55.01 Risk Factors for Venous Thromboembolism in Pediatric Patients with Inflammatory Bowel Disease

Posted on January 31, 2019

K. A. McKie1, R. J. McLoughlin2, M. P. Hirsh2, P. P. Nazarey2, M. Cleary2, J. T. Aidlen2  1University Of Massachusetts Medical School,Worcester, MA, USA 2University Of Massachusetts Medical School,Surgery,Worcester, MA, USA

Introduction:
Patients with inflammatory bowel disease (IBD) have been shown to have twice the risk of developing venous thromboembolism (VTE) when compared to those without IBD. While the overall risk of VTE in the pediatric population is lower, the literature demonstrates that pediatric patients with IBD are also at increased risk of VTE. The factors augmenting the risk of VTE in pediatric IBD patients, including those undergoing major surgery have not been previously determined.

Methods:
Patients (<21 years old) were identified with an ICD-9 diagnosis of IBD (555.X or 556.X) or Crohn’s Disease (CD) (555.X) in the Kids’ Inpatient Database (KID) for the years 2006-2012. Procedure and ICD-9 diagnosis codes were scrutinized. VTE was defined by ICD-9 codes. National estimates were obtained using case weighting. Multivariable logistic regression was performed adjusting for age, race, gender, major surgical procedure, hypercoagulable states or diseases, and obesity. All p-values <0.05.

Results:
A total of 44,554 patients with IBD were identified and 28,132 patients with CD. Of the IBD patients, 456 (1.01%) developed VTE during their hospital admission, while 205 (0.72%) CD patients developed VTE. The oldest patients, those having an increased length of stay, a major surgical procedure or a coagulation disorder had the highest rate of VTE with both IBD and CD.  After performing adjusted logistic regression, undergoing a major operating room (OR) procedure was associated with a 2.04 and 2.35 times greater odds of developing VTE for IBD and CD patients, respectively. A coagulation disorder was associated with increasing the odds of a VTE by 8.95 and 8.90 times in IBD and CD, respectively.

Conclusion:
Pediatric patients with IBD are known to be at increased risk of VTE. Our study demonstrates that undergoing a major surgical procedure increases the risk for VTE in those with a diagnosis of CD or IBD. The pediatric IBD population with known hypercoagulable diagnoses are additionally at risk for VTE.  Given these findings, VTE prophylaxis for pediatric patients with IBD should be considered in both the perioperative setting and for those with concurrent hypercoaguable diagnoses.
 

54.20 Predictive Value of Platelet-to-Lymphocyte Ratio in Patients with Melanoma

Posted on January 31, 2019

C. T. Mayemura1, G. Gauvin1, K. Ruth3, K. Liang1, E. McGillivray1, K. Loo1, A. Olszanski2, S. Movva2, W. H. Ward1, B. Luo5, H. Wu4, S. Reddy1, J. Farma1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Department Of Hematology/Oncology,Philadelphia, PA, USA 3Fox Chase Cancer Center,Department Of Biostatistics,Philadelphia, PA, USA 4Fox Chase Cancer Center,Department Of Pathology,Philadelphia, PA, USA 5Fox Chase Cancer Center,Molecular Diagnostics Laboratory,Philadelphia, PA, USA

Introduction:  While pathology reports provide many prognostic markers for melanoma patients, the utilization of serum complete blood count (CBC) values are less established. Recent studies have shown that platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR) have predictive value for other cancers.  The goal of this study was to explore the association between platelet, lymphocyte and monocyte-derived ratios and the recurrence and survival in stage II and III melanoma patients.

Methods: Using data from a prospectively maintained database at our NCI designated cancer center, patients diagnosed with a stage II or III melanoma between 2005 and 2017 were reviewed. Patients who underwent surgery and had preoperative CBC data available were included for analysis. PLR and LMR values were split into quartile variables to compare overall survival (OS) and cumulative incidence of recurrence or cause-specific mortality using log rank and Gray’s tests.  Competing risk regression methods were used to adjust for age, adjuvant therapy and pathological stage in multivariable models.

Results: A total of 313 patients (57% male) were included, with a median age of 66 (range 21-99). Pathological stage included IIA (N=77), IIB (N=64), IIC (N=33), IIIA (n=42), IIIB (N=63), and IIIC (34). In the follow-up period 78 patients died; of those alive, median follow-up was 27.4 months. Adjuvant therapy was given to 45 patients (14%); treatments included interferon (n=23), PD-1 or CTLA-4 inhibitors (n=21), or chemotherapy (n=1). LMR (range 0.5-22.8) was separated by quartiles, with cutoff values of 2.3, 3.2 and 4.0. Similarly, PLR (range 22.7 – 1406) quartiles had cutoff values of 109.0, 135.3 and 176.2. Patients in the 4th quartile PLR had a significantly  higher rate of recurrence or death due to melanoma (Figure 1) (p=0.01), with a cumulative incidence of melanoma recurrence or death at 3-years of 0.54 compared to probabilities of 0.40, 0.25, and 0.33 for quartiles 1-3.  When using competing risk regression to adjust for age, adjuvant therapy and pathological stage, this same cohort showed higher incidence of recurrence (subHR=1.79, 95% CI=1.05-3.04, p=0.031).

Conclusion: In looking at preoperative CBC values, we found that PLR values were independently associated with melanoma recurrence or death for stage II and III melanoma patients, while LMR values held less predictive value.  We look forward to evaluating this finding in a larger cohort.

54.19 Have Cancer-Related Outcomes Data Led to Changes in Complex Oncologic Surgery Referral Patterns?

Posted on January 31, 2019

Y. Song1, A. D. Tieniber1, R. E. Roses1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: An increasing body of literature has demonstrated improved cancer-related outcomes for complex oncologic surgeries performed at specialized centers. We studied a national sample to determine whether these data have led to a shift in hospital referral patterns for such cases over time, using teaching hospitals (TH) as a surrogate for specialized centers.

Methods: Patients who underwent major elective resections for esophageal, gastric, liver, and pancreas cancers between 2003 and 2015 were identified using the National Inpatient Sample (NIS). Patients undergoing ventral hernia repairs (VHR) and appendectomies were used as a reference group. Primary outcome was the proportion of operations performed at TH over time. Secondary outcomes measured included trends in patient age, number of comorbidities, and inpatient mortality rate. Average annual percent change (AAPC) was calculated using weighted annual estimates. When there was a significant change in trend, segmented linear regression was performed to calculate AAPC for each time period. Statistical analyses were performed using R version 3.5.1.

