07.15 Measuring Complete Response After Neoadjuvant Therapy for Rectal Cancer: Do X's Really Equal 0's?

Posted on January 25, 2017

C. T. Ellis1, K. B. Stitzenberg1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction: Tumor response to neoadjuvant chemoradiation is increasingly recognized as an important prognostic indicator.  Individuals with a pathological complete response (pCR) to neoadjuvant therapy for rectal cancer have been shown to have greatly improved long-term survival.  Tumor response can be estimated from cancer registry data when both clinical and pathological stage information is reported. Prior studies have presumed ypTXNX is equal to ypT0N0, and thus both are usually grouped together as representing pCR. However, this methodology is unproven. For this study, we sought to determine how pCR-status is best captured for rectal adenocarcinoma patients using cancer registry data.

Methods:   Using the National Cancer Database (NCDB), we included patients with clinical stage II/III rectal adenocarcinoma that underwent neoadjuvant chemoradiation and a proctectomy from 2004 – 2013.  We compared outcomes amongst three goups: those with ypTXNX, those with ypT0N0, and those with ypT>0N>0.  We estimated the difference in OS by treatment received using Kaplan-Meier survival curves and Adjusted Cox proportional hazards models, controlling for patient, tumor, and facility characteristics.

Results:  Overall, 3,700 (13%) and 2,756 (10%) of our cohort (n=27,859) had a pCR as indicated by ypTXNX and ypT0N0, respectively. Over time, there was a decrease in those with ypTXNX and an increase in those with ypT0N0.  In 2004, 28% of our cohort were ypTXNX and 5% were ypT0N0.  In 2013, only 3% were ypTXNX and 14% were ypT0N0.  5-year OS for ypTXNX patients was more similar to that of individuals with an incomplete response than those with ypT0N0; 5-year OS 77%, 73%, and 87%, respectively (Figure).

Conclusion:  Prior studies using the NCDB assumed ypTXNX and ypT0N0 both represented pCR.  This assumption is supported by the increase in ypT0N0 and decrease in ypTXNX over time, consistent with changes in coding practices.  However, survival outcomes suggest otherwise, as long-term survival for the ypTXNX and ypT0N0 groups is different.  Survival for pCR using ypT0N0 alone is most consistent with a true pCR based on previously published survival outcomes.  Registry studies that include ypTXNX in the definition of pCR may not accurately capture the true pCR cases. Additional research is needed to validate this methodology. 

07.14 Impact of Complications on Length of Stay in Elective Laparoscopic Colectomies for Malignancy

Posted on January 25, 2017

M. M. Mrdutt2, C. Shaver2, C. Isbell2, R. Essani2, R. Warrier2, J. S. Thomas2, H. T. Papaconstantinou2  2Scott & White Healthcare,Temple, Texas, USA

Introduction:

Colorectal surgery carries inherent risks and complications.  In contemporary healthcare, quality and cost drive value.  Length of hospital stay (LOS) is an indirect measure of quality and cost as LOS is influenced by post-operative complications and the average hospital cost is >$1600/day. However, the impact of specific complications on LOS is not well defined. The purpose of this study is to determine the contribution of specific complications to the LOS in elective laparoscopic colectomy patients with malignancy.

Methods:

ACS NSQIP database (2011-2014) was queried for patients undergoing elective laparoscopic partial colectomy due to malignancy.  Demographics, 30-day post-operative complications (superficial surgical site infections (superficial SSIs), wound occurrences, return to OR, transfusion requirement, sepsis, pulmonary outcomes, DVT/PE, acute renal failure, urinary tract infection (UTI) and cardiac outcomes) and length of stay were evaluated.  Wound occurrences include deep and organ space SSIs as well as wound disruption or dehiscence.  A logistic regression model based on LOS and demographic variables for each individual complication was performed to determine LOS impact.  Significance set at p<0.05.  

Results:
59,118 patients were evaluated.  Over 70% were age 50-79, 34.6% obese (BMI ±30), mean BMI 28.6, 47.5% male and 5.3% with current immunosuppression.  Overall mean LOS was 5.4 days.  Observed rate of complications and associated average expected LOS are listed for infectious complications (Table 1).  Complications including return to OR, transfusion requirements, failure to wean from ventilator, reintubation, deep vein thrombosis, pulmonary embolism, cardiac complications (MI or cardiac arrest) and acute renal failure also all increased expected LOS by at least two additional days (p<0.0001).  Right parital colectomy (23%) versus left/sigmoidectomy (77%) was not statistically significant in the multi-variant analysis for LOS (p = 0.095).

Conclusion:

Post-operative complications increase LOS in laparoscopic colectomy patients undergoing elective resection of malignancy, with superficial SSIs increasing predicted LOS by 2 days, wound occurrences by 6 days and pneumonia by roughly a week in addition to average baseline LOS of 5.4 days.  By identifying the financial impact of complications, with LOS as a surrogate for cost, future QI efforts can target high yield post-operative complications to improve care and minimize health care cost. 

 

07.13 Response to Neoadjuvant Radiation Does Not Effect Survival of Patients with Esophageal Adenocarcinoma

Posted on January 25, 2017

M. Waldrop1, J. Swords1, R. J. Cerfolio1, C. M. Contreras1, M. J. Heslin1, T. N. Wang1, S. Reddy1  1University Of Alabama at Birmingham,Surgical Oncology,Birmingham, Alabama, USA

Introduction: The Dutch CROSS trial established the role of neoadjuvant chemoradiotherapy for improved survival in the treatment of patients with advanced esophageal adenocarcinomas. Both surgery and radiation therapy represent means of loco-regional control, and esophageal cancer is disease that is associated primarily with systemic failure. The goal of the current study is assess the clinico-pathological features of patients with resected esophageal cancer undergoing neoadjuvant radiation therapy on long-term survival.

 

Methods: All patients at a single institution who underwent esophagectomy for esophageal adenocarcinoma after neoadjuvant radiation therapy from January 2004 to December 2014 were included. Patients were divided into short-term survivors (STS) who died of disease-specific causes within 1 year of resection and long-term survivors (LTS) who lived in excess of 5 years after surgery. Peri-operative deaths were excluded. Logistic regression analysis was performed to identify factors predicting LTS.

