal carcinoids in the United States since the implementation of screening colonoscopy. OBJECTIVE: The goal of this study was to identify epidemiological differences between rectal and small intestinal carcinoids. DESIGN: This study was retrospective in design. SETTING: Surveillance, Epidemiology and End Results registry data from 1992 to 2008 were examined. PATIENTS: Patients with rectal carcinoids included those with carcinoid tumors of the rectum. Patients with small intestinal carcinoids included those with carcinoids in the duodenum, jejunum, or ileum. MAIN OUTCOME MEASURE: Epidemiological characteristics of rectal carcinoids were identified and compared with small intestinal carcinoids using multiple variable logistic regression. RESULTS: Patients with rectal carcinoids were more likely to be women (OR, 1.196 (95% CI, 1.090-1.311); p < 0.001). Rectal carcinoids were more common among all minorities, including Asians (OR, 10.063 (95% CI, 8.330-12.157); p < 0.001), blacks (OR, 1.994 (95% CI, 1.770-2.246); p < 0.001), and Hispanics (OR, 2.682 (95% CI, 2.291-3.141), p < 0.001). Patients in the 50- to 59-year age group (OR, 0.752 (95% CI, 0.599-0.944); p = 0.014) were more likely to be diagnosed with rectal carcinoids than those in the 60- to 69-year (OR, 0.481 (95% CI, 0.383-0.605); p < 0.001) and ≥70-year age groups (OR, 0.220 (95% CI, 0.175-0.277); p < 0.001). Rectal carcinoids were more likely to be diagnosed in the screening colonoscopy era among the 50- to 59-year age group (OR, 1.432 (95% CI, 1.082-1.895); p = 0.012). Since the implementation of screening colonoscopy in 2000, the proportion of patients diagnosed with rectal carcinoids has been greater than the proportion diagnosed with small intestinal carcinoids in every year except 2001, and the proportion of patients diagnosed with rectal carcinoids after 2000 has been greater than the proportion diagnosed with small intestinal carcinoids in 12 of 13 Surveillance, Epidemiology, and End Results registry reporting agencies. CONCLUSIONS: Rectal carcinoids and small intestinal carcinoids are epidemiologically distinct tumors with unique presentations. In the era of screening colonoscopy, rectal carcinoids are the more common tumor.

Bracketed Localization in Breast-Conserving Surgery: Indications and Success Rates From a Single, High Volume, Academic Breast Cancer Center.

BACKGROUND: Bracketed localization is a technique used to help localize lesions for breast-conserving surgery (BCS). To date, there are no guidelines for when bracketed localization should be used in clinical practice. Based on our experience, we aim to provide criteria that should prompt surgeons to consider bracketing. METHODS: A single-institution retrospective chart review was performed on patients who underwent bracketed localization for BCS between 2015 and 2021. Lesion characteristics were recorded including lesion span, number of lesions, histology type on core needle biopsy and surgical specimen, margin status, and need for additional surgery. RESULTS: One hundred and thirteen cases were analyzed. Imaging showed an average lesion span of 5.0-cm. Multifocal lesions represented 45% of cases. Ductal carcinoma in situ (DCIS) was a histological component in 64% of core needle biopsies and 76% of surgical specimens. Negative margins were achieved in 82% of patients on the first excision. Additional surgery was performed in 17% of patients. Invasive lobular carcinoma had the highest additional surgery rate at 23%. Negative margins with BCS were achieved in 96% of cases, including those with successful re-excision. DISCUSSION: This descriptive study shows that bracketed localization was most often employed for patients with large lesion spans, multifocality, and a DCIS or invasive lobular component. While these characteristics are typically associated with higher rates of positive margins, our cohort's rate of additional surgery was comparable to the national average for all BCS operations. These results argue that surgeon utilization of bracketed localization may be beneficial in these clinical scenarios.

Sentinel Lymph Node Identification in Patients With Breast Cancer Using Lymphosonography.