Results: Between 2003 and 2015, an estimated 227,311 resections for esophageal (19,351), gastric (58,408), primary (22,743) and secondary (49,130) liver, and pancreas (77,712) cancers were performed. In the same time period, there were 338,223 VHR and 1,910,884 appendectomies. The proportion of cancer operations occurring at TH increased over time (AAPC=2.2, P<0.001, adjusted P*<0.001), with a concurrent decline at both rural (AAPC= -12, P<0.001, P*=0.004) and non-TH centers (AAPC= -10, P<0.001, P*<0.001). The largest increase in referral to TH occurred for gastrectomy (AAPC=3.5, P<0.001, P*=0.006), followed by pancreatectomy (AAPC=2.0, P<0.001, P*<0.001), esophagectomy (AAPC=1.8, P<0.001, P*=0.048), and hepatectomy (AAPC=0.98, P=0.002, P*=0.001). Notably, adjusted trends in the proportion of VHR and appendectomies performed at TH was not statistically significant. For cancer operations, there was an increase in number of patient comorbidities (AAPC=0.92, P=0.029), but decrease in inpatient mortality rate (AAPC= -5.6, P<0.001) over time. Mean patient age and number of comorbidities increased significantly for both VHR and appendectomies with no significant change in mortality rate.

Conclusions: The proportion of major operations for gastrointestinal and hepatobiliary cancers performed at TH has increased over time, driven primarily by an increase in gastrectomies. Additionally, inpatient mortality rates for these operations decreased. Further studies are needed to identify barriers that may impede appropriate referrals of complex oncologic surgeries to specialized centers.

54.18 Comparing Surgical Outcomes Between Total and Nontotal Pelvic Exenterations

Posted on January 31, 2019

J. K. Kim1, J. Patel1, M. Billah3, N. Suri4, O. Mahmoud2, R. Chokshi1  1New Jersey Medical School,Surgical Oncology,Newark, NJ, USA 2New Jersey Medical School,Radiation Oncology,Newark, NJ, USA 3New Jersey Medical School,Urology,Newark, NJ, USA 4New Jersey Medical School,Medicine,Newark, NJ, USA

Introduction:

Pelvic exenteration is a radical operation offered to patients with locally advanced primary or recurrent pelvic malignancy in an attempt to improve survival. However, it is unclear whether the extent of pelvic exenteration affects outcome. In this study, we compared the patient demographics and surgical outcomes of patients who underwent total and nontotal pelvic exenterations. 

Methods:

With Institutional Review Board approval, we performed a retrospective analysis of patients who underwent pelvic exenterations for treatment of various advanced malignancies between 2005 and 2017. Patients were divided into total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE) which included anterior pelvic and posterior pelvic exenterations. TPE involved excision of the rectum, bladder, and if applicable, the female reproductive organs, followed by a urinary and fecal diversion. Anterior pelvic exenteration involved removal of the urinary tract requiring urinary diversion. Posterior pelvic exenteration involved removal of the rectum, requiring fecal diversion. Survival was monitored by  follow up visits. Complications were reported according to Clavien-Dindo classification. T-test for continuous variables and Chi-square test for categorical variables were employed with p<0.05 for statistical significance.

Results:

Sixteen patients underwent TPE and seven patients underwent NTE. Baseline demographics of both groups were similar. Mean ages for TPE and NTE group were 58.4 years and 61.9 years respectively (p =0.426). Gender distribution and distribution of ethnicity were also similar in both groups (p=0.266 and p=0.591 respectively). Mean body mass index, however, was significantly lower in the TPE group compared to the NTE group (23.4 and 29.8 respectively with p=0.015). Double barrel wet colostomy was the most common form of urinary and fecal diversion for TPE (62.5%) while ileal-conduit or end colostomy were the most common forms of urinary or fecal diversion in the NTE. There was a significantly higher six month overall survival in the TPE group (75%) compared to NTE group (43%); (p=0.0404). Long term survival data was not available due to poor follow up. TPE had a tendency for higher class I/II Clavien-Dindo complications (54%) compared to NTE (14%); (p=0.0849). Rate of class III/IV Clavien-Dindo classifications were similar in TPE and NTE (31% and 43% respectively with p=0.589). Urinary tract infection was the most common postoperative complication in both groups (56% in TPE, 71% in NTE, p= 0.493) followed by sepsis (37.5%, 28.5% respectively with p=0.679). 

Conclusion:

Patients that underwent TPE compared to NTE had a lower body mass index. Severity of complications between the two groups did not differ. Infection was the most common complication in both TPE and NTE. TPE had a lower mortality at six months compared to NTE but long term overall survival still needs to be determined.

54.17 Extent of Lymphadenectomy is Not Associated with Improved Survival in Esophageal Cancer

Posted on January 31, 2019

S. Mahoney1, P. Strassle2, M. Meyers1  1University Of North Carolina At Chapel Hill,Dept Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,School Of Public Health, Dept Of Epidemiology,Chapel Hill, NC, USA

Introduction: The impact of lymph node (LN) dissection in esophageal cancer outcomes remains unclear.  We sought to examine trends in LN yield over time in patients undergoing curative resection for esophageal cancer and the relationship with survival.

Methods: All National Cancer Database patients >18yo undergoing esophagectomy for adenocarcinoma or squamous cancer from 2004-2015 were included except those with metastatic disease or palliative treatment.  Bivariate analyses comparing demographics and cancer characteristics, stratified by LN yield, were compared using Chi-square and Wilcoxon-Mann-Whitney tests.  Trends in LN yield over time were assessed using Poisson regression.  5-year survival differences were compared using Kaplan-Meier curves and multivariable Cox proportional hazards regression. 

Results:  20,588 patients were included.  71% received neoadjuvant therapy.  Most (82%) were adenocarcinoma.  Stage II (44%) and stage III (40%) predominated.  Average LN yield increased over time from 11.7 to 16.4 (p<0.0001) as did the proportion of patients with 10-19 LN examined (32% to 45%) and >20 LN examined (14% vs. 28%).  The average number of positive LN remained the same (1.4 vs. 1.2; p=0.21).  Although crude survival was associated with increased LN yield (Table), adjusted survival had no association with LN yield.  Similarly, there was no association with survival when LN yield was treated as a linear variable (HR for any 5 LN increase 0.99, 95% CI 0.98, 1.01).

Conclusion:  Improvements in LN yield with esophagectomy has been seen on a population level over time.  However, higher LN yield is not associated with improvements in adjusted survival in patients with resected esophageal cancer. 