 

Results: Of the 334 patients who underwent esophagectomy for adenocarcinoma after neoadjuvant radiation, there were 74 (22.2%) STS and 28 (8.4%) LTS. STS were older (median age 65.5 vs. 56.6 years, P=0.003) and were more likely to have lymph node metastases prior to radiation (93.2% vs. 39.3%, P<0.0001) than LTS. LTS had a trend towards having a complete pathologic response to radiation (46.4% vs. 27.0%, P=0.10), undergoing an open operation (92.9% vs. 77.0%, P=0.09), and having a shorter post-operative length of stay (median 8.5 vs. 11.5 days, P=0.10). Univariable and multivariable analyses are shown in the Table. Only the absence of lymph node metastases on the initial evaluation correlated with LTS (P=0.04), whereas pathologic complete response to neoadjuvant radiation did not (P=0.18).

 

Conclusion: Response to neoadjuvant radiation therapy in patients with esophageal cancer does not correlate to survival. Presence of pre-treatment lymph node metastases is likely a marker of systemic disease and is the only variable that predicts outcome with patients with esophageal adenocarcinoma. Clinical response to radiation therapy should not dictate decision for esophagectomy.

07.10 Modified Frailty Index Predicts Postoperative Outcomes in Older Gastrointestinal Cancer Patients

Posted on January 25, 2017

S. Vermillion2, F. Hsu3, R. Dorrell2, C. Clark1  1Wake Forest Baptist Health,Department Of Surgery,Winston Salem, NORTH CAROLINA, USA 2Wake Forest University School Of Medicine,Winston Salem, NORTH CAROLINA, USA 3Wake Forest University School Of Medicine,Public Health Sciences,Winston Salem, NC, USA

Introduction:  

Frailty disproportionately impacts older patients with gastrointestinal cancer, rendering these patients at increased risk for poor outcomes following surgery. A frailty index may aid physicians in preoperative risk stratification. We hypothesized that high modified frailty index (mFI) scores are associated with adverse clinical outcomes after tumor resection in older, gastrointestinal cancer patients.

Methods:

All patients (over 60 years) who underwent tumor resection of the liver and bile duct, pancreas, colon and rectum, esophagus, or stomach were identified in the 2005-2012 NSQIP Participant Use File. Patients who were categorized as ASA 5, diagnosed with preoperative sepsis, or underwent emergency procedures were excluded. mFI was defined by 11 previously described, preoperative variables. Frailty was defined by an mFI score > 0.27. The postoperative course was evaluated using univariate and multivariate analysis. 

Results: 

41,455 patients (mean age 72.4 years, 47.4% female) met the eligibility criteria. Within the study population, the most prevalent form of cancer was colorectal (68.3%, n=28,708), the mean mFI score was 0.11, and 2.8% of patients had a mFI > 0.27 (n=1,164).  Patients with high mFI (>0.27) were significantly more likely to have increased length of stay (12.3 vs 9.0 days), major complications (13.9 vs. 10.5%), and 30-day mortality (5.5 vs. 2.5%), (all p<0.001). Univariate analysis revealed that mFI was associated with significantly increased major complications (OR 1.88, 95% CI 1.75-2.02, p<0.001) and 30-day mortality (OR 2.35, 95% CI 2.03-2.72, p<0.001). After adjusting for age, gender, BMI, ASA, albumin level, mFI was identified as an independent predictor of major complications (OR 1.52, 95% CI 1.39-1.65, p< 0.001) and 30-day mortality (OR 1.48, 95% CI 1.24-1.75, p< 0.001).

Conclusion:

mFI was found to be associated with the incidence of postoperative complications and mortality in older surgical patients with gastrointestinal cancer. mFI serves as a useful tool for preoperative risk stratification in this vulnerable population.

07.09 OMISSION OF RADIOTHERAPY IN THE U.S. AFTER BREAST CONSERVATION IN THE POST-NEOADJUVANT SETTING.

Posted on January 25, 2017

A. C. Esposito1, J. L. Crawford2, E. R. Sigurdson2, E. Handorf4, R. J. Bleicher2  1Lewis Katz School Of Medicine At Temple University,Philadelphia, PA, USA 2Fox Chase Cancer Center,Surgical Oncology,Philadelpha, PA, USA 4Fox Chase Cancer Center,Biostatistics,Philadelphia, PA, USA

Introduction:

Breast conservation has been standard of care for invasive breast cancer, and complete treatment via breast conservation therapy (BCT) is comprised of both breast conservation surgery and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) is given to make tumors having skin or chest wall involvement resectable, and to downstage those too large for local excision to a size amenable to BCT. On reviewing patterns of postneoadjuvant RT administration in the National Cancer Database (NCDB), we found that significant numbers of BCT patients did not receive RT after NACT. This study was performed to determine what factors predicted RT omission, which is nonstandard therapy.

Methods:

NCDB cases were reviewed for women having unilateral, invasive, non-inflammatory, non-metastatic, clinical stage 2-3 breast cancer, treated with NACT and subsequent BCT between 2008-2012. Only those starting NACT <90 days after diagnosis but 80-270 days preoperatively, and RT 0-20 weeks post-op were included. We used Pearson Chi-square and tests for trend to determine the relationship between patient, tumor, and facility factors and receipt of RT.  We then determined simultaneous effects of these factors using multiple logistic regression with robust standard errors to account for within-hospital clustering.

Results:

10,220 patients were identified who received NACT prior to breast conservation with 974 (9.53%) not receiving RT after surgery. The majority of patients were white, female, had invasive ductal carcinoma, and received therapy at comprehensive community cancer centers or academic/research programs. Predictors of failure to receive RT included older age (ORs 1.17; 95% CI: 1.09-1.27, P=<.0001), more recent year of diagnosis (OR 1.06; 95% CI: 1.01-1.12, P=.0267), US region (ORs varied), insurance status (ORs varied), facility type (ORs 1.48; 95% CI: 1.02-2.16, P=.0404), positive margins (ORs 1.67; 95% CI: 1.29-2.16, P=.0001), receptor status unknown (OR 1.68; 95% CI: 1.19-2.37, P=.003), and HER2 status positive or unknown (ORs varied). Factors increasing the likelihood of RT receipt included N3 disease (ORs 0.59; 95% CI: 0.36-0.95, P=.0312), known grade (ORs varied), primary tumor downstaging (ORs 0.84; 95% CI: 0.72-0.98, P=.024), and receptor positivity (ORs 0.85; 95% CI: 0.73-0.99, P=.0391). Factors having no effect on likelihood of RT included race, education, income, and Charlson comorbidity index. When excluding 314 patients in whom RT was recommended, only age, US location, receptor status, and margins remain predictors.

Conclusion:

It is encouraging that racial and socioeconomic disparities were not found among the predictors for lack of RT receipt. Unfortunately however, comorbidities did not explain the difference in treatment. It remains unclear whether some omission of RT is due to lack of physician knowledge. Further efforts may be needed to ensure that physicians and patients recognize that RT is a required part of BCT even after NACT.

