51.05 Optimizing Survivorship Care Using a Patient-Centered Treatment and Care Plan

Posted on December 22, 2014

J. G. Ulloa1, M. Hemmelgarn2, L. Viveros2, P. Odele1, P. Ganz3, M. Maggard Gibbons1,2  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2Olive View-UCLA Medical Center,Surgery,Sylmar, CA, USA 3University Of California – Los Angeles,Medicine,Los Angeles, CA, USA

Introduction:
Low income minority women with breast cancer can experience a range of barriers to quality care including poor access, treatment adherence, and follow-up care.  Some hospitals adopted navigators to improve patient experience and delivery of care; however studies suggest communication of health information may still be limited, possibly related to low health literacy.  Our objective was to test a novel patient-centered survivorship card (language appropriate) containing treatment and survivorship care plans targeted to improve health information communication.

Methods:
Breast cancer survivors were enrolled over 8 months at a public safety net hospital. All patients completed active therapy 2 years prior and were provided standardized educational information throughout treatment.  After completion of treatment, patients were surveyed on their health literacy (SILS-Single Item Literacy Screener), knowledge of long term care and recall of stage, node status and treatment plan.  Patients were given an individualized survivorship card (reviewed by a navigator or community health worker [CHW]).  The card included information on cancer stage, treatment received, and recommendations from the American Society of Clinical Oncology regarding need for annual physical exam. A follow-up survey to assess retention was completed within 1 week.  Z-test of proportions was used to assess knowledge differences pre and post-survivorship card.

Results:
130 women completed the baseline survey; 104 completed post-survivorship card survey (80% retention).  34.6% had stage II disease and 15.4% had stage III; mean age was 54.6 (+/-) 9.1 years.  25.0% completed 6th grade education or less.  42.3% needed help reading health related information; 64.4% were Spanish speakers.  Responses between baseline and post-survivorship card intervention were respectively: 66.3% to 93.3% for correctly knowing cancer stage (P<.05), 72.1% to 84.6% node status (P<.05) and 80.8% to 93.3% (P<.05) for past treatment.  Knowledge of risk for cancer recurrence increased from 69.2% to 85.6% (P<.05) and knowledge of symptoms of recurrence increased from 44.2% to 91.3% (P<.05).  39.8% did not know when they needed a physical exam at baseline, which was reduced to 13.6% (P<.05) post-survivorship card. 38.5% of patients rated the card as very easy to understand. 

Conclusion:
Use of a patient-centered survivorship information wallet card improves short-term recall of disease specific knowledge and survivorship care.  This approach further reduces barriers of communication and is effective in ethnic minorities that demonstrate difficulty with provider communication.  We are collecting 3 month post-intervention data for assessment of longer term retention and will explore the effectiveness of CHW versus a navigator.

49.01 Low Anterior Resection after Neoadjuvant Chemoradiation for Rectal Cancer: To Divert or Not Divert?

Posted on December 22, 2014

A. N. Kulaylat1, T. M. Connelly1, J. Miller2, N. J. Gusani2, G. Ortenzi1, J. Wong2, N. H. Bhayani2, E. Messaris1  1Penn State Hershey Medical Center,Division Of Colon And Rectal Surgery,Hershey, PA, USA 2Penn State Hershey Medical Center,Division Of General Surgical Specialties & Surgical Oncology,Hershey, PA, USA

Introduction:  A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer in patients that have undergone neoadjuvant chemoradiation (nRT) thus protecting the newly created anastomosis by diverting the fecal stream. The aim of this study was to examine large cohort of rectal cancer patients undergoing elective LAR after nRT.  

Methods:  The National Surgical Quality Improvement Program database records from 2005 – 2012 were utilized to identify patients undergoing LAR for rectal cancer following nRT (ICD-9 diagnosis code 154.*). Patients who underwent emergency resection, had Stage IV disease and/or had a permanent end colostomy were excluded. Patients were grouped for comparison based on Current Procedural Terminology (CPT) codes:  diverting stoma (CPT code 44146, 44208) or no diverting stoma (CPT code 44145, 44207). The primary outcomes were postoperative infectious complications, reoperation and mortality.

Results: 1,406 patients were included in the analysis: 607 (43.2%) received a protective stoma and 799 (56.8%) were not diverted. There were no significant differences between the stoma and no stoma groups in demographic variables, comorbidities (except hypertension) or weight loss (p>0.05). The mean body mass index was greater in the stoma group (28.3±7.2 m/kg2 versus no stoma, 27.4±6.6 m/kg2, p=0.02). Although operative time was increased in patients that received a stoma (230±94 minutes versus no ostomy, 218±99 minutes, p=0.02), there were no differences in overall anesthesia time or hospital length of stay (p>0.05). Overall morbidity was 27.3% in the LAR cohort vs 29.7% in the stoma cohort (p>.05). There were no significant differences in   deep organ space infection, sepsis and septic shock, unplanned reoperation and overall mortality between the groups (p>0.05).  

Conclusion: 1) Diverting stoma does not decrease mortality or infectious complications in rectal cancer patients undergoing a low anterior resection after neoadjuvant radiation. 2) No factors were identified that could assist surgeons in deciding whether to perform a protective ostomy in patients undergoing neoadjuvant radiation and subsequent LAR for rectal cancer. Patients with higher body mass index have higher chances of receiving a protective stoma.

 

49.08 Voice Messaging System Associated With Improved Survival In Patients With Hepatocellular Carcinoma

Posted on December 22, 2014

A. Mokdad1, A. Singal1, J. Mansour1, G. Balch1, M. Choti1, A. Yopp1  1University Of Texas Southwestern Medical Center,Surgery Oncology,Dallas, TX, USA

Introduction:  Hepatocellular carcinoma (HCC) treatment involves multiple specialties risking delayed treatment and worse outcomes. The aim was evaluating outcomes following implementation of a voice messaging system (VMS) designed to reduce delays in treatment following HCC diagnosis.

Methods:  A retrospective study of HCC patients was conducted in an outpatient safety net hospital between February 2008 and January 2012. In February 2010, VMS notification of HCC to the ordering physician and downstream treating physicians was implemented. Patients were divided into: 1) pre-intervention: diagnosis two years prior to implementation or failure of notification following implementation, 2) post-intervention: diagnosis two years following implementation. Demographics, tumor characteristics, treatment, and survival were compared.

Results: Ninety-seven patients diagnosed with HCC, 51 in the pre-intervention group and 46 in the post-intervention group. The main etiology of chronic liver disease was HCV infection and no differences in symptoms, liver dysfunction, tumor characteristics, or treatment were observed between groups. The time from diagnosis to clinic contact (0.5 months vs. 2.9 months, p=0.003) and time from detection to treatment (2.2 months vs. 5.5 months, p=0.005) was significantly shorter following VMS. BCLC A status (HR 3.4, 95%CI 2,6), treatment (HR 2.0, 95%CI 1,4), and VMS (HR 1.7, 95%CI 1,3) were independently associated with improved overall survival. Patients diagnosed following VMS had a median survival of 31.7 months compared to 15.7 months, p=0.008.

