Limited English Proficiency and Graves' Disease at an Urban Safety Net Hospital.

INTRODUCTION: Decision-making regarding definitive therapy for Graves' disease requires effective patient-provider communication. We investigated whether patients with limited English proficiency have differences in thyroidectomy outcomes or perioperative management when compared to English proficient (EP) patients at a safety net hospital with high-volume endocrine surgery practice. METHODS: Retrospective study of patients who underwent thyroidectomy (2012-2021) for Graves' disease within a tertiary referral system. Demographics, preoperative factors, and postoperative outcomes were abstracted via chart review and compared between EP and limited English proficient (LEP) patients in univariate analyses. Odds of postoperative complications were assessed via multivariable logistic regression. Time metrics such as time from endocrinology consultation to surgery were compared via Kaplan-Meier analysis and adjusted Cox proportional regression models. RESULTS: Of 236 patients, 85 (36%) had LEP. Low and equivalent complication rates occurred across language groups (<1% permanent). LEP patients had similar odds of thyroidectomy-specific complications (odds ratio = 1.2; 95% confidence interval 0.6-2.4). Adjusted Cox proportional hazards ratios showed that LEP patients experienced significantly shorter time from endocrinology consultation to surgery compared to EP patients [hazard ratio = 0.7; 95% confidence interval 0.5-0.9]. CONCLUSIONS: Thyroidectomy-specific complication rate for patients with Graves' disease was low, and we detected no independent association between complications and English language proficiency. Non-English primary language was independently associated with reduced time from endocrinology consultation to surgery. This finding must be interpreted with nuance and is likely multifactorial. It may reflect a well-organized, efficient system for under-resourced patients, or it may derive from communication barriers that limit robust shared decision-making, thus accelerating time to surgery.

Trends in access to minimally invasive pancreaticoduodenectomy for pancreatic cancers.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear. METHODS: The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD. RESULTS: Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774). CONCLUSION: SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.

The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival.

OBJECTIVE: To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer. BACKGROUND: Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980. METHODS: In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region. RESULTS: Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty. CONCLUSIONS: The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.

The Evaluation of Gallstone Disease in the Year Before Pancreatic Cancer Diagnosis.

INTRODUCTION: Patients with pancreatic cancer can present with a variety of insidious abdominal symptoms, complicating initial diagnosis. Early symptoms of pancreatic cancer often mirror those associated with gallstone disease, which has been demonstrated to be a risk factor for this malignancy. This study aims to compare the incidence of gallstone disease in the year before diagnosis of pancreatic ductal adenocarcinoma (PDAC) as compared to the general population, and evaluate the association of gallstone disease with stage at diagnosis and surgical intervention. METHODS: Patients with PDAC were identified from SEER-Medicare (2008-2015). The incidence of gallstone disease (defined as cholelithiasis, cholecystitis and/or cholecystectomy) in the 1 year before cancer diagnosis was compared to the annual incidence in an age-matched, sex-matched, and race-matched noncancer Medicare cohort. RESULTS: Among 14,654 patients with PDAC, 4.4% had gallstone disease in the year before cancer diagnosis. Among the noncancer controls (n = 14,654), 1.9% had gallstone disease. Both cohorts had similar age, sex and race distributions. PDAC patients with gallstone disease were diagnosed at an earlier stage (stage 0/I-II, 45.8% versus 38.1%, P < 0.0001) and a higher proportion underwent resection (22.7% versus 17.4%, P = 0.0004) compared to patients without gallstone disease. CONCLUSIONS: In the year before PDAC diagnosis, patients present with gallstone disease more often than the general population. Improving follow-up care and differential diagnosis strategies may help combat the high mortality rate in PDAC by providing an opportunity for earlier stage of diagnosis and earlier intervention.