 

54.16 Minimally-Invasive Esophagectomy May Underestimate Nodal Staging in Cancer Operations

Posted on January 31, 2019

T. J. Mouw1, A. Saedi1, J. H. Ashcraft1, J. D. Valentino1, B. M. Martin1, P. J. DiPasco1, M. F. Al-Kasspooles1  1University of Kansas Medical Center,Surgery,Kansas City, KANSAS, USA

Introduction:
The average patient undergoing esophagectomy has been changing over years. There has been a shift towards adenocarcinoma as the dominant pathology. There has also been an increase in the rates of obesity among this patient population. Additionally, there have been numerous advancements in surgical technology allowing for various minimally invasive approaches to esophagectomy. With changing patient demographics and the development of new minimally invasive techniques, the traditionally cited complication rates for esophagecmay no longer be valid. Furthermore, the ability to perform an oncologically sound resection has not been evaluated for minimally-invasive approaches. A thorough investigation of these techniques in the context of a changing patient population is warranted to guide surgeons in perioperative decision making. 

Methods:
To investigate the perioperative outcomes of minimally invasive esophagectomy, a query of the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted esophagectomy data file for 2016 was conducted.  A specific analysis of minimally invasive and open approach esophagectomies was performed. The primary outcome was the rate of nodal upstaging. Secondary outcomes included anastomotic leak and Clavien-Dindo classification for perioperative complications. 

Results:
This query returned 1034 cases. The majority of cases were performed for adenocarcinoma. There was no statistically significant difference in patient characteristics or clinical staging between the minimally-invasive or open groups. Pathologic upstaging occurred more commonly in open cases compared to minimally invasive esophagectomy (45.79% vs. 36.63%, p=0.03). There was no difference in leak rates between minimally invasive esophagectomy and open esophagectomy, however minimally invasive esophagectomy leaks were more commonly treated percutaneously.  The specific surgical approach or location of the anastomosis did not impact leak rates. 

Conclusion:
Minimally invasive esophagectomy is a safe alternative to open esophagectomy with similar rates of complications and favorable severity of anastomotic complications. However, minimally invasive esophagectomy may be inappropriate for cancer operations due to underestimation of nodal stage. Further work is necessary to determine if this underestimation has an impact on survival or recurrence. 
 

54.15 Liquid Biopsy and Histopathologic Results versus Outcomes in Mutation-Negative Lung Cancer Patients

Posted on January 31, 2019

S. Zhang2, T. Boyle1,2, C. Williams1,2, S. Antonia1,2, A. Chiappori1,2, J. Gray1,2, T. Tanvetyanon1,2, B. Creelan1,2, E. Haura1,2, M. Shafique1,2, J. Fontaine1,2, J. Cox1,2, F. Kaszuba1,2, R. Keenan1,2, V. Nair1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   When tumor biopsies are not feasible, liquid biopsy of peripheral blood circulating tumor DNA (ctDNA) and protein has been shown to capture genetic and proteomic data that represent the entire tumor burden of each cancer patient.  We sought to investigate whether liquid biopsy can correlate histopathologic factors, treatment, or outcomes with peripheral blood ctDNA mutations and proteomic signatures.

Methods:   We retrospectively analyzed data from all non-small cell lung cancer (NSCLC) patients who underwent liquid biopsy analysis of ctDNA and proteins on peripheral blood samples from August 2016 to June 2018.  This ctDNA analysis detected presence of targetable mutations, and proteomic analysis grouped patients into either Good or Poor status.  Patients with targetable mutations were excluded.  Liquid biopsy results were then correlated with histopathologic factors, such as tumor histology, grade of differentiation, tumor (T) status, nodal (N) status, metastasis (M) status, pathologic stage (pStage), and treatment.  Student’s t-test, Kruskal-Wallis test, or Chi-square test were used to compare these factors between groups, and Kaplan-Meier curves were used to compare survival.  Statistical differences were significant at p≤0.05.

Results:  Of 522 patients analyzed by liquid biopsy, 92 (17.6%) mutation-positive patients were excluded.  Of 430 (82.4%) mutation-negative patients, 376 (87.4%) had proteomic Good status, and 54 (12.6%) had proteomic Poor status.  Mean age did not differ between Good and Poor groups (68.4 yr vs. 65.1 yr; p=0.07).  Mean primary tumor size did not differ between Good and Poor groups (p=0.342).  Histology (i.e. adenocarcinoma, squamous cell carcinoma, neuroendocrine carcinoma, etc.) did not differ between Good and Poor groups (p=0.11).  However, tumor grade of differentiation, N status, M status, and pStage differed between Good and Poor groups, with the Poor group having more patients with poorly-differentiated (G3) tumors (p<0.01), with N2 or N3 status (p<0.01), with M1 status (p<0.01), and with pStage III and IV cancers (p<0.01).  Similarly, treatment differed between Good and Poor groups, with the Good group more likely to have surgery and the Poor group more likely to receive systemic therapy (p<0.01).  In Kaplan-Meier survival analysis, the Good group had 1-year overall survival (1-yr OS) of 88.5% compared to a 1-yr OS of 48.4% for the Poor group (p<0.01).

Conclusion:  Using a commercially-available peripheral blood liquid biopsy kit, mutation-negative NSCLC patients were identified by ctDNA analysis and as Good or Poor status by proteomic analysis.  While age and tumor size did not correlate with Good versus Poor status, the Poor group had significantly more poorly-differentiated tumors, more mediastinal LN (N2 and N3) involvement, more distant metastases, and higher pStaged cancers, required systemic therapy more often, and had significantly worse 1-yr OS than proteomic-Good patients.

54.14 Intra-Operative Fluid Volume and Post-Operative Leak After Colectomy in Patients with Colon Cancer

Posted on January 31, 2019

V. Pandit1, M. Zeeshan1, C. Martinez1, P. Omesiete1, M. Hamidi1, Y. Villalvazo1, V. Nfonsam1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
Post-operative leak (PoL) in patients undergoing colectomy for colon cancer is a known complication and associated with adverse outcomes. Multiple factors are established to impact (PoL) however; volume of intra-operative fluids (IoF) remains unclear. The aim of the study was to assess the impact of IOF on PoL in patients undergoing colon surgery. We hypothesized that minimizing IOF results in lower PoL.

Methods:
A 2 year (2016-2017) prospective analysis of all patients undergoing elective colon resection was performed. Patient data age, gender, co-morbidities, ASA score, indication of procedure, procedure type, IoF, post-operative outcomes for 30days were collected. Outcome measure was PoL. ROC analysis was performed to assess optimum cutoff for IoF.

Results:
A total of 160 patients were included with mean age was 64.5±15.6 years, 52.5% male, median ASA 3[3-4], median BMI 32[29-34], 45% of procedures were performed laparoscopic, the median IoF 1300 [1000-2500] and PoL was 7.5%. Among POL, 50% were colo-rectal and 33.3% were colo-anal anastomosis. Patients with PoL received higher IoF (1251±1122ml vs 3758±2100cc p=0.01). After controlling for demographics, procedure type, ASA, BMI, neoadjuvant therapy, anastomotic type, and operative duration higher IoF was independently associated with PoL (1.2 [1.1-2.6], p=0.03). On ROC analysis 1900cc was the optimum fluid cut-off for PoL. 