07.08 Better Outcomes for Surgical Resection of Pancreatic Cancer in Academic versus Nonacademic Centers

Posted on January 25, 2017

O. Moaven1, J. M. Richman1, S. Reddy1, T. M. Wang1, C. M. Contreras1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:  Surgical resection is the only intervention known to significantly affect outcomes in patients with pancreatic cancer. It is very important to identify the factors that can improve the surgical outcomes in pancreatic cancer. In this nationwide retrospective study we compared the outcomes of tumor resection in academic vs. nonacademic centers.

Methods:  We analyzed American College of Surgeons National Cancer Database (NCDB) and included patients with pancreatic adenocarcinoma who have undergone pancreatic resection between 1998 and 2012. Unadjusted chi-square and t-tests and multivariate generalized additive models were used to compare the differences between patient characteristics and outcomes of the patients treated in academic centers vs. nonacademic centers.

Results: We identified 62858 patients with surgical resection of their pancreatic cancer. While 34245 (54.5%) had their resection at an academic (A) center versus 28613 (45.5%) at non-academic (nonA) centers (p<0.001), these proportions varied significantly over time.  Before 2007, 52.2% were in academic centers vs. 47.8% in nonacademic; in 2007 and afterwards, the proportions were, respectively, 56.7% and 43.3% (p<0.001). Overall, Patients traveled further to academic centers (mean miles: A: 75.6, nonA: 26.6, p<0.001), and waited longer for resection (mean days: A 29.2, nonA 20.9, p<0.001). Academic centers also had higher volumes with a mean of 30.1 resections per year vs. 6.9 for nonacademic (p<0.001), examined more lymph nodes per resection with an average of 13.5 vs. 11.0 (p<0.001) and were more likely to achieve negative margins 76.7 vs. 72.5% (p<0.001).  In unadjusted analyses there were several significant differences when comparing outcomes between Academic and Nonacademic centers including: overall survival (A vs. NonA: HR 0.83, 95%CI:0.81-0.84, p<0.001), 30-day post-operative mortality (A vs. NonA: OR 0.64, 95%CI:0.61-0.68, p<0.001), 90-day post-operative mortality (A vs. NonA: OR 0.68, 95%CI:0.65-0.72, p<0.001), and 30-day readmission (A vs. NonA: OR 0.94, 95%CI:0.90-0.99, p=0.03). These differences remained significant in models adjusted for patient, tumor, and operative characteristics but were not significant after surgical volume of the center was added to the adjusted model.

Conclusion: Patients with pancreatic cancer who undergo surgical resection in academic centers have better outcomes likely related to higher annual volume. Centralizing tumor resection in higher volume academic centers is an essential step to improve survival of patients with resectable pancreatic cancer.

 

07.07 Clinical Relevance of MicroRNAs in Breast Cancer Using TCGA

Posted on January 25, 2017

S. Y. Kim1, T. Kawaguchi1, L. Yan2, Q. Qi2, S. Liu2, J. Young1, K. Takabe1  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA 2Roswell Park Cancer Institute,Biostatistics And Bioinformatics,Buffalo, NY, USA

Introduction:  MicroRNAs (miRNAs) are noncoding RNAs with 19-25 nucleotides that exert their genetic effect by either mRNA degradation or inhibition of the translation of mRNA. Dysregulations of miRNAs have been identified to play a critical role in carcinogenesis and the development of various types of cancer including breast cancer (BrCa). Some miRNAs are reported as oncogenic miRNAs that are associated with drug resistance in BrCa patients. Some miRNAs, such as miR-18a and miR-205, are reported to have both oncogenic and suppressive roles. MiR-744, on the other hand, has been reported to promote cell proliferation in vitro, but its relevance in patients is unknown. Identification of novel prognostic biomarkers typically requires a big dataset that provides sufficient statistical power for discovery and validation research. In this study we took advantage of the high-throughput data from The Cancer Genome Atlas (TCGA) as a validation cohort to evaluate the clinical relevance of miR-18a, miR-21, miR-155, miR-205,and miR-744.

Methods:  All data was obtained from The Cancer Genome Atlas (TCGA). Expression of four miRNAs, miR-18a, miR-21, miR-155, and miR-205, which have oncogenic and/or suppressive roles in BrCa patients, and another miRNA with unknown clinical relevance (miR-744) were retrieved from the GDC data portal for analyses.  After miRNA-specific thresholds were derived from the data and used to group the patients into either a high expression or low expression group, survival data was calculated using the Cox proportional hazard model.

Results: Among the 1097 breast cancer samples logged in TCGA, 1053 samples were found to contain both clinical data and microRNA-seq datasets on the miRNAs of interest. High expression of miR-18a, the miRNA that is reported to have both oncogenic and suppressive roles in BrCa patients, demonstrated significantly better prognosis (p=0.037), whereas it was not significant with miR-205 expression (p=0.070). Surprisingly, high expression levels of miR-21 and miR-155, the two miRNAs that are well known as “oncogenic” miRNAs, also demonstrated significantly better prognoses (p=0.030 and 0.005, respectively). MiR-744, which currently has unknown clinical relevance, but has been reported to be oncogenic in vitro, was also associated with a significantly better prognosis when highly expressed (p=0.027).

Conclusion: By utilizing a big dataset (TCGA) with sufficient statistical power, we found that high expression of miR-18a, miR-21, miR-155, and miR-744 were all significantly associated with better overall survival. We were able to clarify that miR-18a and miR-205 had a positive impact on survival despite some reports of their oncogenic functions. We conclude that it is necessary to reevaluate the survival impact of each miRNA whose functions are seemingly straightforward.

 

07.06 Directed Shave Margins in Breast-Conserving Surgery: Accuracy of Intraoperative Surgeon Assessment

Posted on January 25, 2017

J. Yu1, J. Yu1, L. C. Elmore1, A. E. Cyr1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction:
During breast-conserving surgery (BCS), additional cavity shave margins may be excised after removal of the primary specimen at the discretion of the surgeon to reduce rates of positive margins. We sought to evaluate the concordance of directed shave margins with disease on pathology and to assess the accuracy of surgeon judgment. 