The objective of the work described here was to evaluate the efficacy of lymphosonography in identifying sentinel lymph nodes (SLNs) in patients with breast cancer undergoing surgical excision. Of the 86 individuals enrolled, 79 completed this institutional review board-approved study. Participants received subcutaneous 1.0-mL injections of ultrasound contrast agent (UCA) around the tumor. An ultrasound scanner with contrast-enhanced ultrasound (CEUS) capabilities was used to identify SLNs. Participants were administered with blue dye and radioactive tracer to guide SLN excision as standard-of-care. Excised SLNs were classified as positive or negative for the presence of blue dye, radioactive tracer and UCA, and sent for pathology. Two hundred fifty-two SLNs were excised; 158 were positive for blue dye, 222 were positive for radioactive tracer and 223 were positive for UCA. Comparison with blue dye revealed accuracies of 96.2% for radioactive tracer and 99.4% for lymphosonography (p > 0.15). Relative to radioactive tracer, blue dye had an accuracy of 68.5%, and lymphosonography achieved 86.5% (p < 0.0001). Of 252 SLNs excised, 34 were determined to be malignant by pathology; 18 were positive for blue dye (detection rate = 53%), 23 for radioactive tracer (detection rate = 68%) and 34 for UCA (detection rate = 100%) (p < 0.0001). Lymphosonography was similar in accuracy to radioactive tracer and higher in accuracy than blue dye in identifying SLNs. All 34 malignant SLNs were identified by lymphosonography.

A comparison of timely completion of hypofractionated and traditional adjuvant radiation therapy in early-stage breast cancer: Evidence of impact on reducing racial and socioeconomic disparities.

BACKGROUND: Timely completion of adjuvant radiation after breast conservation therapy is associated with decreased mortality and increased disease-free survival. Few data exist comparing timely completion between hypofractionated radiation and traditional radiation at a national level or across racial and socioeconomic cohorts. METHODS: A retrospective review of the National Cancer Database (2012-2016) on patients undergoing breast conservation therapy for early-stage breast cancer, specifically T1 or T2, N0, M0 patients, was performed. Multivariable logistic regression models were used to compare timely completion of hypofractionated radiation (within 5 weeks of initiation) and traditional radiation (within 7 weeks) across patient, tumor, and facility characteristics. RESULTS: In total, 210,816 patients met criteria, with 59.4% receiving traditional radiation (n = 125,140) and 40.6% receiving hypofractionated radiation (n = 85,676). Overall, 82.8% of patients achieved timely completion of radiation. Among hypofractionated radiation patients, 94.5% of patients achieved timely completion, whereas only 74.8% of traditional radiation patients achieved timely completion (P < .0001). Regarding race/ethnicity, all groups benefited substantially in timely completion of hypofractionated radiation over traditional radiation. However, both treatment cohorts demonstrated that Black (odds ratio (hypofractionated radiation) = 0.842, odds ratio (traditional radiation) = 0.821) and Hispanic (odds ratio (hypofractionated radiation) = 0.917, odds ratio (traditional radiation) = 0.907) patients had lower odds of timely completion compared to White patients (P < .0001). Lower high school graduation rate, median income for patients' ZIP code, and Medicaid were also associated with lower odds of timely completion for both hypofractionated radiation and traditional radiation (both P < .0001). CONCLUSION: Timely completion of radiation therapy in breast conservation therapy is greater for patients receiving hypofractionated radiation than traditional radiation across racial and socioeconomic cohorts. Disparities in timely completion were substantially reduced with hypofractionated radiation utilization. However, there are treatment disparities across racial and socioeconomic cohorts that persist in both treatment groups.

Trends in Use of Hypofractionated Whole Breast Radiation in Breast Cancer: An Analysis of the National Cancer Database.

PURPOSE: Use of hypofractionated radiation (HR) as a component of breast-conserving treatment (BCT) in breast cancer is relatively low in the United States despite studies demonstrating its efficacy and guidelines supporting its use from the American Society for Radiation Oncology (ASTRO) in 2011 and 2018. Little is known regarding national trends in uptake and factors associated with uptake of HR in the US since the 2011 ASTRO guidelines. METHODS AND MATERIALS: We performed a retrospective review of the National Cancer Database (2012-2016) on patients undergoing BCT. Logistic regression modeling was used to identify relationships between patient, hospital, and tumor factors with the use of HR or traditional radiation (TR). RESULTS: A total of 259,342 cases of BCT were identified with 60% (n = 155,447) undergoing TR and 40% (n = 103,895) undergoing HR. There was an increase in use among patients meeting 2011 ASTRO criteria from 26.2% in 2012 to 67.0% in 2016. The odds of use of HR increased with year of diagnosis, patient age, higher median income, private insurance, treatment at an academic center, travel distance to treatment >20 miles, smaller tumors, lymph node-negative disease, and without use of chemotherapy (P values <.0001, Table 1). CONCLUSION: Guidelines supporting the use of HR in BCT have been associated with a dramatic increase in use of HR in the US. However, there are substantial, identifiable disparities in the uptake of HR at patient and facility levels. By understanding which patient populations are at risk of not receiving the benefit of this therapy, we can improve our use of HR in the US, potentially leading to reduced health care costs and increased patient satisfaction.