A nationwide propensity score analysis comparing ablation and resection for hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: Studies have reported ambiguous results regarding the efficacy of ablation for early-stage hepatocellular carcinoma (HCC). Our study compared outcomes of ablation versus resection for HCC ≤50 mm to identify tumor sizes that would most benefit from ablation in terms of long-term survival. METHODS: The National Cancer Database was queried for patients with stage I and II HCC ≤50 mm who underwent ablation or resection (2004-2018). Three cohorts were created based on tumor size: ≤20, 21-30, and 31-50 mm. A propensity score-matched survival analysis was performed using the Kaplan-Meier method. RESULTS: In total, 36.47% (n = 4263) and 63.53% (n = 7425) of patients underwent resection and ablation, respectively. After matching, resection was associated with a significant survival benefit compared to ablation (3-year survival: 78.13% vs. 67.64%; p < 0.0001) in patients with HCC of ≤20 mm. The impact of resection was even more striking among patients with HCC of 21-30 mm (3-year survival: 77.88% vs. 60.53%; p < 0.0001) and 31-50 mm (3-year survival: 67.21% vs. 48.55%; p < 0.0001). CONCLUSIONS: While resection offers a survival benefit over ablation in the treatment of early-stage HCC ≤50 mm, ablation may provide a feasible bridging strategy in patients awaiting transplantation.

Disparities in the Receipt of Recommended Curative Treatment for Patients with Early-Stage Hepatocellular Carcinoma.

BACKGROUND: In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC. METHODS: The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004-2017). Cohorts were created based on the receipt or decline of recommended interventions-hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan-Meier method. RESULTS: Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1-1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6-2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2-1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9-2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively). CONCLUSIONS: Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes.

Volume of Pancreas-Adjacent Operations Favorably Influences Pancreaticoduodenectomy Outcomes at Lower Volume Pancreas Centers.

OBJECTIVE: This study assesses how the volume of pancreatic-adjacent operations (PAO) impacts the outcomes of pancreaticoduodenectomy (PD). SUMMARY BACKGROUND DATA: It is well-established that regionalization benefits outcomes after PD. However, due to a multitude of factors, including geographic, financial, and personal, not all patients receive their care at high-volume pancreas surgery centers. METHODS: The National Cancer Database was queried for pancreatic cancer patients who underwent PD. Hospital volume was calculated for PD and PAO (defined as gastric, hepatic, complex biliary, or pancreatic operations other than PD) and dichotomized as low- and high-volume centers based on the median. Three study cohorts were created: low-volume hospitals (LVH) for both PD and PAO, mixed-volume hospital (MVH) with low-volume PD but high-volume PAO, and high-volume PD hospital (HVH). RESULTS: In total, 24,572 patients were identified, with 41.5%, 7.2%, and 51.3% patients treated at LVH, MVH, and HVH, respectively. Thirty-day mortality for PD was 5.6% in LVH, 3.2% in MVH, and 2.5% in HVH. On multivariable analyses, LVH was predictive for higher 30-day mortality compared to HVH [odds ratio (OR) 2.068; 95% confidence interval (CI) 1.770-2.418; P< 0.0001]. However, patients at MVH demonstrated similar 30-day mortality to patients treated at HVH (OR 1.258; 95% CI 0.942-1.680; P = 0.1203). CONCLUSIONS: PD outcomes at low-volume centers that have experience with complex cancer operations near the pancreas are similar to PD outcomes at hospitals with high PD volume. MVH provides a model for PD outcomes to improve quality and access for patients who cannot, or choose not to, receive their care at high-volume centers.

The Effect of Hospital Versus Surgeon Volume on Short-Term Patient Outcomes After Pancreaticoduodenectomy: a SEER-Medicare Analysis.

BACKGROUND: The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience. OBJECTIVE: This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD. METHODS: Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort. RESULTS: In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts. CONCLUSION: Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals.

Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy.

BACKGROUND: Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy. PATIENTS AND METHODS: This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals. RESULTS: Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97). CONCLUSIONS: Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.

Surveillance Patterns for Hepatocellular Carcinoma among Screening-Eligible Patients in the Medicare Population.