Methods:
Utilizing a prospectively-maintained institutional database, we reviewed all women undergoing re-excision following breast-conserving surgery for invasive breast cancer or ductal carcinoma in situ (DCIS) from 2010-2013.  We then identified all patients who had directed shave margins taken due to clinical or radiographic suspicion during the index procedure.  Surgeon judgment was considered concordant when the shave margin that was taken corresponded to a positive or close margin on the primary tumor specimen. Positive margins were defined as invasive disease or DCIS touching the edge of the specimen, and close margins were defined as disease within 2 mm of the edge. Descriptive statistics were used in data analysis.

Results:
Of the 384 women undergoing re-excision, 99 patients had additional shave margins taken during their index procedures.  18 (18.2%) patients had invasive carcinoma alone, 27 (27.3%) had DCIS alone, and 54 (54.5%) had both. Of 191 total shave margins, an average of 1.9±0.9 shave margins were taken per patient, and the mean shave margin volume was 10.43 cm3.  Ninety-six (50.3%) shave margins were positive for invasive disease or DCIS. However, only 74 (38.7%) shave margins were taken when the corresponding primary tumor margin was positive or close. There was no difference in concordance when the shave was taken for clinical or radiographic suspicion (38.2% vs. 36.6%, p>0.05). Forty-six (24%) shave margins were positive for disease when the corresponding primary tumor margin was negative. On re-excision histology, 66 (66.7%) patients had no disease, 25 (25.2%) had DCIS, 7 (7.1%) had invasive disease and one had both (1.0%). 

Conclusion:
Surgeons are limited in their ability to accurately assess margin status intraoperatively which leads to imprecise use of directed shave margins. Implementation of routine shave margins or alternative margin assessment methods may be more likely to reduce the rates of positive margins following BCS, and further research is necessary to define the best standard of practice. 

07.05 Utility of CT Imaging in a Novel Form of High-Dose-Rate Intraoperative Breast Radiation Therapy

Posted on January 25, 2017

T. Hassinger1, K. Rea1, A. Schroen1, D. Brenin1, A. Berger2, B. Libby3, T. Showalter3, S. Showalter1  1University Of Virginia,Department Of Surgery, Division Of Surgical Oncology,Charlottesville, VIRGINIA, USA 2Thomas Jefferson University,Department Of Surgery,Philadelphia, PENNSYLVANIA, USA 3University Of Virginia,Department Of Radiation Oncology,Charlottesville, VIRGINIA, USA

Introduction:  Intraoperative radiation therapy (IORT) is an increasingly popular approach to breast conservation. A drawback to conventional breast IORT (CB-IORT) is the lack of CT imaging. We pioneered a novel method of IORT that incorporates customized, CT-based treatment planning and high-dose-rate (HDR) brachytherapy; Precision Breast IORT (PB-IORT). Our aim is to report on the unique utility of CT imaging in PB-IORT, both intraoperatively and in dosimetric planning for the first 84 patients treated in two prospective trials. 

Methods:  We retrospectively reviewed the first 84 patients who participated in prospective clinical trials of PB-IORT. The first 28 were enrolled in the phase I trial, and the subsequent 56 are enrolled in the ongoing phase II trial. All patients underwent lumpectomy, multicatheter balloon placement, intraoperative CT scan, and HDR brachytherapy treatment delivery to 12.5 Gy to 1 cm from the balloon surface. This report focuses on the intraoperative CT findings that led to clinical changes and the use of the CT to make adjustments to the dosimetry.

Results: After initial intraoperative CT, 18 patients (21.4%) had findings that prompted surgical adjustment of the balloon applicator to eradicate large air cavities and/or improve tissue conformity between the balloon and the breast tissue before planning and delivering IORT. In 1 patient, an additional intraoperative CT scan was performed to localize a biopsy clip and aid in excision to negative margin. In 66 patients (78.6%), the dosimetry plan was modified based on intraoperative CT findings in order to sculpt the radiation dose off of the chest, ribs, or skin, with 31 patients (36.9%) adjusted for one reason and 35 patients (41.7%) adjusted for more than one reason. 

Conclusion: Intraoperative CT findings were used in a majority of patients treated with PB-IORT in order to enhance tissue conformity between the breast tissue and the balloon and to sculpt the radiation dose away from normal tissues. CT imaging is not available in CB-IORT. These findings suggest the potential for clinical superiority of our technique employing intraoperative CT given its allowance for patient-specific alterations in both the area and dose of HDR brachytherapy. 

 

07.04 National Trends in Surgical Decision-Making for Early-Stage Esophageal Cancer

Posted on January 25, 2017

E. C. Sturm3, W. E. Zahnd3, J. D. Mellinger3, S. Ganai3  1Southern Illinois University,Department Of Surgery,Springfield, IL, USA 2Southern Illinois University,Center For Clinical Research,Springfield, IL, USA 3Southern Illinois University School Of Medicine,Department Of Surgery,Springfield, IL, USA

Introduction:
Despite high morbidity after esophagectomy, improvements in perioperative management and preoperative staging have led to satisfactory outcomes at high-volume centers. While management of early-stage cancers have recently transitioned to include endoscopic interventions for T1a and induction chemotherapy for high-risk T2 adenocarcinomas, esophagectomy has been the mainstay of management of early-stage (I-IIA) esophageal cancer. This study examines whether or not patients with early-stage, resectable cancers are being offered surgery.

Methods:
A retrospective cohort study was conducted on resectable esophagus cancer cases in the National Cancer Database diagnosed between 1998 and 2012, including AJCC clinical T1 or T2 patients with no lymph node or metastatic involvement. We determined frequencies and percentages to describe the demographic characteristics of patients. We also categorized patients by surgical decision: had surgery and reasons why if they did not have surgery (not offered, refused, comorbidities or advanced age, unknown or died before surgery). We performed a chi-square trend test to determine trends in surgery and reasons for no surgery over time. We performed chi square analysis to compare surgery decisions by demographic characteristics.

Results:
A total of 22,994 patients with T1 or T2 esophageal cancer were identified. 10,150 (44%) had surgery while 12,844 (56%) did not have surgery. Of those who did not undergo surgery, reasons given included advanced age or comorbidities (5.8%), refused (2.5%), unknown or died before surgery (6.7%), or that surgery was not offered to the patient (40.9%).  The proportion of patients who had surgery increased from 33% in 1998 to 50% in 2012 while the proportion who were not offered surgery decreased from 44% to 38% (p<0.001). Surgical decision varied significantly by demographic characteristics. Patients who were women, older, non-white minorities (especially blacks), uninsured or Medicaid insurance status, not treated at an academic center, less educated, and low income were all significantly associated with lower rates of surgery (p<0.001).

Conclusion:
A large proportion of patients with potentially resectable esophageal cancer are not being offered surgery. This percentage has decreased over time but is still unacceptably high. Disparities exist in types of patients who are offered surgery. Further study on surgical access disparities in esophageal cancer are warranted.
 