Conclusion:
Intra-operative fluid volume significantly impacts post-operative leak after colon surgery. Minimizing intra-operative fluids to less than 1900cc crystalloids may help to reduce post-operative leak rate. Further studies validating optimum intra-operative fluids may help optimize patient care. 
 

54.13 The Role of Primary Tumor Infiltrating Lymphocytes in Patients Receiving Immunotherapy for Melanoma

Posted on January 31, 2019

G. Gauvin1, K. Liang1, K. Ruth2, C. Mayemura1, E. McGillivray1, K. Loo1, A. Olszanski3, S. Movva3, M. Lango1, J. D’Souza5, H. Wu4, S. Reddy1, J. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Department Of Biostatistics,Philadelphia, PA, USA 3Fox Chase Cancer Center,Department Of Hematology/Oncology,Philadelphia, PA, USA 4Fox Chase Cancer Center,Department Of Pathology,Philadelphia, PA, USA 5Fox Chase Cancer Center,Molecular Therapeutics Program,Philadelphia, PA, USA

Introduction:  Advanced melanoma treatment has significantly evolved in the past decade with the development of immunotherapy-derived treatments, and the approval of the first targeted immunotherapy in 2011. The goal of this study was to investigate the impact of the presence of tumor infiltrating lymphocytes in the primary tumor on patients’ response rate to targeted immunotherapies.

Methods:  A retrospective chart review was conducted on patients diagnosed with melanoma at our tertiary center between 2011 and 2018.  Patients who were treated with immunotherapy and in which tumor infiltrating lymphocytes (TILs) were positive or absent on the initial biopsy were included. Demographic and clinical data were collected and response to therapy was determined by Kaplan-Meier survival and Cox regression analyses.

Results: Twenty-seven patients (67% male) were included in this study. The median age was 58 (range 24-86) and the median follow-up time was 12.9 months. Patients were staged as stage II (n=1), stage III (n=22), and stage IV (n=4). Tumor infiltrating lymphocytes (TILs) were present (brisk or non-brisk) in 12 patients and absent in 15 patients. TILs present patients received anti-CTLA4 antibody (n=6) or PD-1 inhibitor (n=6). TILs absent patients received anti-CTLA4 antibody (n=7) or PD-1 inhibitor (n=8). Recurrence occurred in 3 of TILs present and 7 of TILs absent. Disease progression did not occur in the TILs present cohort but was seen in 2 of the TILs absent (their median PFS was 6.9 months). Death due to disease did not occur in TILs present, but was seen in 4 TILs absent (stage III n=2, stage IV n=2), all of whom were treated with anti-CTLA4 antibody. Two were free of disease, subsequently recurred, and were treated with combination anti-CTLA4 and PD-1 inhibitor (n=1) or just PD-1 inhibitor (n=1). Death due to other causes was seen in one patient from each group, both stage III and received ipilimumab. When comparing the TILs present and TILs absent groups, the median disease-free survival (DFS) was 16.9 months versus 10.5 months and overall survival (OS) was 15.9 months vs 11.9 months, respectively. Kaplan-Meier survival curves demonstrated that DFS was significantly higher in patients with TIL (p=0.04), but there was no significant difference in OS (p=0.25). Multivariate analysis using Cox regression model adjusting for age confirmed that the presence of TILs is associated with an increased DFS (p=0.05) (HR=0.114, 95%CI 0.013-1.029), but not for OS (p=0.12).

Conclusion: Immunotherapy has marked the beginning of a new era in treatment of advanced melanoma. In this pilot study, TIL has the potential to be a first screening tool to orient patients to these targeted treatments while waiting for genetic testing. We will continue to investigate this marker in larger studies.

54.12 The Prognostic Role of Tumor Infiltrating Lymphocytes in Non-Metastatic Melanoma Patients

Posted on January 31, 2019

K. Liang1, G. Gauvin1, K. Ruth2, E. McGillivray1, C. Mayemura1, K. Loo1, H. Wu3, J. D’Souza4, A. Olszanski5, S. Movva5, S. Reddy1, J. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Department Of Biostatistics,Philadelphia, PA, USA 3Fox Chase Cancer Center,Department Of Pathology,Philadelphia, PA, USA 4Fox Chase Cancer Center,Molecular Therapeutics Program,Philadelphia, PA, USA 5Fox Chase Cancer Center,Department Of Hematology/Oncology,Philadelphia, PA, USA

Introduction: Staging for melanoma continues to evolve. Although the prognostic value of tumor thickness and presence of ulceration is widely accepted, the clinical role of tumor infiltrating lymphocytes (TILs) is not as clear. The development of targeted immunotherapy may enlighten the role of TILs, which is easily evaluated at the time of initial biopsy. In this study, we investigated the prognostic value of TILs in non-metastatic melanoma patients and its relationship to recurrence.

Methods:  A retrospective chart review of patient with melanoma from 2003 and 2017 was conducted at our NCI designated cancer center. Non-metastatic patients who underwent surgery and had a documented presence or absence of TIL on initial pathology were included. Cumulative incidence of recurrence including cause-specific mortality (CSM) was calculated. Survival distributions were compared using Gray’s test, and subdistribution hazard ratios adjusting for covariates were estimated using Fine and Gray competing risk regression methods.

Results: Of 645 patients, 341 had TILs (present, brisk or non-brisk) and 304 did not have TILs (n=304).  Fifty five percent were male with a median age of 63 (range 21-99). Patients were pathologically staged with stage I (n=339), II (n=171) or III (n=135) disease. Forty-six patients received adjuvant therapy (stage II n=5, stage III n= 41), of which 22 received interferon, 20 immunotherapy (anti-CTLA4 antibody, PD-1 inhibitor), 3 chemotherapy, and 1 vaccine trial. During follow-up, 83 patients died, 75% from their melanoma (n=62); median follow-up was 18.2 months for those alive. Ninety-seven patients recurred. In stage III patients, the cumulative probability of recurrence/CSM was lower for patients with TIL (p=0.035); at 36 months, the cumulative probability was 0.33 (95% CI 0.20-0.47) for patients with TILs present compared to 0.50 (95%CI 0.37-0.62) for TILs absent. Recurrence did not differ by TIL status in stage I and stage II patients. For stage III patients, cumulative incidence of recurrence/CSM did not differ by adjuvant therapy status (p=0.116); at 36 months this was 0.41 for adjuvant compared to 0.43 for non-adjuvant patients. Competing risk regression was used to adjust for age, adjuvant therapy use, and pathologic staging. With adjustment, patients with TILs were less likely to have recurrence (subHR=0.71, 95% CI=0.49-1.03, p=0.067).