A contemporary analysis of goiters undergoing surgery in the United States.

INTRODUCTION: We identified disparities and at-risk populations among patients with goiters undergoing thyroidectomy. MATERIALS AND METHODS: The National Inpatient Sample (NIS) database was queried for patients with goiter who underwent thyroidectomy between 2009 and 2013. Multivariable logistic regression was used to determine factors associated with goiters undergoing thyroidectomy. RESULTS: The study consisted of 103,678 patients with thyroidectomy and a goiter diagnosis, which included: simple goiter (n = 7,692, 7.42%), nodular goiter (n = 73,524, 70.92%), thyrotoxicosis (n = 14,043, 13.54%), thyroiditis (n = 1,248, 1.20%), and thyroid cancer (n = 7,169, 6.92%). Factors associated with operation for simple goiter included age >65 years (AOR 1.43 [1.15-1.79]), black race (AOR 1.35 [1.14-1.58]), and being uninsured (AOR 2.13 [1.52-2.98]). Patients with cancerous goiters undergoing thyroidectomy were less likely to be Black (AOR 0.38 [0.31-0.48]) or uninsured (AOR 0.25 [0.07-0.89]). DISCUSSION: Understanding disparities within populations undergoing thyroidectomy for goiter may allow for targeted efforts to more effectively treat goiters nationwide.

The overuse of radioactive iodine in low-risk papillary thyroid cancer patients.

BACKGROUND: The aim of this study was to use current American Thyroid Association (ATA) management guidelines to identify groups who might be at risk of overtreatment with radioactive iodine (RAI) ablation after surgery for low-risk papillary thyroid cancer (PTC). METHODS: PTC patients were identified using the Surveillance, Epidemiology and End Results database. Characteristics of low-risk patients (defined as T1 without metastasis) were compared to those not low-risk. Predictors of receiving RAI for low-risk disease were determined using logistic regression. RESULTS: Of 32,229 cases, 17,286 (53.6%) were low-risk. Low-risk patients, compared to others, were older (mean age 51.3 versus 48.5 years), and more often female (81.6% versus 71.7%), white (69.7% versus 62.0%), and insured (87.6% versus 85.6%)(all p-values < 0.001). Nearly 25% of low-risk patients received RAI. Predictors of overtreatment with RAI included age <45 years (OR: 1.393; 95% CI: 1.250-1.552), age 45-64 years (OR: 1.275; 95% CI: 1.152-1.412), male sex (OR: 1.191; 95% CI: 1.086-1.305), Hispanic (OR: 1.236; 95% CI: 1.110-1.376) and Asian (OR: 1.306; 95% CI: 1.159-1.473) race, and extensive lymphadenectomy (OR: 1.243; 95% CI: 1.119-1.381). CONCLUSION: Low-risk PTC patients were more likely to receive post-surgical RAI when not indicated under ATA guidelines if they were younger, male, Hispanic or Asian, or underwent extensive lymph node surgery. Identification of groups at risk for overtreatment can help impact practice patterns and improve the effective utilization of healthcare resources.

Disparity in the use of adjuvant radioactive iodine ablation among high-risk papillary thyroid cancer patients.