Conclusion: Implementation of VMS reduces time to treatment and reduction in time to initial clinic visit. Reduction in time to treatment is associated with improved outcome independent of tumor stage, underlying liver function, and treatment.

 

45.10 Outcomes Using Double-Stapled Technique for Esophagoenteric Anastomosis in Gastric Cancer

Posted on December 22, 2014

A. Falor1, A. Choi1, S. Merchant1, M. Lew2, B. Lee1, I. B. Paz1, R. Nelson3, J. Kim1  1City Of Hope National Medical Center,Division Of Surgical Oncology,Duarte, CA, USA 2City Of Hope National Medical Center,Department Of Anesthesia,Duarte, CA, USA 3City Of Hope National Medical Center,Department Of Biostatistics,Duarte, CA, USA

Introduction: Several surgical techniques to perform esophagoenteric anastomosis for total/proximal gastrectomy have been described including the double-stapled technique (DST), which involves a circular stapled anastomosis across the stapled end of the esophagus. Since prior reports on DST for gastric cancer are limited, our objective was to examine rates of anastomotic leak and stricture with DST for esophagoenteric anastomosis in patients with gastric cancer.

Methods: A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2014. All DST were performed using the OrVil™ and an end-to-end anastomosis (EEA) stapler. Patient and treatment-related variables were tabulated. Anastomotic leaks were defined as perianastomotic extravasation of oral contrast on radiographic imaging or anastomotic disruption on endoscopy. Stricture was defined as symptomatic anastomotic narrowing requiring dilation.

Results: Of 55 patients who underwent DST between 2006 and 2014, total gastrectomy was performed in 44/55 (80%), proximal gastrectomy in 6/55 (11%) and completion gastrectomy in 5/55 (9%). Eleven patients (20%) had multi-visceral resection at the time of gastrectomy. Fifty patients (91%) had adenocarcinoma on final pathology, and 22 patients (40%) received neoadjuvant chemotherapy. Six patients (10.9%) had undergone radiation therapy prior to completion gastrectomy for recurrent disease. Operative approach was open (n=26/55; 47.2%), laparoscopic (n=26/55; 47.2%), and robotic (n=3/55; 5.4%). The leak rate was 5/55 (9%) occurring at a median of 14 days (5-20 days). The stricture rate was 12/55 (21.8%) occurring at a median of 86 days (40-405 days). Leak and stricture rates improved with increased experience. During the 2012-2014 period, the rates of anastomotic leak and stricture were 0/19 (0%) and 3/19 (15.7%), respectively. The overall complication rate was 21/55 (38.1%) of which 60% were classified as Clavien-Dindo grade III-V complications. On multivariate analysis, none of the aforementioned variables correlated with risk for leak or stricture.

Conclusion: In the largest Western series of DST esophagoenteric anastomoses for gastric cancer, our experience demonstrates that DST is a safe and effective technique with low rates of anastomotic leak and stricture.

 

46.01 Both Systemic Inflammation and Visceral Obesity Are Associated with Colorectal Cancer Recurrence

Posted on December 22, 2014

C. T. Aquina1, A. S. Rickles1, C. P. Probst1, B. J. Hensley1, A. A. Swanger1, K. Noyes1, J. R. Monson1, F. Fleming1  1University Of Rochester,Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.),Rochester, NY, USA

Introduction:  Much recent attention has been directed towards the detrimental effects of a pro-inflammatory state on tumorigenesis and oncologic outcomes. Our research group has previously shown a relationship between elevated metabolically active visceral fat volume and recurrence-free survival in colorectal cancer. Other studies have demonstrated a similar link to colorectal cancer outcomes with laboratory inflammation markers such as the neutrophil-to-lymphocyte ratio. We sought to investigate whether pre-operative inflammatory indices are associated with long-term colorectal cancer outcomes and whether this relationship is mediated by visceral obesity.

Methods:  A single-center retrospective chart review was performed for patients undergoing surgical resection for colorectal cancer between 2000 and 2009. Pre-operative CT scans were used to calculate visceral fat volume (VFV) based upon a previously validated method. Pre-operative laboratory values within 90 days of the date of surgery were used to calculate the neutrophil-to-lymphocyte ratio (NLR). A pre-operative NLR>3 was used as a cut-off to define high NLR according to previous literature. Visceral obesity was defined as VFV>1620cm3 based upon the results of a receiver operating characteristic curve. Five-year recurrence-free survival was defined as locoregional or distant recurrence within 5 years of surgery. Chi-square, Student’s T-test, Kaplan-Meier, and Cox proportional-hazards analysis were used to compare pre-operative and surgical characteristics with recurrence-free survival.  

Results:  Overall, 141 patients met inclusion criteria with 75 patients having a high NLR (53.2%) and 48 patients having visceral obesity (34%). Patients with a high NLR had significantly higher levels of VFV (mean=1741cm3 vs. 1399cm3, p=0.04). On Kaplan-Meier analysis, both high NLR (p=0.03) and visceral obesity (p=0.005) were independently associated with reduced 5-year recurrence-free survival for stage II colorectal cancer but not stages I or III. Using separate Cox proportional-hazards models due to the association between high NLR and visceral obesity, both high NLR (HR=4.04, p=0.04) and visceral obesity (HR=4.05, p=0.03) were associated with a more than 4-fold risk of cancer recurrence within 5 years for stage II colorectal cancer.

Conclusion:  Both pre-operative systemic inflammation, as captured by an elevated pre-operative neutrophil-to-lymphocyte ratio, and visceral obesity are associated with worse recurrence-free survival for stage II colorectal cancer. Additional study is warranted at exploring the association between these two factors and developing strategies at improving outcomes for this high-risk population.

 

46.02 Minimally invasive distal pancreatectomy for cancer: Short-term oncologic outcomes in 1733 patients

Posted on December 22, 2014

M. Abdelgadir Adam1, K. Choudhury3, M. Dinan2, S. Reed2, R. Scheri1, D. Blazer1, S. Roman1, J. Sosa1,2  1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke Clinical Research Institute,Durham, NC, USA 3Duke University Medical Center,Biostatistics,Durham, NC, USA

Introduction: Emerging data from high-volume institutions suggest that minimally invasive distal pancreatectomy (MIDP) provides favorable perioperative outcomes and adequate oncologic resection.  However, it is unclear if these outcomes are generalizable at a population level. This study examines patterns of use and short-term outcomes from MIDP vs. open distal pancreatectomy for pancreatic cancer.  