07.02 Young patients with Gastric Cancer: A National Cancer Data Base Study

Posted on January 25, 2017

I. Nassour1, A. A. Mokdad1, M. Khan1, J. C. Mansour1, A. C. Yopp1, R. M. Minter1, P. M. Polanco1, M. M. Augustine1, M. A. Choti1, S. C. Wang1, M. R. Porembka1  1University Of Texas Southwestern Medical Center,Division Of Surgical Oncology,Dallas, TX, USA

Introduction:  About 10% of patients with gastric cancer present at young age. Previous studies have reported conflicting prognosis for young gastric patients.  The aim of this study is to describe the clinicopathological characteristics, prognostic features, and outcomes from gastric cancer among young patients (18-49 years) compared to middle aged (50-69 years) and elderly patients (70 years).

Methods:  We identified patients with gastric cancer in the National Cancer Data Base between 2006 to 2013. We analyzed patient-, tumor-, and treatment-related factors among all three groups using standard statistical methods. Disease stage was divided into early stage (IA), locally advanced (IB-IIIC), and metastatic (IV). Relative survival was calculated as the ratio of observed survival to expected survival for the United States general population matched for age and sex. The log-rank test was used to compare survival rates among the groups. Cox proportional hazard analysis was used to evaluate the impact of age on survival.

Results: We identified 101,481 patients with gastric cancer with 10.5% being young, 41.6% middle aged and 47.9% elderly. Young patients were more likely to be Hispanic compared to middle-aged and elderly patients (24%, 10.8% and 7.9%, respectively; p<0.01) and were more likely to be uninsured (13.3%, 6.5% and 0.9%, respectively; p<0.01). Young patients presented more often with metastatic disease (46.3%, 37.0% and 27.6%, respectively; p<0.01), and high grade histology (79.9%, 67.4% and 61.7%, respectively; p<0.01). Young patients had increased 5-year relative survival compared to middle aged and elderly patients for both early disease (76.8%, 75.0% and 56.1%, respectively; p<0.01) and locally advanced disease (39.1%, 36.7% and 30.7%, respectively; p<0.01). For metastatic disease, young and middle aged patients had prolonged 5-year relative survival compared to elderly patients (5.2%, 5.2% and 3.0%, respectively; p<0.01). When adjusting for relevant patient-related, tumor-related, and treatment-related factors, young patients had favorable prognosis when compared to middle aged (HR=1.07, 95%CI: 1.04-1.1) and elderly patients (HR=1.44, 95%CI: 1.40-1.48).

Conclusion: While young patients were more likely to present with advanced disease, more aggressive histology, and lower socioeconomic status, younger age was associated with prolonged relative survival compared to their elderly counterparts when adjusting by stage and with prolonged overall survival when adjusting by other relevant clinical and treatment factors. Future studies are needed to determine if the differences seen in presentation and outcome between age groups are due to socioeconomic factors, ability to tolerate treatment, and/or inherent biology.

 

06.20 Sarcopenic obesity predicts poor outcome after hepatectomy for colorectal liver metastases

Posted on January 25, 2017

B. J. Kim1, J. W. Denbo1, J. Ma2, G. Passot1, M. H. Katz1, Y. S. Chun1, C. Conrad1, J. Vauthey1, T. A. Aloia1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA 2University Of Texas MD Anderson Cancer Center,Department Of Radiology,Houston, TX, USA

Introduction:
Although recent studies suggest that sarcopenia (ratio of skeletal muscle volume to height) correlates with complications after hepatectomy, these studies are confounded by variability in tumor and procedure factors.  This study focused on a large cohort of colorectal liver metastasis (CLM) patients surgically treated exclusively with open formal right hepatectomy to isolate the influence of nutritional and physical fitness factors on post-hepatectomy outcomes. 

Methods:
A prospectively maintained institutional liver surgery database was queried to identify a continuous set of CLM patients treated with right hepatectomy as their first liver directed therapy.  Preoperative CT imaging was used to acquire skeletal muscle area, visceral adipose area and subcutaneous adipose area using published techniques and advanced imaging software.  These measures were standardized to height (m2) to define the skeletal muscle index, visceral adipose index, subcutaneous adipose index, sarcopenia and sarcopenic obesity.  These indices were compared along with patient factors including preoperative chemotherapy, postoperative morbidity and mortality. 

Results:
180 patients met the inclusion criteria including 108 men and 72 women with a median age of 57 years.  72.1% received pre-hepatectomy chemotherapy.  The prevalence of sarcopenia and sarcopenic obesity was 35% and 17%, respectively.  Cohort outcomes included severe complication rate (30%), liver failure rate (6.7%), readmission rate (6.1%), 30-day mortality rate (2.8%) and 90-day mortality rate (4.4%).  Sarcopenia was associated with higher 30-day mortality (6.3% vs 0.9%, p=0.05), and sarcopenic obesity was further associated with pneumonia (9.7% vs 2.0%, p=0.07), bile leak (16.1% vs 6.0%, p=0.05) and liver failure (16.1% vs 4.7%, p=0.02).  In patients over 65 years old, sarcopenic obesity was also associated with a higher 1-year all-cause mortality rate (21.4% vs 2.6%, p=0.05).

Conclusion:
After controlling for tumor factors and case magnitude by limiting the patient cohort to only right hepatectomies, sarcopenic obesity was found to significantly impact post-hepatectomy outcomes, including longer-term survivals in elderly patients.  Given that most patients have ample time for intervention during preoperative systemic therapy administration, sarcopenia should be assessed at diagnosis of liver metastases and remedied with nutritional and physical prehabilitation prior to surgery.
 

06.19 Rates and Trends in Utilization of Palliative Therapies for Stage IV Rectal Adenocarcinoma

Posted on January 25, 2017

A. S. Kulaylat1, C. S. Hollenbeak1, D. B. Stewart1  1Penn State Hershey Medical Center,Surgery,Hershey, PA, USA

Introduction: Despite data suggesting decreased cost of care and improved quality of life for patients with terminal cancers, palliative therapy is a frequently under-utilized resource in a variety of malignancies. There is little data on patterns of implementation of palliative therapy in the management of stage IV rectal cancer in the United States.

Methods: Patients diagnosed with rectal adenocarcinoma between 2004 and 2011 were identified within the National Cancer Database (NCDB); those with stage IV disease who did not undergo definitive surgery due to patient or disease-related contraindications comprised the study cohort. Patients undergoing palliative interventions were indicated by a specified variable within the NCDB and were stratified by type of palliation (surgery, radiation, systemic, pain control, a combination thereof, or referral without specified intervention). Multivariable logistic regression was used to identify patient factors associated with receipt of palliative therapy.