INTRODUCTION: Routine screening plays a critical role in the diagnosis of hepatocellular carcinoma (HCC), but not all patients undergo consistent surveillance. This study aims to evaluate surveillance patterns and their association with diagnosis stage and survival among Medicare patients at risk for HCC. PATIENTS AND METHODS: Patients with HCC and guideline-based screening eligibility who underwent imaging with ultrasound or abdominal magnetic resonance imaging (MRI) in the 2 years prior to diagnosis were identified from SEER-Medicare (2008-2015). Three surveillance cohorts were created: diagnostic (imaging only within 3 months prior), intermittent (imaging only once within 2 years prior, excluding diagnostic), and routine (at least two imaging encounters within 2 years prior, excluding diagnostic). Multivariable logistic regression was used to predict early-stage diagnosis (stage I-II), and 5-year survival was evaluated using the accelerated failure time method with Weibull distribution. RESULTS: Among 2261 eligible patients, 26.1% were classified as diagnostic, 15.8% as intermittent, and 58.1% as routine surveillance. The median age was 74 years (IQR 70-78 years). The majority of patients had a preexisting cirrhosis diagnosis (81.5%). Routine and intermittent, compared with diagnostic, surveillance were predictive of early-stage disease (routine: OR 2.05, 95% CI 1.64-2.56; intermittent: OR 1.43, 95% CI 1.07-1.90). Patients who underwent routine surveillance had significantly lower risk of mortality (HR 0.84, 95% CI 0.75-0.94) compared with the diagnostic group. CONCLUSIONS: A large proportion of screening-eligible patients do not undergo routine surveillance, which is associated with late-stage diagnosis and higher risk of mortality. These findings demonstrate the impact of timely and consistent healthcare access and can guide interventions for promoting surveillance among these patients.

Incidental Adrenal Masses: Adherence to Guidelines and Methods to Improve Initial Follow-Up: A Systematic Review.

OBJECTIVE: Incidental adrenal masses (IAMs) are detected in approximately 1%-2% of abdominal computed tomography (CT) scans. Recent estimates suggest that more than 70-million relevant CT scans are performed annually in the United States; thus, IAMs represent a significant clinical entity. Most clinical guidelines recommend an initial follow-up evaluation that includes imaging and biochemical testing after index IAM detection. METHODS: Systematic review of literature in the PubMed, EMBASE and Web of Science databases to determine whether guidelines regarding IAM evaluation are followed and to identify effective management strategies. Our initial search was in January 2018 and updated in November, 2019. RESULTS: 31 studies met inclusion criteria. In most institutions, only a minority of patients with IAMs undergo initial follow-up imaging (median 34%, IQR 20%-50%) or biochemical testing (median 18%, IQR 15%-28%). 2 interventions shown to improve IAM evaluation are IAM-specific recommendations in radiology reports and dedicated multi-disciplinary teams. Interventions focused solely on alerting the ordering clinician or primary care provider to the presence of an IAM have not demonstrated effectiveness. Patients who are referred to an endocrinologist are more likely to have a complete IAM evaluation, but few are referred. DISCUSSION: Most patients with an IAM do not have an initial evaluation. The radiology report has been identified as a key component in determining whether IAMs are evaluated appropriately. Care teams dedicated to management of incidental radiographic findings also improve IAM follow-up. Although the evidence base is sparse, these interventions may be a starting point for further inquiry into optimizing care in this common clinical scenario.

Beyond insurance status: the impact of Medicaid expansion on the diagnosis of Hepatocellular Carcinoma.

BACKGROUND: Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability. METHODS: Patients with HCC <65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability. RESULTS: Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p < 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability. CONCLUSION: Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels.

The impact of upper gastrointestinal surgical volume on short term pancreaticoduodenectomy outcomes for pancreatic adenocarcinoma in the SEER-Medicare population.

BACKGROUND: Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD. METHODS: Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008-2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications. RESULTS: In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165-1.783; mixed-low: OR 1.374, 95%CI 1.085-1.740; mixed-high: OR 1.418, 95%CI 1.098-1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454-3.209; mixed-low: OR 2.068, 95%CI 1.347-3.175; mixed-high: OR 1.96, 95%CI 1.245-3.086). CONCLUSION: Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center.

The Impact of Residential Segregation on Pancreatic Cancer Diagnosis, Treatment, and Mortality.