Methods: Adult patients undergoing distal pancreatectomy were identified from the National Cancer Database, 2010-2011. Descriptive statistics were used to characterize patterns of laparoscopic and/or robotic MIDP use. Multivariable modeling was applied to determine factors associated with use of MIDP and compare short-term outcomes from MIDP vs. open surgery, while adjusting for patient, clinical, and tumor characteristics.

Results: A total of 1,733 patients underwent distal pancreatectomy for cancer: 535 had MIDP and 1,198 had open surgery. Use of MIDP increased 43% between 2010 to 2011, from 220 to 315 cases. Across both study years, the conversion rate from MIDP to open distal pancreatectomy was 23%. MIDP cases were performed at 215 hospitals, with the overwhelming majority of hospitals (97%) performing <10 cases overall. The majority of MIDP cases (67%) were performed at academic institutions. Patients were more likely to undergo MIDP if they were older [odds ratio (OR) 1.02 (95% confidence interval (CI) 1.01-1.04), p<0.01], privately insured [OR 1.41 (CI 1.04-1.92), p=0.03], diagnosed in 2011 (vs. 2010) [OR 1.48 (CI 1.17-1.86), p<0.01], or had a diagnosis of a neuroendocrine malignancy (vs. adenocarcinoma) [OR 1.82 (CI 1.37-2.40), p<0.01]. After adjustment, compared to the open group, those who underwent MIDP were more likely to have negative surgical margins [OR 1.66 (CI 1.12-2.46), p=0.01] and a shorter length of stay [relative risk (RR) 0.82 (0.76-0.89), p<0.01]; the number of lymph nodes removed [RR 0.94 (0.85-1.04), p=0.24], rates of 30-day readmission [OR 1.15 (0.72-1.83), p=0.57] and 30-day mortality [OR 0.34 (0.06-1.80), p=0.20] were similar between groups.     

Conclusion: Use of MIDP for cancer is increasing, with most centers performing a low volume of these procedures. Use of MIDP for body and tail malignancies of the pancreas appears to have short-term outcomes that are similar to those of open procedures with the benefit of a shorter length of hospital stay. Larger studies with longer follow-up should be undertaken to examine clinical outcomes.

 

46.03 Menopausal Status Does Not Predict Recurrence Score Using Oncotype DX Assay

Posted on December 22, 2014

D. N. Carr3, N. Vera3, J. Mullinax1, D. Korz1, W. Sun1, M. Lee1, S. Hoover1, W. Fulp2, G. Acs4, C. Laronga1  1Moffitt Cancer Center And Research Institute,Breast Program,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Biostatistics,Tampa, FL, USA 3University Of South Florida College Of Medicine,Tampa, FL, USA 4Women’s Pathology Consultants, Ruffolo Hooper & Associates,Tampa, FL, USA

Introduction:  Adjuvant treatment planning for early stage, estrogen receptor (ER) positive invasive breast cancer has been historically based on menopausal status. The Recurrence Score (RS) from the 21-gene breast cancer assay (ODX) is predictive of distant recurrence in this population, but is rarely applied to younger, premenopausal patients (pts). To evaluate the validity of this historical bias, we sought to evaluate the relationship between menopausal status and the recurrence score derived from the Oncotype DX assay.

Methods:  An IRB-approved retrospective review was conducted of invasive breast cancer pts with known RS. Eligibility for performance of the ODX was based on NCCN guidelines or physician discretion. Data collected included demographics, clinical-pathologic variables, surgery type, adjuvant treatment and outcomes. Menopausal status was documented at time of ODX. Perimenopausal women were classified with premenopausal for statistical analyses. Comparisons on RS were made by menopausal status (premenopausal vs. postmenopausal) using general linear regression model and the exact Wilcoxon Rank Sum Test. 

Results: 607 pts with invasive breast cancer and a RS were identified. Menopausal status was available for 600 pts (166 premenopausal, 434 postmenopausal) comprising our study population. Median age for the entire population was 58yrs (range: 27-84); 47yrs for premenopausal and 62yrs for postmenopausal. Median invasive tumor size was 1.5 cm for both cohorts. No significant differences were seen between cohorts for overall survival, metastatic disease rate, histologic grade, lymphovascular invasion (LVI), nodal status, stage, adjuvant chemotherapy, or endocrine therapy use. Mastectomy rate was higher in the premenopausal group (53.8%), compared to postmenopausal (41.9%) (p=0.0001), and thus receipt of breast irradiation was lower in premenopausal women. Despite the higher mastectomy rate in premenopausal women, a higher local-regional recurrence rate (3% vs. 0.7%; p=0.0384) was observed. Degree of ER expression was lower in premenopausal women (95%) than postmenopausal (100%) (p<0.0001). Median RS was the same (16) for both premenopausal (range: 0-62) and postmenopausal (range: 0-63) women. Tumor size, nodal status, and stage did not affect RS. Menopausal status as a categorical variable was not predictive of RS (p value = 0.7731). Factors predicting higher RS included higher mitotic rates (p<0.0001), higher nuclear grade (p<0.0001), decreased tubule formation (p=0.0001), presence of LVI (p=0.002), high grade (p<0.0001), and lower expression levels of ER/PR (p<0.0001).  

Conclusion: Menopausal status has limited predictive power for distant breast cancer recurrence. We have shown that RS across the spectrum of menopausal status is well distributed in this cohort of women. Therefore, menopausal status alone should not preclude recommendations for performance of ODX in ER-positive, early stage breast cancer.
 

46.04 Tumor Associated Macrophage Expression of Folate Receptor β in Lung Cancer: Prognostic Significance

Posted on December 22, 2014

A. Bain1, A. Vachani6, P. Low7, S. Singhal4, C. Deshpande5  6Perelman School Of Medicine At The University Of Pennsylvania,Department Of Medicine,Philadelphia, PA, USA 1Perelman School Of Medicine At The University Of Pennsylvania,Philadelphia, PA, USA 4Perelman School Of Medicine At The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 5Perelman School Of Medicine At The University Of Pennsylvania,Department Of Pathology,Philadelphia, PA, USA 7Purdue University,Department Of Chemistry,West Lafayette, IN, USA

Introduction:  This study was undertaken in order to better elucidate the relationship between Folate Receptor Beta (FRβ) positive macrophages and cancer prognosis. Tumor associated macrophages (TAMs) play a key role in promoting inflammation and regulating the immune response to malignancies.  FRβ is a useful target because its expression is limited to activated macrophages in a subset of disease conditions, including neoplasms.  While previous work has suggested a relationship between FRβ+ macrophages and cancer prognosis, to our knowledge no such studies exist for lung adenocarcinoma.