Conclusion: This study shows that the presence of tumor infiltrating lymphocytes (TILs) is associated with lower probability for recurrence, especially in stage III patients. This is an important finding that warrants further evaluation in a larger cohort.

54.11 Urgent Surgery for Gastric Adenocarcinoma Demonstrates Worse Outcomes

Posted on January 31, 2019

B. Fisher1, M. Fluck1, M. Hunsinger1, J. Blansfield1, M. Shabahang1, T. Arora1  1Geisinger Health System,Department Of Surgery,Danville, PA, USA

Introduction:   Gastric adenocarcinoma is the 2nd leading cause of cancer death in the world, and 16th most common in the United States. Gastric cancer can present emergently as an upper GI bleed or perforation. No large studies have examined how urgent surgery for gastric cancer effects patient outcomes. The aim of this study is to examine outcomes of urgent vs elective surgery for gastric cancer.

Methods:   Patients from the National Cancer Database (NCDB) with gastric adenocarcinoma from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 4 days of diagnosis. Univariate and multivariate analysis of surgical and oncologic outcomes were performed, in addition to patient factors. All p-values <0.01

Results:  Of 26,116 total patients, 2648 had urgent surgery and 23,468 had elective surgery. Patients in the urgent surgery cohort were significantly older, male, non-white, had higher pathologic stage, and were treated at a low volume center. Urgent surgery was associated with decreased quality lymph node harvest (OR 0.68 95%CI [0.62,0.74]), positive surgical margin (OR 1.48, 95%CI [1.32,1.65]), increased 30-day mortality (OR 1.38, 95%CI [1.16,1.65]), increased 90-day mortality (OR 1.30, 95%CI [1.14,1.49]), and decreased overall survival (HR 1.21 95%CI [1.15-1.27]).

Conclusion:  Urgent surgery for gastric cancer is associated with significantly worse surgical and oncologic outcomes. Stable patients requiring urgent surgical resection for gastric masses may benefit from referral to a high-volume center for resection by an experienced surgeon. In addition, surgeons should maintain a high level of suspicion for gastric cancer in any patient with perforation or upper GI bleed.

 

54.10 The Role of Sentinel Lymph Node Biopsy in Perineal Melanoma

Posted on January 31, 2019

R. A. Patel1, P. D. Patel1, K. Ashack1, D. C. Wan2  1University Of Illinois At Chicago,College Of Medicine,Chicago, IL, USA 2Stanford University,Plastic And Reconstructive Surgery,Palo Alto, CA, USA

Introduction: The role of sentinel lymph node biopsy (SLNB) in melanoma is highly controversial topic. Current data is primarily drawn from the MSLT-1 Trial. Although results showed no overall survival benefit, SLNB provided a disease-free survival benefit for intermediate thickness (1.2-3.5mm) and thick (>3.5mm) melanoma. In the perineum, melanoma is often more advanced at presentation, with current guidelines primarily translated from melanoma in a non-anatomic specific fashion. As a result, the role of SLNB in this anatomic region is even more poorly understood.

Methods: The Surveillance, Epidemiology, and End Results (SEER) program is a large population-based cancer registry including survival data from millions of patients in the United States. The registry was used to generate patient data for analysis from 2004-2015. Inclusion criteria included melanoma of the vulva, penis, and scrotum; Breslow depth >0.80mm with ulceration and >1.00mm with any features; and nodal intervention of SLNB with associated lymph node dissection if performed, or none. A χ2 analysis was performed to determine predictors of sentinel node status. Kaplan-Meier regression analysis was performed for SLNB stratified by Breslow depth. Subsequently a multivariate cox proportional hazards regression was performed to determine predictors of disease-specific survival (DSS) and overall survival (OS).

Results: Aggregates for disease-specific and overall survival was improved with implementation of SLNB. 5-year survival rates with SLNB were 52.9% and 49.6%, as compared to those without SLNB at 32.5% and 32.5% for DSS (p = 0.001) and OS (p <0.001) respectively. Patients with positive node status had a 5-year DSS and OS of 24.1% and 22.3% respectively, compared to 63.8% DSS and 60.2% OS for a negative node status (p <0.001 and p <0.001). Stratification by Breslow depth yielded significant OS advantage for the 0.80-2.00mm group (33.7% benefit; p = 0.001). Significant predictors of survival (DSS; OS) include age greater than 75 (HR 2.108, p = 0.030; HR 2.136, p = 0.010), Clark level IV-V (HR 2.474, p = 0.035; HR 2.05, p = 0.035), and positive ulceration status (HR 1.946, p = 0.011; HR 1.941 p = 0.003). High mitotic rate (HR 1.865, p = 0.053) was a predictor for poor OS only.

Conclusion: SLNB may be offered to patients with melanoma of the perineum with Breslow depth >0.80mm with ulceration up to 2.00mm, or any lesions >1.00mm up to 2.00mm for prognostic information as well as therapeutic benefit through an increase in 5-year overall survival. Additional randomized controlled trials are necessary before more definitive conclusions are made.

54.09 Impact of Preoperative Narcotic Use on Perioperative Outcomes in Complex Gastrointestinal Surgery

Posted on January 31, 2019

M. Sunkara1, R. C. Martin1, P. Philips1, K. M. McMasters1, C. R. Scoggins1, M. E. Egger1  1University Of Louisville,Surgery,Louisville, KY, USA

Introduction: Patients undergoing complex gastrointestinal surgery often take narcotics prior to surgery for chronic pain. The impact of the use of preoperative narcotics on perioperative outcomes and long-term narcotic use are unknown. We hypothesized that use of preoperative narcotics would negatively impact perioperative outcomes in patients undergoing complex gastrointestinal surgery.

Methods: Patients undergoing complex gastrointestinal surgery in an academic surgical oncology practice were identified from a prospectively collected database. Complex gastrointestinal surgery was defined as an operation requiring general anesthesia and an inpatient stay involving gastric, esophageal, hepatic, or pancreatic resection, or cytoreductive surgery for peritoneal malignancy. Medication use was determined by review of the medical records. Perioperative outcomes, including complications, length of stay, and 90 day readmission were compared. Major complications were defined as Clavien-Dindo grade 3 or greater. Early postoperative narcotic use was defined as continued use of narcotics at 30 days postoperatively, and prolonged postoperative narcotic use was defined as use of narcotics 90 days postoperatively.