Results:A total of 11,245 patients were included in this study, of which 2,314 (20.6%) received palliative therapy. While the rates of patients receiving referrals for palliative therapy (Fig. 1) without a specified intervention did increase significantly (0.1% to 1.5%, p=0.001), the overall utilization of palliative interventions did not change significantly over time (19.4% to 23.0%, p=0.14). During the study period, the use of chemotherapy nearly doubled from 4.7% to 8.7% (p<0.001), while the use of palliative radiation diminished significantly from 7.6% to 5.6% (p=0.001). Patient characteristics associated with the utilization of palliative interventions included patient age greater than 60 years (odds ratios [OR] ranging from 1.17 to 1.35 for age groups over 60, all p<0.02) and increasing chronic comorbidities (OR 1.20, p=0.004 for one comorbidity; OR 1.24, p=0.036 for two or more comorbidities). Differences in gender and race, however, were not associated with receipt of palliative therapy. Patients in the highest income quartile were less likely to undergo palliative interventions (OR 0.84, p=0.018), but insurance status did not have a significant effect on utilization of palliative methods.

Conclusion:For patients with stage IV rectal adenocarcinoma who were managed without curative intent, rates of utilization of palliative therapy were consistently low, with patients who were older and more sickly being more likely to receive palliative care. While insurance and lower socioeconomic status did not appear to limit utilization, identification of barriers to receipt of palliative care requires further study.

 

06.18 Evaluation of Molecular Profile in High Risk Class 2 MelanomaDx Melanoma Patients

Posted on January 25, 2017

M. Renzetti1, I. Soliman1, H. Wu1, B. Luo1, H. Liu1, A. Olszanski1, S. Movva1, M. Lango1, S. Reddy1, F. Zih1, J. M. Farma1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:  The use of next generation sequencing (NGS) molecular profiling has become increasingly important in providing valuable prognostic information on primary cancers with the potential to uncover actionable mutations. Our institution has been using NGS to examine mutations in 50 cancer-related genes. Here we examine molecular profiling of melanoma patients who were classified as Class 2 based on the MelanomaDx test.

Methods:  Melanoma patients who underwent both NGS and Melanoma Dx GEP testing, and were Class 2 were evaluated. Using NGS, we analyzed malignant melanoma (MM) tissue samples for somatic mutations in targeted regions of 50 common cancer related genes. We generally order this testing on advanced melanoma patients. Tissue samples were also sent for the Melanoma Dx test. Clinical and pathologic data were collected.

Results: We performed NGS on 133 patients with MM, and 18 of those patients also underwent MelanomaDx GEP testing and 15 were Class 2. In Class 2 patients, median age at diagnosis was 66 years (range 27-79) and 80% were male (n=12). Median follow up was 2 months (range 1-27). Location of the primary included upper extremity (n=4), trunk (n=4), and lower extremity (n=7). At presentation, 2 MM were stage I, 13 were stage II. All Class 2 tissue samples were taken from primary tumors. In total, 22 mutations were identified, affecting 12 unique genes. No mutations were found in 13.3% of patients (n=2), 33.3% had one mutation (n=5), 46.7% had 2 mutations (n=7), and 6.7% had 3 mutations (n=1). The most frequently identified mutations were BRAF (n=4), CDKN2A (n=3), NRAS (n=4), and TP53 (n=3) (Fig. 1).

40% of the patients had a MM recurrence (n=6), 83.3% of which had distant metastasis (n=5). Median time to recurrence was 16 months (range 9-53). Recurrent melanomas had 10 mutations over 7 unique genes. 4 patients had 2 gene mutations, and 2 only had 1. Most common gene mutations were BRAF (n=2) and NRAS (n=3).

Conclusion: Using both our NGS platform and MelanomaDx GEP for Class 2 MM patients, we identified that the most common mutations in both recurrent and nonrecurrent MM are BRAF and NRAS in 22.2% of patients each. Future studies will identify and correlate specific molecular profile patterns with treatment response and survival outcomes.

06.17 Utilization of External Beam Radiation in Differentiated Thyroid Cancer

Posted on January 25, 2017

C. M. Kiernan1, A. A. Parikh1, C. C. Solorzano1  1Vanderbilt University Medical Center,Nashville, TN, USA

Introduction: External beam radiation (EBRT) for differentiated thyroid cancer (DTC) is recommended in patients >45 years old, with locally advanced unresectable or metastatic disease. This study describes the patterns of EBRT utilization and overall survival of patients with DTC who received EBRT.

Methods:
A total of 46,095 patients diagnosed with DTC between 2003-2006 were identified using the National Cancer Database.  Patients with anaplastic thyroid cancer and patients with more than one cancer diagnosis were excluded. The use of EBRT was documented. Descriptive statistics, Kaplan Meier estimator of overall survival and multivariate cox-proportional hazards regressions were used.

Results:
A total of 546 (1.2%) patients received EBRT.  Patients in the EBRT cohort were on average older (60 vs. 48 years, p<0.001) and presented with larger tumors (4.2 vs. 3.5cm).  They were also more likely to have extrathyroidal extension (46% vs. 11%, p<0.001), positive lymph nodes (65% vs. 34%, p<0.001), positive margins (41% vs. 9%, p<0.001), and distant metastases (34% vs. 1%, p<0.001). The majority of patients in the EBRT group (60%) had stage IV disease at presentation. The 5-year overall survival (OS) was lower in the EBRT group (53% vs. 95%, p<0.001).  On subgroup analysis of patients >45 years of age who underwent total thyroidectomy and had gross extrathyroidal extension EBRT was also associated with decreased OS (84% vs. 42%, p<0.001).  Stage for stage, the 5-year OS was lower in the EBRT group: stage II (96% vs. 81%, p=0.001), stage III (92% vs. 75%, p<0.001) and stage IV (72% vs. 33%, p<0.001).  By cox-proportional hazards regression controlling for multiple patient and tumor factors, EBRT was associated with increased all-cause mortality (HR 2.76, CI 2.01-3.79, p<0.001).

Conclusion:
EBRT is used infrequently in DTC. Patients who receive EBRT are older with more advanced disease. In this large population database study, the utilization of EBRT was associated with decreased overall survival by multivariable analysis. Further study regarding the impact of EBRT on the quality of life of patients with DTC is needed.
 