Methods: 69 patients underwent resection for primary lung adenocarcinoma from 2003-2006.  Under IRB approved protocol, a tissue microarray (TMA) was constructed using formalin-fixed, paraffin-embedded specimens from patient tumors.  A TMA section was stained using FRβ-specific monoclonal antibody m909 in antibody diluent (1:100).  Cytoplasmic staining was measured for FRβ+ macrophage frequency and staining intensity. Samples were scored as 0, no staining; 1+, weak; 2+, moderate; and 3+, strong.  Average scores for patients with ≥2 scored TMA tumor cores (n=50) were included in the analysis.  An unweighted product score was derived from the frequency and intensity scores to yield a total score of 0-9.  Clinical measures including tumor staging and survival status were followed for a minimum of 4 years.  The relationship between FRβ expression and survival time was tested using a student's t-test, and differences of tumor staging and survival times were compared by one-way ANOVA.  Statistical analyses were done with Stata 13 (StataCorp., College Station, TX).

Results: 37 patient TMA cores had FRβ product scores ≥4, and 29 patients had product scores ≥6.  The difference in mean survival time for patients with product scores ≥6 (1750.8 days) and patients with product scores <6 (1417.0 days) was 333.8 days (p-value = 0.0493).  Among deceased patients, mean survival time for the ≥6 group (1121.1 days) was greater than for the <6 group (901.5 days).  The difference in mean survival time between patients with Stage I/II disease and Stage III disease was 257.0 days (p-value = 0.1588).  The relationship between tumor stage and FRβ expression was not statistically significant (Fisher’s exact, p-value = 0.180).

Conclusion: Previous clinical studies have suggested that FRβ expression is limited to M2 macrophages and is associated with poor outcomes.  However, our results indicate that FRβ expression may be associated with longer survival times in patients with lung adenocarcinoma.  FRβ expression was also a better prognostic indicator of survival time than tumor stage alone.

46.05 Accuracy of Surgeons In Predicting the Dose of Levothyroxine After Total Thyroidectomy

Posted on December 22, 2014

H. M. Yong1, T. W. Yen1, K. Doffek1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Department Of Surgery / Division Of Surgical Oncology,Milwaukee, WI, USA

Introduction:  Following total thyroidectomy, levothyroxine (LT4) is often prescribed at discharge by the surgical team, with follow-up thyroid function tests (TFTs) and dose adjustments primarily managed by the endocrinologist or primary care physician (PCP). The aim of this study was to investigate the accuracy of the surgical team in determining the initial LT4 dose.

Methods:  A retrospective chart review of a prospectively collected, thyroid database was performed of 420 patients with benign thyroid disease who underwent a completion or total thyroidectomy between 1/2009-10/2014 and were prescribed an initial LT4 dose by the surgeon. Data collected included age, gender, body mass index (BMI: kg/m2), pre- and postoperative final pathology, initial surgeon-prescribed LT4 dose, TFTs, subsequent modifications to LT4 dose by the primary care physician/endocrinologist, and the time to achieve biochemical (TSH 0.45 – 4.5 uIU/mL) euthyroidism. All patients had follow-up with an endocrinologist or PCP within 8 weeks of surgery; data on LT4 doses were collected for six months postoperatively.

Results: The final cohort consisted of 289 patients. Median age was 53 years (range, 18-86) and 248 (86%) were female. Median BMI was 31.1 (range, 16.1-63.7). The median LT4 dose initially prescribed was 137 mcg (1.65mcg/kg; range –75-200); 119 (41%) patients achieved normal serum TSH values at initial follow-up and required no dose adjustments. Of the remaining 170 patients, 52 (31%) had elevated TSH levels at initial follow-up, requiring a median adjustment of 25 mcg (range, 11-50). Of the 118 patients with suppressed TSH levels at initial follow-up, the median adjustment was 21.5 mcg (range, 3-60). At 6 months, 59 (34%) of the 170 patients who required an initial dose adjustment had follow-up data; 57 (97%) were euthyroid, achieved at a median of 4.6 months (range, 2–6) and a median of 2 provider visits (range, 2-5).  

For the overall cohort, there was no difference in the proportion of patients who required dose adjustment by BMI or race. However, there was a significant difference in the proportion of patients requiring dose adjustment by age; older patients were more likely to be on too high a dose of LT4 at initial follow-up (p=0.0117; Table).

Conclusion: The initial dose of LT4 prescribed by the surgical team after total thyroidectomy was accurate in less than 50% of patients, with more patients being prescribed a higher dose of LT4 than ultimately required, particularly in the elderly. This underscores the importance of follow-up with thyroid function testing within the initial postoperative period and suggests that preoperative discussion with their referring provider for initial LT4 doses may be appropriate.
 

46.06 Preoperative Anemia Predicts Poor Outcomes for Non-Metastatic RCC Patients with Venous Thrombus

Posted on December 22, 2014

K. E. Zorn1, W. P. Christensen1, V. Margulis3, T. M. Bauman1, C. G. Wood2, E. J. Abel1  1University Of Wisconsin,Urology,Madison, WI, USA 2University Of Texas MD Anderson Cancer Center,Urology,Houston, TX, USA 3University Of Texas Southwestern Medical Center,Urology,Dallas, TX, USA

Introduction: In approximately 10% of renal cell carcinoma (RCC) patients, tumor extends beyond the kidney into the venous system, increasing the risk of postoperative recurrence.  Anemia is known to predict worse survival in patients with metastatic RCC, but the prognostic ability of preoperative anemia has not been studied in non-metastatic high risk RCC patients. The purpose of this study was to evaluate whether patients with preoperative anemia had worse postoperative cancer outcomes using a multi-institutional contemporary series of non-metastatic RCC patients with venous involvement.

Methods: A comprehensive review of clinical and pathological risk factors was performed for consecutive RCC patients with thrombus treated between 2000 and 2012 at three separate institutions. Univariate and multivariate Cox proportional hazards analysis was used to evaluate association of anemia or other common risk factors for cancer specific survival (CSS) and recurrence free survival (RFS).

Results:  A total of 470 non-metastatic patients were treated surgically for RCC with venous thrombus invasion from 2000-2012 at participating centers. Thrombus extended into the renal vein in 259 (55.1%) patients, into the IVC <2cm in 65 (13.8%) patients, into the IVC >2cm but below hepatic veins in 81 (17.2%) patients, and within the IVC above the hepatic veins in 65 (13.8%) patients.

Median follow-up was 28.4 months (IQR 12.2-54.9) and 188 (40.0%) patients developed recurrent disease within the follow-up period. Of patients that developed recurrent disease, initial site of recurrent disease was solitary for 128 (68.1%) patients while 60 (31.9%) patients presented initially with multiple sites of metastatic disease.  Preoperative hemoglobin was independently predictive of recurrence with a hazard ratio of 1.727 (95% CI: 1.251-2.385, p=0.0009). Other independent predictors of recurrence included BMI ≤20, perinephric fat invasion by tumor, non-clear cell histology and tumor width.

