98.14 Smoking and GI cancer patients—is smoking cessation an attainable goal?

Posted on January 31, 2019

J. R. Barrett1, L. Cherney-Stafford1, E. Alagoz1, M. Piper2, J. Cook2, S. Campbell-Flohr2, S. M. Weber1, E. R. Winslow1, S. M. Ronnkleiv-Kelly1, D. E. Abbott1  1University Of Wisconsin,Surgical Oncology,Madison, WI, USA 2University Of Wisconsin,School Of Medicine And Public Health, Center For Tobacco Research An Intervention,Madison, WI, USA

Introduction:

The negative consequences of tobacco use during cancer treatment are well-documented, but there are no high quality, patient-level data to help us understand patient beliefs about continued smoking (versus cessation) during gastrointestinal (GI) cancer treatment. We aimed to better describe patient attitudes about smoking cessation during cancer treatment.

Methods:

We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers; we also interviewed 5 caregivers. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo for data management and analysis. We consensus coded 10% of data inductively using conventional content analysis and developed our codebook and code descriptions. We collaboratively developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy.

Results:

Our interviews revealed three consistent themes. First, smoking cessation is not necessarily desired by many patients who have received their cancer diagnosis. Second, failure in past attempts may lead to patients feeling hopeless about future attempts, especially at such a stressful time. Third, while all patients were heavy smokers and received smoking cessation treatment throughout their life, there was little to no perceived smoking cessation treatment at the time of their cancer diagnosis.

Conclusion:

Because GI cancer patients who smoke perceive a lack of dedicated smoking cessation treatment (both counseling and pharmacologic therapy), well-designed coaching sessions educating patients—as well as providers— may be helpful in promoting healthy tobacco-free behavior during cancer treatment. However, these data also suggest that this patient population exhibits feelings of hopelessness and/or a lack of desire to quit tobacco. These realities must be considered as leaders consider dedicating valuable human and fiscal resources to smoking cessation in this population.

94.14 Changes in Maximum Axial Diameter of Pancreatic Cystic Lesions Poorly Estimate Volumetric Changes.

Posted on January 31, 2019

V. Rendell1, A. Awe1,2, M. Lubner2, E. Winslow1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA

Background: Determining surveillance and treatment plans for indeterminate pancreatic cystic lesions (PCs) is challenging due to an overall lack of understanding of their natural history. Clinical guidelines use unidimensional size thresholds and growth criteria, but the correlation between cyst size and malignant potential has been variable. It is unclear if unidimensional size changes accurately capture true volumetric changes of PCs, which may better predict clinical risk. We aimed to determine if changes in maximum axial diameter (MAD) of PCs accurately reflect changes in volume.

Methods: We performed an imaging search at our institution from 2012-2013 for contrast-enhanced CT or MR scans demonstrating a PC>1cm. We selected the first and most recent scan for patients with two studies >1 year apart. Pseudocysts and solid tumors were excluded. Imaging analysis of PCs was performed using a novel analytics software, HealthMyne, to measure MAD, volume, sphericity, and surface area. To compare changes in MAD to changes in volume, the estimated change in volume over time based on MAD was calculated as follows: eΔvol =  4π(MADtime 2/2)3/3 – 4π(MADtime 1/2)3/3. The difference between measured (actual) change in volume, (Δvola = voltime2 – voltime1) and estimated change in volume was used to calculate the absolute value of the percent difference in volume change: %diffabs = ? (eΔvol – Δvola)/Δvola? x 100% . The %diffabs by high vs low PC sphericity and surface area to volume ratio (SA:V) were compared by chi-square analysis. 