06.15 Renal Oncocytic Neoplasms; Observe, Excise or Ablate?

Posted on January 25, 2017

J. R. Van Roo1, B. L. Miller1, T. J. Ziemlewicz2, S. L. Best1, S. A. Wells2, M. G. Lubner2, J. Hinshaw2, F. Shi1, F. T. Lee, Jr.2, S. Y. Nakada1, E. Abel1  1University Of Wisconsin,Department Of Urology,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA

Introduction:

Approximately 15-20% of renal masses are classified as oncocytomas, oncocytic neoplasms or chromophobe renal cell carcinomas (chRCC). Historically, oncocytic renal neoplasms were excised because of the risk for RCC and because definitive diagnosis of benign tumors was difficult. However, thermal ablation and surveillance have emerged as alternative treatment options for renal masses over the last decade. The purpose of this study is to evaluate outcomes for surgery, ablation, and active surveillance of oncocytic neoplasms.

Methods:

Patients with pathologic diagnosis of renal oncocytic neoplasms from 2003-2016 were identified. Clinical, radiologic and pathologic data were collected for each patient.  Oncologic outcomes, adverse events classified using Clavien system within 90 days of treatment, and renal functional outcomes were compared among patients treated surgically, using thermal ablation or with surveillance.

Results:

A total of 165 patients were identified with oncocytic renal masses including: 117 oncocytoma, 2 oncocytic neoplasms and 46 chRCC. Median tumor diameter was 2.9 cm [IQR 2-3.2] and median age was 67.3 years.  A total of 131 (79.4%) patients were asymptomatic at presentation. Charlson Comorbidity Index(CCI) was 0 in 65(39.4%) and ≥1 in 98(59.6%). Patients treated surgically were more likely to have larger tumor diameter compared to other modalities (p=<.0001). Patients treated surgically or with ablation were older and had higher CCI when compared with patients undergoing active surveillance. (p<0.01, 0.02)

Definitive management included surgery for 77(46.7%), thermal ablation in 32(19.4%), and active surveillance in 56(33.9%).  Median follow-up interval from diagnosis is 41 months [IQR 14-74]. Outcomes are displayed in table.  A total of 3(1.8%) patients developed metastatic RCC (mRCC), and 2(1.2%) patients have died of disease. In patients who developed mRCC, tumor size at presentation was 5,10, 13 cm and all patients were symptomatic at presentation.

Patients treated surgically had higher rates of complications and longer length of hospitalization (p<0.01, <0.01). Patients treated with radical nephrectomy were more likely to have decreased renal function and 13(7.9%) patients died from other causes during surveillance. 

Conclusion:

Renal oncocytic neoplasms have low metastatic potential overall.  Active surveillance and thermal ablation should be considered for patients with oncocytic tumors <4cm.

06.13 Surveillance strategies in the follow-up of melanoma patients: too much or not enough?

Posted on January 25, 2017

J. Kurtz2, G. Beasley1, K. Kendra1, T. Olencki1, A. Terando1, J. Howard1, D. Agnese1  1Ohio State University,Surgical Oncology,Columbus, OH, USA 2Doctor’s Hospital,General Surgery,Columbus, OH, USA

Introduction: After appropriate initial therapy for patients with stage II-III melanoma, there is no consensus regarding surveillance, thus follow up is highly variable among institutions and individual providers.  The NCCN recommends routine clinical exam and consideration of imaging for stage IIB-IIIC every 3-12 months with no distinction between stages.  Detection of recurrence is important as novel systemic therapies and surgical resection of recurrence can provide survival benefits.

Methods:   We retrospectively reviewed 369 patients with Stage II and III melanoma treated at Ohio State University from 2009-2015 who underwent surgery as primary initial therapy.  246 patients who were followed for a minimum of 6 months after completion of surgical therapy to achieve no evidence of disease status (NED) were included in this analysis while 123 were lost to follow up after surgery and were excluded.

Results: The rate of recurrence for stage IIA/IIB patients was 11% (14/123).  Eight of the 14 (57%) recurrences were detected by clinical symptoms or physical exam. Thirty-eight percent (47/123) of stage IIA or IIB patients were followed by clinical exam only while 64% (76/123) were followed with at least 2 serial chest x-rays. The median time to first chest x-ray after NED status was 4.7 months (n=76), median time to second chest-xray after NED status was 12.7 months (n=76), and 66% (50/76) continued to have additional serial chest x-rays.   At median follow-up of 35 months for the 123 patients with stage IIA/IIB, there was no difference in survival between those followed clinically (95% (95% CI: 0.88-.99)) versus those followed with at least 2 serial x-rays (96% (95% CI: 0.89-0.98).   For stage IIC/IIIA-C patients, recurrence was detected in 24% (29/123) at median follow-up 31.2 months.  Imaging detected 51% (15/29) of those recurrences in asymptomatic patients while 40% (14/29) had recurrence detected on imaging with associated clinical findings.  Eighty six percent (106/123) of stage IIC/IIIA-C patients were followed with at least 2 serial whole body PET/CT scans or whole body CT scans plus brain MRI; median time between NED status and second scan was 10.3 months.  Of stage IIC/stage III patients with recurrence, 68% (19/28) went on to surgical resection of the recurrence while 18 (64%) patients received B-RAF inhibitor therapy, immune blockade therapy, or combination therapy.

Conclusion: For stage IIA and IIB melanoma, surveillance chest x-rays did not improve survival compared to physical exam alone.  However for IIC and IIIA-C melanoma, where the recurrence rates are higher, routine whole body imaging detected recurrences not found on clinical exam leading to additional surgery and/or treatment with novel systemic therapies for the majority of patients. Detection of melanoma recurrence is important and specific sub stage should be used to stratify risk and define appropriate follow up.
 

06.11 Impact of High-Risk Microscopic Features Among Patients with Resected Stage II Colon Cancer

Posted on January 25, 2017

A. Ejaz2, L. Casadaban1, M. Kobialka1, A. V. Maker1  1University Of Illinois At Chicago,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  The impact of negative prognostic factors among patients with stage II colon cancer is ill-defined. We sought to define the incidence and impact of microsatellite instability (MSI), lymphovascular invasion (LVI), and perineural invasion (PNI), features often not captured in large cancer population databases, on overall (OS), and recurrence-free survival (RFS) following resection among patients with stage II colon cancer.

Methods:  Using a prospectively-collected multi-institutional database across 8 hospitals, we identified 345 stage II colon cancer patients who underwent curative resection between 2010-2013. The impact of high-risk microscopic features (MSI, LVI, PNI) and clinicopathologic and treatment factors were evaluated using multivariate regression models. 