Median CSS was 136.6 (IQR 43.8-NR) months and 112 (23.8%) patients died of RCC within the follow-up period. BMI, systemic symptoms, IVC thrombus level above the hepatic veins, and estimated blood loss were associated with CSS on univariate analysis. On multivariate analysis, only preoperative hemoglobin less than lower limit of normal (HR 2.051, p=0.02) and tumor width per cm (HR 1.078, p=0.02) were independently predictive of CSS.

Conclusion: In non-metastatic RCC patients with venous invasion, preoperative anemia and tumor diameter were independent predictors of recurrence and cancer mortality.

46.07 Right vs. Left Colectomy Outcomes in Colon Cancer Patients

Posted on December 22, 2014

H. Aziz1, M. R. Torres1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

Introduction:

Optimization of surgical outcomes after colectomy continues to be actively studied, but most studies group right-sided and left-sided colectomies together. The aim of our study was determine whether the complication rate differs between right-sided and left-sided colectomies for cancer.

Methods:

We identified patients who underwent laparoscopic colectomy for colon cancer in the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database and stratified cases by right and left side. The two groups were matched using propensity score matching for demographics, previous abdominal surgery, pre-operative chemotherapy and radiotherapy, and pre-operative laboratory data. Outcome measures were: 30-day mortality and morbidity.

Results:

We identified 2,512 patients who underwent elective laparoscopic colectomy for right-sided or left-sided colon cancer in the database. The two groups were similar in demographics, and pre-operative characteristics. There was no difference in overall morbidity (15% vs 15.7%; p-0.8) or 30 day mortality (1.5% vs 1.5%; p-0.9) between the two groups. Sub-analysis revealed higher surgical site infection rates (9% vs 6%; p-0.04), higher incidence of ureteral injury(0.6% vs 0.49%; p-0.04), higher conversion rate to open colectomy (51% vs. 30%; p-0.01) and a longer hospital length of stay (10.5+/-4 vs. 7.1+/-1.3 days; p-0.02) in patients undergoing laparoscopic left colectomy.

Conclusion:

Our study highlights the difference in complications between right-sided and left-sided colectomies for cancer. Further research on outcomes after colectomy should incorporate right vs left side colon resection as a potential preoperative risk factor.

46.08 Impact of laterality on perioperative morbidity and mortality following major hepatic resection.

Posted on December 22, 2014

S. C. Pawar1, A. Robinson1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: Anatomic variations and technical nuances involved in performing a left sided hepatic resection versus a right-sided hepatic resection make the procedures distinctly different. This study examined the relationship between laterality and perioperative outcomes in hepatic hemi-resection and aimed to determine whether specific complications are associated with the types of hepatic resection, and if so whether unique complication profiles exist for left and/or right hemiresections.

Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to identify patients who underwent elective open hepatectomies between 2002 and 2012. Demographics, 60 perioperative risk factors, and 32 postoperative complications were analysed using Multivariate analyses. 

Results: Among 5,355 patients, 2,614 underwent right hepatic resection, 1,439 left hepatic resection, and 1,302 extended hepatic resection. The median age was 60 years; with a male to female ratio of 1:1 and 65 % of patients had an ASA score of 3 to 4. Among patients undergoing open elective hepatectomies 44 % had disseminated cancer and 22 % had received chemotherapy prior to surgery. The most prevalent co-morbidity was hypertension (46%).The three groups were similar with regards to preoperative comorbidities.Overall 30-day mortality rate was 3.3% (173/5,243) and morbidity was 50.5%. The 30 day mortality rate was significantly higher among trisegmentectomy and right hepatectomy patients relative to left hepatectomies (4.8% and 3.6 % Vs 1.5%).  Patients with right sided hepatic resections had a higher rate of morbidity in terms of number of cases with 5 or more complications (4.6% vs. 2%; p < 0.001), and overall morbidity (51% vs. 41%, p < 0.001). Though superficial site infection (SSI) rates were similar for both procedures (5% vs. 4.6 %, p < 0.04), right hepatic resections had a higher rate of organ/space SSI (7.3% vs. 6%, p < 0.001). Left sided hepatic resection had lower rates of blood transfusions (28.6% vs. 36%, p < 0.0001); lower respiratory complications (3.5% vs 5%, p < 0.001), lower renal complications (0.8% vs. 1.6%, p < 0.001) and a shorter hospital stay (6 vs 7, p < 0.05).

 

Conclusion: Analysis of the NSQIP perioperative outcomes data confirms that extended hepatectomies (trisegmentectomy) are associated with the highest risk for mortality and morbidity.  Right hepatic lobectomy is associated with a significantly higher incidence of post-operative complications than left hepatic lobectomy, most notably with regards to intraoperative/postoperative blood transfusions, biliary leaks, cardiac complications, sepsis and 30 day operative mortality.

 

 

 

46.09 Aggressive Papillary Thyroid Microcarcinoma: Population based study from SEER database (1989-2011).

Posted on December 22, 2014

S. C. Pawar1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: Papillary thyroid microcarcinoma (PTMC) usually follows an indolent course and is considered a low risk tumor.  However recent studies have identified several cases of PTMC with locoregional recurrences in the neck and with distant metastases.  It is imperative that the clinicians have a better understanding of PTMC and specifically characteristics of PTMC with aggressive behavior.

Methods: The Surveillance, Epidemiology, and End Results (SEER) program was queried for patients diagnosed with PTMC between 1989 and 2011. Age, gender, tumor size, lesion type, extent of disease, stage, surgery, and mortality were analyzed for papillary thyroid micro carcinomas (≤ 1cm) and compared to papillary tumors of size (> 1 cm).  Clinical and pathological characteristics of patients with PTMC were compared to PTMC patients who died of cancer specific death using multivariate analyses. 

Results:Among 53,429 patients diagnosed with Papillary thyroid carcinoma, 36,093(67%) were diagnosed with PTC tumors of size (> 1 cm) and 17,336 (32%) were PTMC (≤ 1 cm). The median age of the entire cohort was 48 yr (PTMC (49 yr) and PTC (48 yr)), however patients with PTMC with aggressive behavior were significantly old (64 yr). Females dominated the study cohort for both PTC (> 1 cm) and PTMC (≤ 1 cm) (73% vs 81% respectively). PTMCs were more likely to present as multifocal tumors compared to PTC (> 1 cm) (14% Vs 8% respectively). 82% of PTMCs had localized disease at the time of diagnosis, 17% had regional spread, and 1% had distant metastasis. Multivariate analysis identified extrathyroidal invasion, multifocality, male gender, Asian race, and tumors with regional and distant metastasis at diagnosis as significant independent predictors of mortality in PTMC patients.  Patients with PTMC who died were more male (Odds ratio [OR], 4.34; p < 0.0001), of Asian ethnicity (OR, 1.35; p < 0.005), and elderly (OR, 9.77; p < 0.001). 