BACKGROUND: Disparities in pancreatic cancer outcomes between black and white patients are well documented. This study aimed to use a more novel index to examine the impact of racial segregation on the diagnosis, management, and outcomes of pancreatic cancer in black patients compared with white patients. METHODS: Black and white adults with pancreatic cancer in urban counties were identified using data from the 2018 submission of the Surveillance, Epidemiology and End Results (SEER) Program and the 2010 Census. The racial index of dissimilarity (IoD), a validated proxy of racial segregation, was used to assess the evenness with which whites and blacks are distributed across census tracts in each county. Multivariate Poisson regression was performed, and stepwise models were constructed for each of the outcomes. Overall survival was studied using the Kaplan-Meier method. RESULTS: The study enrolled 60,172 adults with a diagnosis of pancreatic cancer between 2005 and 2015. Overall, the black patients (13.8% of the cohort) lived in more segregated areas (IoD, 0.67 vs 0.61; p < 0.05). They were less likely to undergo surgery for localized disease (relative risk [RR], 0.80; 95% confidence interval [CI], 0.76-0.83) and more frequently had a diagnosis of advanced-stage disease (RR, 1.09; 95% CI, 1.01-1.19) with increasing segregation. They also had shorter survival times (9.8 vs 11.4 months; p < 0.05). CONCLUSIONS: Disparities in advanced-stage disease at diagnosis, surgery for localized disease, and overall survival are directly related to the degree of residential segregation, a proxy for structural racism. In searching for solutions to this problem, it is important to account for the historical marginalization of black Americans.

Undertreatment of Gallbladder Cancer: A Nationwide Analysis.

BACKGROUND: Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer. METHODS: Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan-Meier and Cox proportional hazard methods. RESULTS: The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p < 0.0001), private insurance (41.6% vs 27.1%; p < 0.0001), academic centers (50.4% vs 29.7%; p < 0.0001), and treatment location in the Northeast (22.8% vs 20.4%; p = 0.0011). Compared with no re-resection, re-resection was associated with pT stage (pT2: 47.6% vs 42.8%; p = 0.0139) and pN stage (pN1-2: 28.1% vs 20.7%; p < 0.0001), negative margins on final pathology (90.1% vs 72.6%; p < 0.0001), and receipt of chemotherapy (53.7% vs 35.8%; p < 0.0001). The patients who underwent re-resection demonstrated significantly longer overall survival (OS) than the patients who did not undergo re-resection (median OS, 44.0 vs 23.0 months; p < 0.0001). After propensity score-matching, re-resection remained associated with superior survival (median OS, 44.0 vs 31.0 months; p = 0.0004). CONCLUSIONS: Re-resection for gallbladder cancer is associated with improved survival but remains underused, particularly for early-stage disease.

The role of racial segregation in treatment and outcomes among patients with hepatocellular carcinoma.

BACKGROUND: There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes. METHODS: We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates. RESULTS: Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD. CONCLUSIONS: Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes.

Provider-patient Language Discordance and Cancer Operations: Outcomes from a Single Center Linked to a State Vital Statistics Registry.

INTRODUCTION: Patterns of worldwide immigration have resulted in high rates of discordance between medical providers and the patients they treat. For example, in the USA, 25 million individuals in the USA self-identified that they speak English less than "very well." Previous studies have generated mixed results regarding differences in postoperative outcomes between English proficient (EP) and limited English proficient (LEP) patients. Our objective was to determine whether a difference in outcomes exists for non-English-speaking patients compared to English-speaking patients after operations commonly performed to treat cancer. STUDY DESIGN: A retrospective cohort study was performed in an urban, safety net and tertiary referral medical center over a five-year period. Adult patients undergoing cancer operations were stratified as EP and LEP. We evaluated 30-day revisit to the ED, length of stay (LOS), long-term all-cause mortality, and any major complication on index admission. Regression was used to adjust for baseline comorbidities, case risk, and socioeconomic factors. RESULTS: A total of 2467 patients were included. There was no difference in case risk between language groups, but EP had a larger proportion of high comorbidity scores. Patients in the non-English group were more likely to be uninsured/self-pay and live in neighborhoods with lower median income. After adjustment, we found no difference in long-term mortality [hazard ratio: 0.87 (95% CI 0.52-1.45)]. LEP patients had the same LOS compared to primary EP patients with an IRR of 0.99 (95% CI 0.88-1.10). There was no difference in the odds of revisit to hospital for LEP versus EP, with an OR of 1.08, 95% CI [0.75-1.53] and no difference in major complication (OR 0.76 (95% CI 0.39-1.45). CONCLUSIONS: We found no association between language and outcomes after cancer operations. This lack of difference may reflect local efficacy at treating non-English-speaking patients, and health systems with fewer services for LEP patients might show different results.