BACKGROUND: We sought to identify treatment disparities existing prior to publication of the 2015 American Thyroid Association Management Guidelines in order to identify patients with papillary thyroid cancer (PTC) at risk for receiving inadequate treatment. METHODS: Patients diagnosed with PTC from 2011 to 2013 were identified using Surveillance, Epidemiology and End Results database. High-risk disease was defined as T4, N1, or M1. Chi-square tests compared characteristics of patients with and without high-risk disease and characteristics of high-risk patients who did and did not receive radioactive iodine ablation (RAI). Likelihoods of having high-risk disease, of receiving RAI, and of cause-specific death were calculated using regression analyses. RESULTS: Sample included 32,229 individuals; 7894 (24.5%) had high-risk disease. Mean age was 50.0 years, 24,815 (77.0%) were female, and 21,318 (66.2%) were white. Odds of high-risk disease were greater among males (OR:2.04; 95% CI:1.92-2.16), Hispanics (OR:1.67; 95% CI:1.56-1.79) and Asians (OR:1.49; 95% CI:1.37-1.62), and uninsured (OR:1.24; 95% CI:1.07-1.43), and lower among patients ages 45-64 (OR:0.57; 95% CI:0.53-0.60), and ≥65 years (OR:0.54; 95% CI:0.50-0.59), and Blacks (OR:0.46; 95% CI:0.40-0.53). Most (69.3%) high-risk patients received RAI. Odds of receiving RAI were lower among patients age ≥65 years (OR:0.67; 95% CI:0.58-0.77), uninsured (OR:0.52; 95% CI:0.41-0.67), or with Medicaid (OR:0.58; 95% CI:0.50-0.69). RAI use reduced the risk of cause-specific mortality (HR:0.29; 95% CI:0.18-0.47). CONCLUSION: Knowledge of these treatment disparities will allow recognition of groups at risk for high-risk disease and receiving inadequate treatment.

Understanding nationwide readmissions after thyroid surgery.

BACKGROUND: The 30-day readmission rate is increasingly utilized as a metric of quality that impacts reimbursement. To date, there are no nationally representative data on readmission rates after thyroid surgery. We aimed to determine national readmission rates after inpatient thyroidectomy operations and whether select clinical factors were associated with increased odds of postthyroidectomy readmission. METHODS: Using the 2014 Nationwide Readmissions Database, we identified patients undergoing inpatient thyroid surgery as defined by the International Classification of Diseases, Ninth Revision, procedure codes for thyroid lobectomy, partial thyroidectomy, complete thyroidectomy, and substernal thyroidectomy. Descriptive statistics were used to report readmission rates, most common diagnosis and causes of readmission, and timing of presentation after discharge. Multivariable logistic regression models controlling for potential confounders were used to determine whether select factors were associated with 30-day readmission. RESULTS: A total of 22,654 patients underwent inpatient thyroid surgery during the study period, 990 of whom (4.4%) were readmitted within 30 days. Among these, the most common diagnoses during readmission were disorders of mineral metabolism and hypocalcemia, accounting for 36.0% and 26.6% of readmissions, respectively. This held true regardless of the apparent indication for thyroid surgery (goiter, cancer, or thyroid function disorder) or timing of readmission after discharge. Calcium-related abnormalities were the top diagnoses at readmissions (22.1%). Most readmissions (54.6%) occurred within 7 days of discharge, with 24.6% within the first 2 days Factors associated with an increased odds of readmission included having Medicare (adjusted odds ratio [AOR] 1.47 and 95% confidence interval [CI] 1.03-2.11) or Medicaid insurance (AOR 1.44 [CI 1.04-1.99]), being discharged to inpatient post acute care (AOR 2.31 [CI 1.48-3.62]) or to home health care (AOR 1.78 [CI 1.21-2.63]), having an Elixhauser comorbidity score ≥ 4 (AOR 2.04 [CI 1.27-3.26]), and a duration of stay ≥2 days after the thyroid surgery (AOR 2.7 [CI 1.9-3.82]). The only complication during index admission associated with increased odds of readmission was hypocalcemia (AOR 1.5 [CI 1.1-2.06]. Indications for thyroid surgery were not associated with increased odds of readmission. CONCLUSION: Readmissions after thyroid surgery are relatively low and occur early after surgery. The most common diagnoses identified on readmission were calcium and mineral metabolism disorders, which also were the most common cause of readmission. Socioeconomic factors, comorbidities, and complications during the index admissions were found to be associated with nonelective, postthyroidectomy readmissions. Recognition of these risk factors may guide the development of interventions and protocols to decrease readmissions.