Conclusion:Although most PTMCs are considered low risk, up to 17% of patients with PTMC exhibit aggressive behavior in regards to extrathyroidal invasion, multifocality, regional spread, distant metastasis at diagnosis, and may benefit from a more radical therapeutic approach. PTMCs with aggressive behavior are more common among male gender, elderly age group, and Asian ethnicity.

 

 

46.10 Adjuvant Chemotherapy Attenuated the Impacts of Perineural Invasion in Stage III Colorectal Cancer

Posted on December 22, 2014

T. Suzuki1, K. Suwa1, K. Hanyu1, Y. Mitsuyama1, K. Eto1, M. Ogawa1, T. Okamoto1, T. Fujita1, M. Ikegami2, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Tokyo, , Japan 2The Jikei University School Of Medicine,Department Of Pathology,Tokyo, , Japan

Introduction: Perineural invasion (PNI) is associated with decreased survival in several malignancies, but no robust evidence has been documented in colorectal cancer (CRC). The aim of the present study was to evaluate the association of PNI and outcomes of patients after colorectal resection for CRC, focusing on the impact of adjuvant chemotherapy on survival rates of patients with PNI.

Methods: We retrospectively reviewed 224 consecutive patients who underwent surgery for Stage I to IV CRC between January 1999 and December 2004. The presence or absence of PNI of the tumor was determined by experienced pathologists in our institution. Overall and disease-free survival rates were estimated using the Kaplan-Meier method, and intergroup differences in survival curves were tested with the log-rank test. To evaluate the correlation between PNI and survival, PNI was entered into a Cox proportional hazards model as an independent variable.

Results: PNI was detected in 63 of the 224 patients (28%) and positively correlated with lymphatic invasion (P = 0.003), venous invasion (P = 0.006), lymph node involvement (P = 0.002), size of tumor (P = 0.019), postoperative chemotherapy (P = 0.023), and incidence of metastasis or recurrence (P < 0.0001). The 5-year disease-free survival rate was 1.6-fold in patients with PNI-negative tumors as compared to PNI-positive tumors (66% vs 44%, respectively; P < 0.001). The 5-year overall survival rate was 71% for PNI-negative tumors, which was significantly higher than 40% for PNI-positive tumors (P < 0.001). A multiple regression analysis revealed that PNI was a strong prognostic factor for overall survival. In a subset analysis of patients with stage III CRC, adverse effects of PNI on survival were attenuated by adjuvant chemotherapy, but adjuvant chemotherapy did not completely reverse the effects of PNI.

Conclusion:PNI was associated with poor prognostic markers such as lymphatic invasion and lymph node involvement, and predicted worse survival in patients with stage III CRC. Adverse effects of PNI on survival were attenuated by adjuvant chemotherapy. Intensive chemotherapy and strict surveillance seem be warranted in patients with CRC of stage III with PNI.

 

42.02 Identification of Novel Class II-Promiscuous HER3-Derived CD4+ Peptides for Cancer Immunotherapy

Posted on December 22, 2014

J. Datta1, S. Xu1, J. H. Terhune1, L. Lowenfeld1, C. Rosemblit1, E. Berk1, E. Fitzpatrick1, R. E. Roses1, B. J. Czerniecki1  1University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: HER3 overexpression is associated with resistance to targeted therapies (e.g. BRAF inhibitor in melanoma, trastuzumab in breast cancer) and a poor oncologic prognosis. Since existing anti-HER3 strategies – antibodies inhibiting HER2-HER3 dimerization – are static but not lytic, cellular therapies targeting HER3 are needed. CD4 T-helper type 1 (Th1) cells secrete IFN-γ/TNF-α, inducing tumor apoptosis. Using the extracellular domain (ECD) of HER3 as a candidate tumor antigen, we sought to identify immunogenic Class II-promiscuous HER3 CD4 peptides that generate anti-HER3 Th1 immunity for inclusion in cancer vaccines.

Method: A library comprising 123 overlapping 15 aa-long peptides was generated from HER3-ECD. Autologous monocyte-derived DCs from patients were matured to a type 1-polarized phenotype using IFN-γ/LPS (IL-12 secreting DC1), pulsed with HER3-ECD, and co-cultured with purified CD4 T-cells. After 10 days, sensitized CD4 T-cells were restimulated against immature DCs (iDC) pulsed with HER3 peptide clusters or irrelevant CD4 control. Th1 responses, measured by IFN-γ ELISA, were considered antigen-specific if IFN-γ production was at least twice that of control groups.

Results: Th1 sensitization was performed in 6 breast cancer patients with known anti-HER3 reactivity in order to identify single immunogenic HER3 CD4 epitopes. HER3 ECD-specific CD4 Th1 were sequentially restimulated against 10-peptide clusters, narrowed to 3-peptide clusters, and subsequently to single immunogenic HER3 peptides. Four immunogenic peptides (HER351-75, HER3402-417, HER3417-432, HER3451-465) were reproducibly identified based on two-fold increase in IFN-γ production (Fig). These peptides were promiscuous across HLA-DR, DP, and DQ subtypes. When Th1 cells from 4 non-HER3 reactive donors were sensitized using DC1s pulsed with the four identified HER3 peptides, and subsequently challenged to recognize HER3 ECD-pulsed iDCs, all donors demonstrated successful sensitization not only to individual immunogenic HER3 peptides, but also recognized native HER3-ECD.

Conclusion: DC1 pulsed with an overlapping HER3-derived peptide library identified promiscuous class II peptides for CD4 Th1 vaccine development. Immunogenic HER3 CD4 peptides abrogated anti-HER3 immune self-tolerance. Utilizing these peptides in vaccine construction warrants investigation in patients harboring HER3-overexpressing cancers, and would represent the first cellular therapy targeting IFN-γ-secreting CD4 Th1 cells against HER3-ECD. These data also reveal a novel strategy to rapidly and reproducibly identify class II-promiscuous immunogenic CD4 epitopes from any self-tumor antigen for immunotherapy via a DC1-Th1 platform.

42.03 LIGHT Over-Expression in Colorectal Cancer Stimulates Lymphocyte Proliferation and In-vivo Tumor Rejection

Posted on December 22, 2014

K. H. Pardiwala1, G. Qiao1, B. Prabhakar1, A. V. Maker1  1University Of Illinois At Chicago,Chicago, IL, USA

Introduction:
T-cell infiltration in primary and metastatic colorectal cancer tumors is associated with improved patient survival. LIGHT (TNFSF14) is an immunomodulator that has been shown to increase T-cell trafficking to tumors that we have previously shown to be associated with improved patient survival when expressed at high levels in metastatic colon cancer deposits. However, the mechanism of LIGHT-associated survival benefit is not completely understood. 