Results: We identified 162 patients in the 5-year time period of the study meeting inclusion criteria with records available for review. The most common operation was esophagectomy (34%), followed by pancreatic resection (26.5%), gastrectomy (15%), and hepatic resection (14%).  Most patients (96.3%) underwent surgery for a malignancy. The rate of preoperative narcotic use was 36% overall. The rate of preoperative benzodiazepine use was 16% overall. There were no differences in 90-day readmission rates (14% vs 12%), complication rates (46 vs 48%), major complication rates (19% vs 23%), length of stay (10 vs 9 days), or prolonged length of stay ≥  14 days (27% vs 29%) in patients who did and did not use narcotics preoperatively. Preoperative benzodiazepine use was not associated with any differences in perioperative complications.  Preoperative narcotic use was associated with an increased rate of early postoperative narcotic use at 30 days (90% vs 61%, OR 5.9, 95% CI 1.9-18.3) and prolonged postoperative narcotic use at 90 days (63% vs 29%, OR 4.3, 95% CI 1.9-9.7) (Figure). Neither complications nor preoperative benzodiazepine use predicted early or prolonged postoperative narcotic use.

Conclusion: Perioperative complications are similar in patients who are taking preoperative narcotics compared those that are not. However, patients using narcotics prior to complex gastrointestinal surgery are at increased risk of prolonged narcotic use after surgery. This group may be a target for early intervention to decrease the risk of opioid dependency.

 

54.08 Long-term Outcomes Of Isolated Limb Infusion In Melanoma

Posted on January 31, 2019

N. E. Farrow1, C. J. Puza3, D. S. Tyler2, G. M. Beasley1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 3Duke University Medical Center,School Of Medicine,Durham, NC, USA

Introduction:
Isolated limb infusion (ILI) is an effective treatment for recurrent, unresectable extremity melanoma, with about 30% of patients experiencing a complete response after therapy.  Recent introduction of multiple novel therapies for advanced melanoma has led to decreased utilization of ILI.  Here we report long-term ILI outcomes from a single institution. 

Methods:
Our prospective institutional database was used to identify all patients undergoing ILI with melphalan plus dactinomycin between 2003 and 2013. Data pertaining to tumor characteristics, procedure details of ILI, response at three months, date of in- and out-of-field progression and mortality were collected. 

Results:
There were 167 ILI procedures performed on a total of 131 patients. For the 131 first-time ILI procedures, 38 patients (29%) had a complete response (CR), 17 (13%) had a partial response (PR), 19 (15%) had stable disease (SD), and 51 (39%) had progressive disease (PD) at three months. Six patients were lost to follow up. Overall survival was significantly improved in patients who experienced a CR compared to partial- or non-responders (PR, SD, PD), (P-value < 0.001).  Overall 5-year survival was 62.8% for the CR group vs 28.8% for non-responders.  Among CRs, 15/38 (39%) required no additional therapy and remained free of disease at median 3.9-year follow-up.  Of all 131 patients, 79 patients (60%) developed progressive disease outside of the affected extremity, with an average time to out-of-field progression of 8.5 months (range 25 days to 4.4 years). Of all 131 patients, 33 (25%) went on to have repeat ILI, and 33 (25%) went on to targeted therapy or checkpoint inhibitors after ILI. 

Conclusion:
Patients with a CR to ILI can have prolonged survival with ILI alone. Many patients with regional disease go on to develop systemic disease despite ILI and will require effective systemic therapy for disease control. With multiple new therapies now being applied to patients with recurrent unresectable cutaneous melanoma, ILI can still be considered after systemic treatment failures, for patients who have persistent extremity recurrences without systemic progression, and in combination with systemic therapy.
 

54.07 Outcomes of Palliative Surgery in Retroperitoneal Sarcoma – Results from the US Sarcoma Collaborative

Posted on January 31, 2019

S. Z. Thalji1, M. Hembrook1, S. Tsai1, T. C. Gamblin1, C. Clarke1, M. Bedi2, J. Charlson3, C. G. Ethun4, T. B. Tran5, G. Poultsides5, V. P. Grignol6, J. H. Howard6, J. Tseng7, K. K. Roggin7, K. Chouliaras8, K. Votanopoulos8, D. Cullinan9, R. C. Fields9, K. A. Vande Walle10, S. Ronnekleiv-Kelly10, H. Mogal1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Medical Oncology,Milwaukee, WI, USA 4Emory University School Of Medicine,Division Of Surgical Oncology, Winship Cancer Institute,Atlanta, GA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Ohio State University,Department Of Surgery,Columbus, OH, USA 7University Of Chicago,Department Of Surgery,Chicago, IL, USA 8Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 9Washington University,Department Of Surgery,St. Louis, MO, USA 10University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Objective: While outcomes of patients with Retroperitoneal Sarcomas (RPS) who have microscopically or macroscopically positive margins after curative-intent resection has been studied, few studies have focused on outcomes in patients undergoing surgery with a palliative intent. This study aims to define common indications for and to elucidate factors that determine outcomes after palliative-intent resection of RPS.

 

Patients and

Methods: Using the retrospective 8-institution United States Sarcoma Collaborative (USSC) database, all patients who underwent resection of a primary or recurrent RPS (including intraabdominal or distant metastasis) with palliative intent between 2000 and 2016 were identified. Overall Survival (OS) was estimated by the Kaplan-Meier method and compared using the log-rank test. Multivariable logistic regression and Cox-proportional hazards models of patient- and treatment-related factors were constructed to determine their effect on postoperative complications and OS.

 

Results: Of a total of 3,088 patients, 70 patients underwent 87 distinct palliative-intent surgeries for RPS. Median age was 62.3 years (IQR 46.7–71.5) and 57% (n=50) were female. Most common indications for palliative surgery included pain (n=23, 26%), bowel obstruction (n=18, 21%), bleeding (n=7, 8%), and infection (n=2, 2%). Dedifferentiated liposarcoma (n=18, 21%) and leiomyosarcoma (n=17, 20%) were the predominant tumor types. Median OS for the entire cohort was 10.69 months (IQR 3.91-23.23). R2 resection status was the only factor independently associated with incidence of postoperative complications (OR 4.42, CI 1.01-19.38, p=0.049). The presence of complications (HR 3.25, CI 1.35-7.81, p=0.008) and high-grade histology (HR 4.45, CI 1.19-16.62, p=0.026) were associated with increased mortality. While OS was not independently affected by resection status, in patients who underwent R2 resections, the development of postoperative complications significantly reduced survival (p=0.042) (figure 1).

 

Conclusions: The occurrence of postoperative complications and high grade tumor biology rather than resection status determines survival in patients undergoing palliative-intent resections for RPS. Palliative-intent R2 resections should be cautiously performed for RPS given the higher-incidence of post-operative complications which may significantly lower survival.