Results: 153 patients had two scans, an average of 4.1 years apart (SD 2.7 years). PCs had an average MAD of 2.1cm (SD 1.0cm) on the first scan, and 2.5cm (SD 1.3cm) on the last scan. In total, 9 PCs (6%) decreased in size over time. The average change in MAD per year was 1.0mm/yr (SD 2.5mm/yr) or 5.7%/year (SD 13%/yr). The PCs had an average volume of 5.3cm3 (SD 10.1cm3) on the first scan and 9.2 cm3 (SD 16.7cm3) on the last scan. The average change in volume per year was 0.88 cm3/yr (SD 2.5 cm3/yr) or 4%/yr (SD 87%/yr). For 60 (39%), the actual volume change was larger than the estimated volume change. Sixty-four PCs (42%) had a >100% absolute difference between estimated and measured volumes changes. PCs with high sphericity had significantly better concordance between estimated and actual volumes, but no significant difference was found by SA:V (Table 1).

Conclusions: For many PCs, estimating volume changes using MAD has poor concordance with actual changes in cyst volume. When following PCs over time, volumetric changes may provide better assessments of changing cyst size. The value of volumetric measurements for risk stratification of PCs is in need of further study.

 

75.04 Maximum Diameter is a Poor Surrogate Measure for Volume and Surface Area of Small Pancreatic Cysts

Posted on January 31, 2019

A. M. Awe1, V. Rendell3, M. Lubner2, E. Winslow3  1University Of Wisconsin,School Of Medicine & Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Determining an appropriate surveillance strategy for pancreatic cysts (PC) presents a challenge due to management guideline heterogeneity and a relatively poor ability to predict the malignant potential of PCs. Current management protocols use maximum axial diameter (MAD) to steer treatment; however, other measures may better capture the evolution of PCs. The aim of this study is to determine whether MAD is an appropriate surrogate measure for volume and surface area of PCs.

Methods: A single-institution retrospective analysis of patients with radiologically confirmed PCs was conducted. Patients with a PC >1cm and a contrast-enhanced CT or MR scan were included. Patients with pancreatic pseudocysts, underlying pancreatitis, genetic syndromes, or solid tumors were excluded. MAD, volume, and surface area data were collected using HealthMyne, a novel lesion detecting software. Pearson’s correlations were used to determine associations between volume and MAD, and surface area and MAD for total patients and size sub-groups from the Fukuoka guidelines for PC surveillance and treatment.

Results: In total, 202 patients were included in the analysis. The MADs of the cysts ranged from 1.0 cm to 7.5 cm. PC volume as a function of the MAD for all PC sizes had a strong correlation of r=0.94. When sub-grouped by size based on the Fukuoka guidelines, correlations with volume varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) PCs had correlations of 0.78, 0.53, 0.90, respectively (Fig. 1A-C). Volumes ranged for 1-2 cm cysts from 0.3- 3.8 cm3, for 2-3 cm cysts from 1.1- 10.8 cm3, and for >3 cm cysts from 6.7- 104.3 cm3. Based on volume alone, 95 cysts (47%) overlapped in Fukuoka size groupings. PC surface area as a function of the MAD for all PC sizes had a strong correlation of r=0.96. When sub-grouped by Fukuoka guideline size, correlations varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) had correlations of 0.80, 0.56, 0.92, respectively (Fig. 1D-F). Surface area ranged for 1-2 cm cysts from 0.2- 13.2 cm2, for 2-3 cm cysts from 7.3- 29.6 cm2, and for >3 cm cysts from 19.6- 126.2 cm2.  Based on surface area alone, 77 cysts (38%) overlapped between axial diameter size groupings in the Fukuoka guidelines.

Conclusion: Overall, there is strong correlation between PC volume, surface area and MAD, suggesting that unidimensional size is an appropriate surrogate measure. However, grouping PCs based on the Fukuoka guideline size criteria reveals poor volume and surface area correlation with MAD for small cysts. This suggests volume and surface area may be a useful adjunct measurements to guide surveillance and treatment decisions for smaller PCs.

 

35.07 Understanding Communication Gaps in the Hospital Consultation Process

Posted on January 31, 2019

C. Fischer2, V. Rendell3, E. Winslow3  2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery/School Of Medicine And Public Health,Madison, WI, USA

Introduction: Communication gaps have been tied to medical errors, treatment delays, and patient dissatisfaction. The hospital consultation process is particularly vulnerable to communication gaps, but these gaps have not been well studied. We aimed to evaluate which specific communication issues lend weaknesses to the consult process from the perspective of providers and patients.