Methods:
Murine colorectal cancer cells (CT26) were designed to stabily over-express LIGHT by lentiviral transduction.   Cell morphology was assessed by light microscopy, survival was evaluated with Annexin V/propridium idodide staining, proliferation was determined using the MTS colorimetric assay, and 3D cell migration assays were performed in collagen gel matrix and analyzed on Image J software.  Natural Killer (NK) and T-cells were obtained from the spleens of Balb/C mice and cultured with LIGHT+CT26 syngeneic colon cancer cells in various E:T ratios. Cell proliferation was determined with CFSE staining.  In vivo models were created by tumor cell flank injections of LIGHT+CT26 or wtCT26 cells into syngenic, immunocompetent Balb/C mice. 

Results:

LIGHT+CT26 colon cancer cells demonstrated similar morphology, survival, apoptosis, and migration compared to wtCT26 cells. T-cell proliferation was increased in the presence of LIGHT+CT26 compared to control CT26 cells(67.3%vs. 50.3% ). Similarly, when compared to wtCT26, LIGHT over-expressing CT26 cells stimulated natural-killer (NK) cell proliferation nearly three-fold (24% vs. 8 %).  Eight of eight  mice inoculated with wtCT26 formed palpable tumors with an average volume of 2458 ± 572 mm3  while 0 of 8 mice inoculated with CT26LIGHT developed tumors (p= 0.0026). (figure)

Conclusion:
Over-expression of the immunostimulatory cytokine LIGHT in colorectal cancer cells stimulates lymphocyte proliferation and inhibits in-vivo tumor growth. Further studies to determine the mechanism of LIGHT-induced anti-tumor responses and to determine its potential as an immunotherapeutic agent in colorectal cancer are warranted.

42.04 The Role of Transcription Factor ROR-γt in the Tumor-Driven Induction of Th17 and Treg cells

Posted on December 22, 2014

S. Downs-Canner1, N. Obermajer1, R. Ravindranathan1, K. Odunsi3, R. Edwards1, P. Kalinski1, D. Bartlett1  1University Of Pittsburgh,Surgical Oncology,Pittsburgh, PA, USA 3Roswell Park Cancer Institute,Gynecologic Oncology,Buffalo, NY, USA

Introduction:  To evaluate the role of the Th17 cells in the course of tumor development, we examined the interplay of Th17 and Treg cells.  Tumor-infiltrating Th17 cells constitute a prominent part of the cancer microenvironment and are a potent inflammatory subset of T lymphocytes characterized by their signature cytokine IL-17A and their master transcription factor RORγt.  While Th17 cells from human or murine tumors appear to favor the early growth of a variety of malignancies by promoting angiogenesis or suppressing tumor immunity, limited studies imply that at later time points, adoptively transferred Th17 cells could mediate durable antitumor responses.

Methods:   We used human ascites material to define key subsets of Th17 cells present in ovarian cancer patients. For in depth in vivo mechanistic studies, we used transplantable (ID8-MOSEC and MC-38 cells) and inducible (azoxymethane ± dextran sodium sulfate) tumor models to define the key features of Th17 cell plasticity in the setting of tumor. Further, we evaluated Th17 plasticity in vivo in IL-17aCreRosaeYFP reporter mice which enable fate mapping of cells with highly activated IL-17A, regardless of their IL-17A production at the time of analysis.  We determined the impact of Th17 cell plasticity on tumor progression in B6.129P2(Cg)-Rorctm2Litt/J (Rorγ -/-) mice (characterized by RORγ t deficient T cells).

Results:  Our data demonstrate increased infiltration of IL17+ and FoxP3+ CD4+ T cells in the human cancer microenvironment, with the presence of a distinct IL17+FoxP3+ subset, and a significant correlation between tumor-associated Th17 and Treg cells in cancer patients. The data in IL-17aCreRosaeYFP reporter mice indicate plasticity between Th17 and Treg cells. Moreover, RORγ t is required not only for Th17 development, but also for effective Treg cell induction. While FoxP3 expression was not induced in ROR-γ  -/- cells, TGF-b1 strongly induced FoxP3 expression in control cells. Further, tumor bearing ROR-γ  -/- mice showed significantly less FoxP3+ Treg cells, but higher IFNg+ T cells compared to wild type animals.

Conclusion:  Tumor development fosters an imbalance in the Th17/Treg ratio, driven by plasticity between the two cell types, both regulated in a RORγt dependent manner. The possibility to control Th17/Treg plasticity and prioritize Th1-like immune responses through manipulation of RORγt offers a novel approach to overcome tumor-associated immunosuppression and enhance clinical effectiveness of anticancer immunotherapy by improving local antitumor activities of CTLs, Th1- and NK cells and preventing dominance and persistence of Treg – governed tumor immunosuppression.

 

44.08 Role of Sphingosine-1-phosphate in Inflammation-induced Lymphangiogenesis

Posted on December 22, 2014

L. J. Fernandez1, W. Huang1, K. P. Terracina1, M. Nagahashi3, A. Yamada2, T. Aoyagi4, S. Spiegel5, K. Takabe1,5  1Virginia Commonwealth University,Surgical Oncology,Richmond, VA, USA 2Yokohama City University,Surgery,Yokohama, , Japan 3Nigata University,Digestive And General Surgery,Nigata, , Japan 4Chiba University,Surgery,Chiba, , Japan 5Virginia Commonwealth University,Biochemistry And Molecular Biology,Richmond, VA, USA 6Chang Gung Memorial Hospital,Taipei, , Taiwan

Introduction:
There is growing evidence that sphingosine-1-phosphate (S1P), a pleiotropic bioactive sphingolipid metabolite formed inside cells by two closely related sphingosine kinases, SphK1 and SphK2, is involved in inflammation and cancer. Previously, we have reported the involvement of S1P and SphK1 in colitis and colitis-associated cancer (CAC) utilizing SphK2 knockout mice in Cancer Cell. S1P has been found to play an important role in inflammation and CAC through persistent activation of the NF-kappaB/IL-6/STAT3 axis by S1P. In this current study we sought to investigate the role of S1P in lymphangiogenesis and lymphatic vessel dilatation in a DSS colitis model.