Results: In a subset of 175 patients for whom high-risk microscopic features were available, median patient age was 72 (IQR: 64, 81) years.  The majority of patients were white (77.7%) and female (52.6%).  On pathology, most patients had a T3 tumor (81.3%) with a mean of 20.9±10 lymph nodes examined.  High-risk microscopic features were common as 76.0% of patients had evidence of MSI-stable (63.2%), LVI (31.9%), or PNI (7.1%).  Adjuvant chemotherapy was administered in 30 (17.1%) patients. After a median follow-up of 37 months, 31 patients (17.7%) died within the study period and median overall survival (OS) was not reached. After adjusting for patient-, treatment-, and tumor-related factors, MSI-stable (HR: 1.20; P=0.72), LVI (HR: 0.89; P=0.85), and PNI (HR: 1.98; P=0.48) were not associated with a worse OS.  Similarly, recurrence-free survival was also not affected by high-risk microscopic features (all P>0.05). 

Conclusion: Over three-fourths of patients with resected stage II colon cancer possess at least one high-risk microscopic feature.  The presence of these high-risk features did not impact short-term OS or RFS. Further studies on OS and RFS among patients with stage II colon cancer and high-risk microscopic features are warranted.
 

06.10 Frailty as a Predictor of Acute Mortality among Stage IV Cancer Patients with Bowel Obstruction

Posted on January 25, 2017

S. B. Bateni1, F. J. Meyers2, R. J. Bold1, A. R. Kirane1, D. J. Canter3, R. J. Canter1  1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 2University Of California – Davis,Hematology/Oncology,Sacramento, CA, USA 3Ochsner Clinic,Urology,New Orleans, LOUSIANA, USA

Introduction: Patients with disseminated malignancy (DMa) frequently present with acute surgical conditions. Bowel obstructions are especially common, with rates as high as 28-51% for gastrointestinal and gynecologic cancers. However, surgical intervention performed on this at-risk population is associated with increased rates of morbidity and mortality as high as 44% and 11% respectively. Our objective was to determine the effect of frailty on predicting the risk of acute morbidity and mortality in DMa patients undergoing surgical management of bowel obstruction.

Methods: Patients with DMa and primary diagnosis of bowel obstruction were identified from the 2007 to 2012 American College of Surgeons National Surgical Quality Improvement Program with corresponding ICD-9 codes. The previously validated modified frailty index (mFI) score was calculated for each patient. Univariate and multivariate standard parametric and nonparametric statistical analyses including χ² and logistic regression were utilized to identify predictors of 30-day overall morbidity, Clavien IV/V morbidity and mortality.

Results: We identified 1,928 DMa patients with bowel obstruction who underwent small bowel resection (22.0%, n=424), large bowel resection (20.5%, n=395), celiotomy or lysis of adhesions (22.8%, n=440), gastric (3.7%, n=71) or other abdominal operation (31.0%, n=598). 11.9% (n=181) were identified as frail with mFI≥0.27. Emergency operations were common at 34.6% (n=668). Preoperative impaired functional status and diagnoses of systemic inflammatory response syndrome (SIRS) and sepsis/septic shock were also frequent at 21% (n=404), 17.8% (n=341) and 6.6% (n=127) respectively. Rates of 30-day overall morbidity, ClavienIV/V morbidity, and mortality were 35.8% (n=690), 12.2% (n=235), and 14.8% (n=285) respectively. Predictors of overall and Clavien IV/V morbidity identified on multivariate analysis included impaired functional status, low albumin, SIRS, sepsis and septic shock, and emergency operations. Frailty was significant on univariate, but not multivariate analyses, for overall and Clavien IV/V morbidity (p>0.05). Frailty was identified as a significant predictor for 30-day mortality on univariate (OR=3.56, 95%CI 2.59-5.15) and multivariate analysis (OR=1.73, 95CI 1.09-2.75) in addition to low albumin, SIRS, and ASA 4/5.

Conclusion: Frailty is a predictor of acute mortality after surgery for bowel obstruction among DMa patients. In patients with a terminal malignancy, the goals of surgical therapy for symptom palliation need to be balanced against adverse outcomes, particularly mortality. Risk assessment is essential. The mFI, therefore, may be used as an additional tool by surgeons to determine risk of acute mortality for DMa patients with bowel obstruction. It is important to recognize that the mFI was not a predictor of acute morbidity and, consequently, further research is needed to optimize decision making for this at-risk population.

06.09 Understanding Effects of Age Race & Socioeconomic Status on Outcomes in Patients with Colon Cancer

Posted on January 25, 2017

O. O. Osuchukwu1, V. Pandit1, S. W. Mbugua1, J. Jandova1,2, A. Cruz1, V. N. Nfonsam1  1University Of Arizona,Surgery,Tucson, AZ, USA 2University Of Arizona,Institute For Cellular Transplant,Tucson, 85724, USA

Introduction:

Differences in outcomes among patients based on demographic and racial profile are well established. However; the impact of these differences on patient outcomes with colon cancer (CC) remains unclear. We hypothesized that racial and demographic profile is associated with adverse outcomes among patients with CC.

Methods:
National estimates for patients with CC were extracted from the National Inpatient Sample (NIS) database (2011). Patients were stratified based on age, race and insurance status. Outcome measures were: hospital length of stay (LOS), complications, and mortality. Regression analysis was performed after adjusting for age, gender, race, Charlson co-morbidity index (CCI), and type of surgical intervention.  

Results:
A total of 37,513 patients with CC were analyzed. The mean age was 68.3±13.9 years, 51.1% were females and the mean CCI was 2 [2-3]. Sixty-five and half percent of patients were white and 67.3% were Medicare/Medicaid insured. The overall mortality rate was 4.6%. Mortality rate significantly increased (p=0.04) with increasing age. Native Americans had the highest mortality rate and complication rate among all races. On regression analysis, increasing age (OR: 1.6 [1.1-3.1]), being non-white (OR: 1.3 [1.2-2.7]), and Medicare/Medicaid insurance status (OR: 1.2 [1.05-3.8]) were independently associated with mortality. Additionally, increasing age (OR: 1.9 [1.3-4.4]) and non-white race (OR: 1.4 [1.05-2.9]) were associated with increased in-hospital complication.

Conclusion:

Demographic, racial and socio-economic disparities are prevalent among patients with CC with worse outcomes among old and non-white patients. Native American patients with CC have worse outcomes among all races. Further assessing the causes for these disparities may help mobilization of resources and improve outcomes among patients with CC.
 

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