Correction to: Association of Primary Language with Outcomes After Operations Typically Performed to Treat Cancer: Analysis of a Statewide Database.

In the original article, there were errors in Table 1 that were not in accordance with requirements set by the Healthcare Cost and Utilization Project (HCUP) Data Use Agreement that apply to this article. Following is the corrected Table 1.

Association of Primary Language with Outcomes After Operations Typically Performed to Treat Cancer: Analysis of a Statewide Database.

BACKGROUND: Few studies have evaluated the effect of primary language on surgical outcomes, and no studies have addressed operations typically performed for cancer diagnoses. This study aimed to determine the effect of primary languages other than English on outcomes after surgical oncology operations. METHODS: This study retrospectively analyzed adults undergoing operations typically performed to treat cancer using the NJ Healthcare Cost and Utilization Project State Inpatient Database during the interval of 2009-2014. Language was grouped according to English-, Spanish-, and non-English/non-Spanish (NENS)-speaking groups. The study evaluated in-hospital mortality, 7-day readmission, and hospital length of stay (LOS). Logistic and negative binomial regression methods were applied, and generalized linear mixed models were used to account for nesting within a hospital. RESULTS: This study analyzed 37,531 cases. Non-English speakers were of lower economic status, more likely to be admitted on the weekend, and more likely to undergo higher-risk operations. The likelihood of death in the risk-adjusted multi-level models did not differ between Spanish speakers (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.41-1.10) and NENS speakers (OR, 1.16; 95% CI, 0.77-1.75). Readmission rates exhibited high inter-hospital variability (intra-class correlation, 53%). The odds of readmission among Spanish speakers in the non-hierarchical model was increased (OR, 1.50; 95% CI, 1.11-2.02), but this was ameliorated in the multilevel modeling that accounted for variability between hospitals (OR, 1.29; 95% CI, 0.93-1.80). No changes in LOS were observed. CONCLUSIONS: No independent association was observed between primary language and outcomes after operations typically performed to treat cancer in the study population. The higher proportion of weekend admissions may suggest more acute or advanced presentations for non-English speakers. Long-term outcomes may be necessary to discern an impact.

Opportunity Lost? Diagnostic Laparoscopy in Patients with Pancreatic Cancer in the National Surgical Quality Improvement Program Database.

BACKGROUND: Routine preoperative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) for pancreatic cancer. METHODS: We queried the National Surgical Quality Improvement Program for patients with pancreas cancer (2005-2013) and compared groups who underwent DLAP, exploratory laparotomy (XLAP), pancreas resection (RSXN) or therapeutic bypass (THBP). We compared demographics, comorbidities, postoperative complications, 30-day mortality (Chi-square P < 0.05) and trends over time (R2 0-1). RESULTS: We identified 17,138 patients (RSXN 81.8%, XLAP 16.5%, THBP 8.2%, and DLAP 12.9%), with some having multiple CPT codes. Only 10.3% (n = 1432) of RSXN patients underwent DLAP prior to resection. XLAP occurred in 49.5% of non-RSXN patients, of whom 67.1% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R2 0.81), while DLAP decreased 52.6% (R2 0.92). XLAP patients without other operations decreased from 4.2 to 2.4%, although not linearly (R2 0.31). Only 10.3% of XLAP had a diagnostic laparoscopy as well, leaving nearly 90% of these patients with an exploratory laparotomy without RSXN or THBP. DISCUSSION: Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or therapeutic bypass.