Methods:
SphK2 knockout mice were kindly provided by Dr. Proia, NIH. Dextran Sulfate Sodium (DSS) in drinking water was used to generate accolitis model. Lymphangiogenesis and lymphatic vessel dilatation were determined by micro-vessel density and the area of the vessel with both IHC and Immunofluorescence on colon and mesenteric lymph node (MLN) samples. As methods of blocking S1P signaling, we used SK1-I, a SphK1 specific inhibitor, W146, a S1PR1 specific inhibitor, and FTY720, a S1PR1 functional antagonist

Results:
When comparing wild type (WT) and SphK2 knock out (KO) mice, SphK2 KO mice were shown to overexpress SpkK1 resulting in higher extracellular levels of S1P. We have observed that SphK2 KO mice demonstrated stronger mucosal damage compared to WT mice by histology colitis severity score when treated with DSS. Both lymphangiogenesis and lymphatic vessel dilatation were increased in SphK2 KO after DSS treatment in both colon and MLN. Morphologically, SphK2 KO mice demonstrated increased lymphatic vessel vasculature when compared to WT but the difference was much higher with DSS treated mice, which was evident both in the colon and in the MLNs. The inhibition of SphK1 by SK1-I or S1PR1 by W146 or FTY720 resulted in a significant decrease of lymphangiogenesis and dilatation of lymphatic vessels in DSS induced colitis

Conclusion:
We found that SphK1 overexpressing, thus S1P producing, animals demonstrated severe colitis with S1P mediated enhancement of lymphangiogenesis and lymphatic vessel dilatation. Considering the fact that S1P signaling blockade significantly suppressed lymphangiogenesis and lymphatic vessel dilatation, we conclude that S1P plays a critical role in inflammation-induced lymphangiogenesis and lymphatic vessel dilatation
 

38.07 National Trends in the Receipt of Post-Mastectomy Radiation Therapy

Posted on December 22, 2014

L. L. Frasier5, S. E. Holden5, T. R. Holden6, J. R. Schumacher5, G. Leverson5, B. M. Anderson8, C. C. Greenberg5, H. B. Neuman5,7  8University Of Wisconsin,Department Of Human Oncology,Madison, WI, USA 5University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery,Madison, WI, USA 6University Of Wisconsin,Department Of Medicine,Madison, WI, USA 7University Of Wisconsin,Carbone Cancer Center,Madison, WI, USA

Introduction:  In the past decade, there is new evidence that patients receiving post-mastectomy radiation therapy (PMRT) experience reduced recurrence and an absolute survival benefit, strengthening consideration in patients with risk profiles for which PMRT has not previously been recommended. However, the actual impact of these data on practice has not been examined. We sought to investigate changes in rates of PMRT over time according to risk of recurrence.

Methods:  Female patients with stage I‑III breast cancer who underwent mastectomy from 2000-2011 were identified in the SEER database (n=62,442). Temporal trends in the proportion of patients receiving PMRT were investigated, grouping patients by tumor characteristics associated with prognosis (tumor ≤ vs. > 5 cm; 0, 1‑3, or 4 or more lymph nodes). Joinpoint regression fits a series of joined straight lines together to determine whether there is a statistically significant change in the slope of the line(s) at any given point. We used this to analyze trends of PRMT use over time. Results are further summarized as annual percentage change (APC), or the slope of the line segment. 

Results: The highest receipt of PMRT (initially 62%) was seen in patients at highest risk of recurrence, those with four or more positive lymph nodes (any tumor size) and patients with >5 cm tumors and 1-3 positive lymph nodes. For this group of patients, receipt of PMRT was increasing by 0.8% per year and stable over the study period (no change in slope was identified). PMRT receipt was lowest (initially 7.5%) for patients with tumors ≤5 cm and no positive lymph nodes, and increased by 2.6% per year (no change in slope). In contrast, the cohort of patients with tumors ≤5 cm and 1-3 positive lymph nodes, had a baseline receipt of PMRT of 26.9%, and did not change  from 2000- 2006, after which change of  slope was identified (p=0.0189). Thereafter, the APC increased to 9.0% for the remainder of the study period (2007-2011). 

Conclusion: Since 2000, the use of PMRT has slowly but steadily increased over time for breast cancer patients across risk strata. However, there was a significant acceleration in the increased uptake of PMRT for patients with tumors ≤5 cm and 1-3 positive lymph nodes after 2007, likely representing change in practice patterns related to a broadening of the indications for PMRT in response to new evidence of a survival advantage.  It will be important to monitor the magnitude of benefit from PMRT in current everyday practice to ensure the improvements in disease free survival and overall survival persist and that the benefits of this treatment outweigh the risks.

 

38.09 Quality of Online Information to Support Shared Decision Making in Breast Cancer Surgery

Posted on December 22, 2014

J. G. Bruce1, J. Tucholka3, H. B. Neuman1,2,3  2University Of Wisconsin,Carbone Cancer Center,Madison, WI, USA 3University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery, School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:  Decision-making for breast cancer surgery relies heavily on women’s preferences. To reach an informed decision, women require treatment information that is complete, is easily understandable, and encourages them to consider their values in the context of treatment options. Our objective was to assess the quality of online information available to support shared decision making for breast cancer surgery.

Methods:  Four breast cancer surgery-related queries were done on Google and Bing, and websites from the first two pages reviewed. Two investigators evaluated each website for content pertinent to breast cancer surgery using an investigator generated list. The DISCERN instrument was used to evaluate: 1) websites’ structural components that influenced publication reliability, 2) quality of information on treatment choices. Scores on this 16-item validated questionnaire were normalized to a 5-point scale, with scores of 4/5 considered “good”. Agreement between reviewers on overall website quality was assessed.

Results: 45 unique websites were identified and reviewed (kappa 0.80). Websites were general information or health-care portals (48%), .GOV sites (13%), non-profit foundations (18%), hospitals (18%), and Youtube.com (2%). Websites satisfied a median 5/9 (range 0-9) content questions, with 2.2% covering all topics. Commonly omitted topics included: most women being candidates for both breast conservation and mastectomy (67%), the potential for a 2nd surgery to obtain negative margins after breast conservation (60%), post-surgery recovery times (58%), and equivalent survival regardless of surgery (53%). Websites had a median DISCERN score of 2.9 (range 2.0-4.5). Websites achieved higher scores on structural criteria (median 3.57 [2.07-4.71]), with 24.4% rated as “good”. In contrast, scores on treatment choice questions were lower (2.56 [1.3-4.38]), with only 6.7% scoring “good”. Four websites (all non-profit foundations) rated highly on both (figure). However, reviewers perceived these websites to be challenging to navigate, with significant effort required to find key content.

Conclusion: Although numerous online sources of breast cancer information exist, most websites do a poor job providing women with essential information necessary to play active roles in treatment decision-making. Even highly ranked websites provided information in a manner which was difficult to navigate and did not facilitate easy comparison of treatment choices in the context of women’s values. Access to high quality online breast cancer information that is balanced and approachable for Internet users of all experience levels would improve the quality of care provided to breast cancer patients.

 

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