54.06 Morbidity, Mortality and Temporal Trends in the Surgical Management of Retroperitoneal Sarcoma

Posted on January 31, 2019

S. J. Judge1, K. Lata-Arias5, M. Yanagisawa1, M. A. Darrow3, A. M. Monjazeb4, S. W. Thorpe2, A. R. Kirane1, R. J. Bold1, D. J. Canter5, R. J. Canter1  1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 2University Of California – Davis,Orthopedic Surgery,Sacramento, CA, USA 3University Of California – Davis,Pathology,Sacramento, CA, USA 4University Of California – Davis,Radiation Oncology,Sacramento, CA, USA 5Ochsner Health System,Urologic Oncology,New Orleans, LA, USA

Introduction:

Advocates of extended surgical resection to optimize oncologic outcomes in retroperitoneal sarcoma (RPS) are increasing, and selected studies have demonstrated that short- and long-term outcomes following multivisceral resection (MVR) of RPS are acceptable. We sought to analyze surgical outcomes following RPS resection in a contemporary cohort, hypothesizing that 30-day morbidity and mortality rates and prevalence of MVR in a larger sample size would remain consistent with prior studies.

Methods:

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 636 patients with primary malignant neoplasms of the retroperitoneum from 2012 to 2015. Overall morbidity, severe morbidity, and mortality rates were compared among MVR and non-MVR patients, and univariate and multivariate analysis was performed to identify predictors of overall and severe postoperative morbidity (mortality rate was too low for meaningful analysis). The Cochran-Armitage trend test was used to assess for temporal trends in the utilization of MVR.

Results:
Of the 636 patients, 51% were female with a mean age of 59.8 ± 12.6 years. The majority were ASA class 3 (62%). Overall, median operative time was 228 minutes (range 47-987), and 256 (40%) underwent MVR (bowel resection = 119, nephrectomy = 91, cholecystectomy = 15). When comparing MVR to no MVR, there was no significant difference in overall morbidity (23% vs. 17%), severe morbidity (9% vs. 6%), and mortality (<1% vs. 2%), although overall morbidity approached statistical significance (P = 0.06). MVR patients did experience higher rates of deep incisional surgical site infection (SSI) (3% vs 1%, P = 0.03) and organ space SSI (7% vs 3%, P = 0.05) in the 30-day postoperative period. On multivariate analysis, MVR was not associated with increased overall morbidity (OR 0.92, 95% CI 0.57-1.49) or severe morbidity (OR 0.96, 95% CI 0.47-1.96). Rates of MVR ranged from a low of 38% in 2013 to a high of 45% in 2015 with no significant change over time (P = 0.53).

Conclusion:
Short-term morbidity and mortality rates after multivisceral resection of RPS remain acceptable, although rates of MVR show little change over time in NSQIP hospitals. Concerns about increased morbidity and mortality should not be viewed as a contraindication to wider implementation of extended resection for RPS.

54.05 Developing Patient-Centered Outcomes in Cancer Surgery: Survey Approaches for Digital Phenotyping

Posted on January 31, 2019

N. Panda1,2, I. Solsky1, J. P. Onnela3, A. B. Haynes1,2  1Ariadne Labs,Boston, MA, USA 2Massachusetts General Hospital,Surgical Oncology,Boston, MA, USA 3Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:
Digital phenotyping is the moment-by-moment quantification of physical, social, behavioral, cognitive, and emotional functioning as reflected in smartphone data collected passively from smartphone sensors and actively through surveys. This approach to measuring individual functioning has the potential to improve shared decision-making, patient engagement, and improve outcomes that matter most to patients. The feasibility of active data gathering via surveys as acquired using digital phenotyping requires further investigation.

Methods:
Patients enrolled in a prospective study who underwent surgery for abdominal cancer downloaded the Beiwe smartphone app, developed by our research team for digital phenotyping. Beiwe, in addition to collecting passive data (i.e. GPS, accelerometer, call frequency) from smartphone sensors, pushed perioperative surveys to patients. Pre-operative surveys included the validated Short Form-36 (SF36) and Decision Conflict Scale (DCS) as well as a baseline survey on treatment expectations developed by our research team (ExpB). Post-operative surveys included a single item on the alignment of treatment expectations created by our team (ExpL, pushed at week 1, 4, 12, and 24 after surgery), SF36 (pushed at week 4, 12, and 24 after surgery), and the validated Decision Regret Scale (DRS, pushed at 12 and 24 weeks after surgery). Daily microsurveys (5-question survey generated randomly from SF36) were also administered perioperatively. Enrollment time and survey completion rates were analyzed. Responses gathered via intermittent SF36 versus daily microsurvey pushes were also compared.

Results:
Twenty patients with primary abdominal malignancies (10 sarcoma, 5 liver, 5 colon) who underwent surgery were followed for a median of 117.5 days [IQR 65.5, 158.0]. Pre-operative survey completion rates were 0.90 (±0.31), 0.90 (±0.31), and 0.95 (±0.22) for the SF36, ExpB, and DCS, respectively. Microsurvey completion rate throughout the study was 0.63 (±0.29). Post-operatively, the completion rates of the ExpL (pushed at 1 week), ExpL+SF36 (pushed at 4 weeks), and DRS+SF36+ExpL (pushed at 12 and 24 weeks) were 0.53 (±0.29), 0.71 (±0.32), 0.44 (±0.46), and 0.27 (±0.36), respectively. The mean number of items completed by patients through the intermittent complete SF36 administration was lower (75.9 (±38.5)) compared to daily microsurveys (347.8 (± 276.6), p=0.002).

Conclusion:
Active gathering of patient-reported quality of life outcomes is feasible several months into post-operative recovery in a digital phenotyping study. The daily administration of SF36 microsurveys resulted in a significantly greater number of total items completed throughout the study period in comparison to intermittent distribution of the SF36 in full. This suggests that microsurveys may allow for greater data collection; however, the validity of this approach must be studied further.

54.04 Differentiating ED Diagnosis and ED Use: Healthcare Utilization Patterns and GI Cancer Mortality

Posted on January 31, 2019

D. Steinmetz1, I. Solsky1, B. Rapkin2, M. Parides1, J. M. Leider3, H. In1,2  1Montefiore Medical Center/Albert Einstein College of Medicine,Department Of Surgery,Bronx, NY, USA 2Montefiore Medical Center/Albert Einstein College of Medicine,Department Of Epidemiology And Population Health,Bronx, NY, USA 3Jacobi Medical Center/ Albert Einstein College of Medicine,Internal Medicine,Bronx, NY, USA

Introduction:  Diagnosis of a gastrointestinal (GI) cancer via the emergency department (EDdx) is considered a marker of poor outcomes. Understanding patterns of health care usage of EDdx patients may illuminate targets for intervention to improve patient outcomes.