Methods: As part of an existing quality improvement project at our institution, we evaluated inpatient communication event reports from clinicians and staff from February 2017 to January 2018. We also performed semi-structured interviews of inpatients who had received either a medical oncology (MO) or general surgery (GS) consult. Interviews were transcribed. A qualitative content analysis was performed on the event reports and interviews to uncover themes illustrating consult communication challenges. Themes were enumerated, and percentages determined out of total event reports or total interviews as appropriate.

Results: Of the 782 event reports reviewed, 59 (9%) were directly related to physician-physician communication during consultations and were categorized into six main groups: 1) inadequate verbal communication between providers (73%); 2) inadequate verbal communication between the provider(s) and the patient and/or their family (10%); 3) inadequate chart documentation from providers (10%); 4) delays in communication (3%); 5) inappropriate communication (2%); and 6) not accepting a consult (2%). Inadequate verbal communication was further categorized by environment: ED (23%), inpatient (47%), and inpatient involving an operation/procedure (30%).

Interviews of 33 inpatients with GS consults and 17 with MO consults were conducted between June and August 2018. Five major patient-perceived issues with provider communication were identified with sub-themes detailed in Table 1: 1) inadequate verbal communication between provider(s) and the patient/family; 2) poor communication between physicians; 3) communication with the patient before consensus on a plan has been reached; 4) use of excessive medical terminology; and 5) inadequate non-verbal communication. Only patients with GS consults reported use of excessive medical terminology.

Conclusion: Inadequate verbal communication between providers is frequently identified as problematic in the inpatient setting by both clinicians and patients. The periprocedural setting represents a significant portion of these verbal communication issues. In order to improve communication within the hospital consultation process, strategies that target the quality of provider-to-provider and provider-to-patient communication, particularly in the peri-procedural setting, are likely to be most productive.
 

34.05 The Impact of Diagnosis on Patient Satisfaction in a Large Sample of General Surgery Outpatients

Posted on January 31, 2019

N. Bandealy1, V. R. Rendell1, K. A. LeRette2, M. A. Leaf2, E. R. Winslow1  2UW Health,Enterprise Analytics,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Growing emphasis on Value Based Purchasing and patient-reported outcomes has increased interest in drivers of patient satisfaction. While demographic and other patient-related factors are known to impact satisfaction, the role of disease-related factors, specifically primary diagnosis, is not well studied. We aimed to determine if primary diagnosis affects satisfaction scores in the surgical outpatient setting.

Methods:  Primary diagnosis was examined in relation to patient experience scores as reported in Medical Practice Survey responses of general surgery patients seen in an outpatient setting from July 2016-2018. Diagnoses with similar presentations, treatments, and prognoses were merged into groups prior to viewing survey results to ensure unbiased sorting. Groups with fewer than 50 surveys were excluded. Chi squared univariate analyses compared the percentage of top box responses to three key survey questions regarding provider and overall clinic evaluation across patient, clinic, provider, and survey-related variables. Multivariate logistic regression was performed to determine factors associated with top box responses.

Results: Survey results were extracted for 1,262 patients across 6 clinical groups:  breast cancer (n=411), benign gallbladder disease (n=83), hernias (n=285), thyroid/parathyroid hormonal disorders (n=161), and hormonally inactive thyroid masses and cancer (n=225). On univariate analyses, female patients had higher percent top box scores for question 1 (Time spent with provider) and question 3 (Likelihood of recommending the clinic) (p<0.05). Female providers had higher percent top box scores for question 1 and question 2 (Likelihood of recommending provider) (p<0.05).  Responses to questions 2 and 3 differed by clinic location (p=0.01 and p=0.04, respectively) and by diagnosis group (p=0.001 and p=0.02, respectively). On multivariate analyses, only diagnosis group r­­­­­­­­­­­­­­­­­­­emained significant for all three questions (Table 1). Patients in the breast cancer group were more likely to recommend the clinic than patients in all but one diagnosis group. They were also more likely to recommend their provider than the thyroid/parathyroid hormonal disorders group. Clinic location was significant for the amount of time provider spent and likelihood of recommending clinic, but was not significant for the likelihood of recommending the provider.

Conclusion: For general surgery outpatients, breast cancer patients have higher satisfaction scores compared with patients with several other examined diagnoses on multivariate analyses. This suggests diagnosis alone may influence outpatient patient satisfaction survey results. Institutions should consider the role diagnosis plays when evaluating provider performance.

 

33.05 Specific Growth Rate as a Predictor of Survival in Pancreatic Neuroendocrine Tumors

Posted on January 31, 2019

J. J. Baechle1, P. M. Smith2, M. Tan2, C. Bailey2, C. Solorzano2, A. G. Lopez-Aguiar3, M. Dillhoff4, E. W. Beal4, G. Poultsides5, E. Makris5, F. G. Rocha6, A. Crown6, C. Cho7, M. Beems7, E. R. Winslow8, V. R. Rendell8, B. A. Krasnick9, R. Fields9, S. K. Maithel3, K. Idrees2  1Meharry Medical College,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 3Emory University,Department Of Surgery,Atlanta, GA, USA 4Ohio State University,Comprehensive Cancer Center,Columbus, OH, USA 5Stanford University Medical Center,Palo Alto, CA, USA 6Virginia Mason Medical Center,Seattle, WA, USA 7University Of Michigan,Hepatopancreatobiliary And Advanced Gastrointestinal Surgery,Ann Arbor, MI, USA 8University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 9Washington University,School Of Medicine,St. Louis, MO, USA

Introduction:  Pancreatic neuroendocrine tumors (PNETs) are often indolent, but rapidly progressing variants have been reported. To better inform prognosis and treatment decisions, improved understanding of patients at-risk for rapidly progressing PNETs is critical, particularly for patients with small PNETs who may be candidates for expectant management under current treatment guidelines. Specific growth rate (SGR) has been demonstrated in multiple malignancies to be predictive of overall and disease-free survival, but SGR has not been examined in PNETs. The aim of this study is to determine the predictive value of SGR on oncological outcomes in patients with PNETs.

Methods:  A retrospective cohort study of adult patients who underwent surgical resection of PNET from 2000-2016 was performed utilizing the multi-institutional U.S. Neuroendocrine Study Group database. Patients with PNET and more than one pre-operative cross-sectional imaging study at least thirty days apart were included in our analysis. The tumor SGR (% growth/day) was calculated using the tumor diameters measured on initial (Di) and final (Df) pre-operative imaging utilizing the previously published equation: SGR = 3ln(Di-Df)/ΔT. Patients with a SGR above the ninetieth percentile were termed “high SGR” and the remaining patients were termed “low SGR”. Overall survival (OS) was analyzed by Kaplan-Meier method and log-rank test. Cox proportional hazard models were used to assess the impact of SGR on OS after adjusting for patient and tumor characteristics. 

Results: Of the 1,247 PNET patients who underwent resection, 288 (23%) had two or more pre-operative cross-sectional imaging studies at least 30 days apart. High SGR was associated with higher T Stage at resection (p=0.01), shorter doubling time (p<0.01), and elevated HbA1c (p=0.01). Patients with high SGR also had significantly decreased 5-year OS and disease-specific survival (DSS) compared to those with low SGR (63 vs 80%, p=0.01, Figure 1a; 72 vs 86%, p=0.03, Figure 1b). In patients with small (≤2cm) tumors, high SGR predicted lower 5-year OS (85 vs 91%, p=0.01, Figure 1c). When examining all patients by multivariate analysis controlling for T, N, M stage and HbA1c, high SGR was independently associated with worse OS (Hazard Ratio 2.67, 95% Confidence Interval 1.05 – 6.84, p=0.04).

Conclusion: High SGR in PNETs, including small tumors (<2cm), is associated with worse survival. High SGR can potentially be utilized as a useful marker in the clinical decision process particularly when weighing close observation versus surgical resection in patients with small PNETs.