Methods:  Cancer registry and pre-diagnosis administrative data were collected for patients diagnosed with GI cancers (esophagus, stomach, pancreas, colon, rectal and anal cancers) in 2010-2014 at a single academic institution serving one of the poorest urban regions of the country. Persons with an ED visit in the month prior to cancer diagnosis were considered to have EDdx. Descriptive statistics were performed including classification of patients by patterns of healthcare utilization in the year prior to diagnosis (outpatient only, ED with or without outpatient visits (EDuser), no visits, and prior hospitalizations). Logistic regression identified predictors of EDdx. Kaplan-Meier method and Cox proportional hazards regression assessed the influence of patterns of healthcare utilization on survival for EDdx and non-EDdx patients.

Results: Of 3,174 patients analyzed, 13% were EDdx patients. EDdx patients were more commonly non-white (82.5% vs. 77.8%), with non-private insurance (72.4% vs. 66%), more comorbidities (≥3: 74% vs. 67%), upper GI cancers (52% vs. 39%) and late cancer stage (56% vs. 40%). Patients with prior hospitalizations were more likely to be EDdx (OR 1.76, 95%CI: 1.21-2.54); however no difference in ED diagnosis rates was observed for other care patterns. EDdx was associated with improved survival for EDuser and worse survival for all other care patterns (Figure 1). Significant interaction was found between EDdx and care patterns for overall mortality (p = <0.05).  After controlling for demographics and cancer factors, EDusers had improved mortality regardless of location of diagnosis, with markedly improved outcomes when diagnosed in the ED (EDuser & non-EDdx HR 0.74 95% CI: 0.58-0.94, EDuser & EDdx HR 0.42 95% CI: 0.25-0.71) compared to patients who were outpatient only and non-EDdx. As expected, EDdx patients with no prior visits or with prior hospitalizations had the worst outcomes (no visits & EDdx HR: 1.20 95% CI 1.65-2.94, prior hospitalization & EDdx HR: 1.52 95% CI 1.11-2.06).

Conclusion: Diagnosis in the ED was not uniformly a predictor of poor outcomes. Patients in this inner city hospital who rely on routine ED healthcare experienced better than expected outcomes and the diagnosis of cancer in the ED resulted in improved outcomes for these patients. Results suggest the need to understand benefits as well as harms before implementing broad-brush policies to divert routine ED care.

 

54.03 Patient Perceptions about the Role of Spirituality and Faith During Cancer Treatment

Posted on January 31, 2019

E. N. Palmer Kelly1, B. A. Fischer3, A. E. Onuma2, K. J. Deans3, T. M. Pawlik2  1Ohio State University,Comprehensive Cancer Center,Columbus, OH, USA 2The Ohio State University Wexner Medical Center,Surgery,Columbus, OH, USA 3Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA

Introduction: The availability of spiritual/faith resources during cancer treatment may positively impact patient outcomes, feelings of wellbeing, and be important components of holistic, patient-centered care. We sought to characterize the perspectives of cancer patients on the role of spirituality and faith in order to better define the desired access to related resources during cancer care.

Methods:  The listserv ResearchMatch was utilized to survey a convenience sample of adult cancer patients electronically. Demographic data were collected and information on spirituality/faith was assessed using quantitative tools such as FACIT-SP, Meaning of Cancer Subscale (IOC), and select items from the AYA HOPE survey. The bidirectional influence between cancer and spirituality/faith, including access to related resources, were assessed using open-ended questions. Analyses included descriptive statistics and content analysis.

Results: Among the 116 respondents, cancer diagnoses included breast (n=39), prostate (n=17), thyroid (n=10), gastrointestinal (n=8), and other (n=29). Surgery was the most common treatment modality (n=77) followed by radiation (n=54) and chemotherapy (n=52).  Overall, 72% of respondents (n=100) self-identified with a religion (Christian/Protestant: n=49, 49%; Christian/Catholic: n=19, 19%; Judaism: n=8, 9% other: n=7, 7%) and 13 (13%) identified as Agnostic. Roughly one-half of patients (48%) reported that their cancer diagnosis had an impact on their spiritual/religious beliefs, noting that cancer deepened (n=19, 40%) more often than weakened (n=9, 19%) their beliefs. Participants were asked to rank-order who they would want to speak to about their spirituality/faith. Rather than a member of the healthcare team, the first preference was a family or friend (n=39, 48%), followed by hospital chaplain (n=12, 15%) or personal spiritual advisor (n=11, 13%). Content analysis identified a subset of patients who expressed a desire to have the healthcare team introduce the topic of spirituality/faith (n=13, 20%); however, more patients did not see this as part of the healthcare team’s role (n=24, 38%).  Rather, participant responses suggested that utilized spirituality/faith resources were mostly personal (e.g., their pastor, family, books; n=17; 37%) rather than a resource provided by the medical center (e.g., chaplaincy; n=7, 16%).

Conclusion:Spirituality/faith can be an important need for some cancer patients as one-half of respondents expressed a relationship between the cancer diagnosis and their spiritual/religious beliefs. However, most patients desired to talk about spirituality/faith with a family or friend instead of a member of the healthcare team. These data can help inform future research aimed at addressing patient-centered spirituality/faith needs of cancer patients.

 

54.02 Patient Preferences on the Use of Technology in Cancer Surveillance After Curative-Intent Surgery

Posted on January 31, 2019

A. Onuma2, E. Palmer2, J. Chakedis2, B. Wiemann2, M. Johnson2, K. Merath2, O. Akgul2, J. Cloyd2, T. Pawlik2  2The Ohio State University Medical Center,Department of Surgery,Columbus, OHIO, USA

Introduction:  Advances in communication technology have enabled new methods of delivering test results to patients. Nevertheless, patient preferences regarding the manner in which surveillance test results are shared with cancer patients during the survivorship period have not been previously assessed.

Methods:  A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication vs. phone-call or office visit) to receive surveillance test results was undertaken.

Results:Among 241 respondents over a 6-month period, the average age was 68.4±13.6 years and 61.8% were female. The most common malignancies included breast (22.8%), melanoma/sarcoma (29.5%), gastrointestinal (22.0%) and thyroid (25.7%). Patients were surveyed on average 33.6±31.5 months following surgery. While patients expressed a relative preference to receive normal surveillance results via MyChart/Secure-email, the majority of patients preferred that abnormal imaging (56.2%) or blood (50.4%) results be communicated only by in-office appointments regardless of age or cancer type. Patients with a college degree were more likely to prefer receiving normal imaging (52.7% vs 38.1%, p=0.029) and blood (69.6% vs 48.9%, p=0.002) results electronically than those without a degree. Patients < 65 more often preferred to receive normal blood surveillance results electronically versus patients ≥65 years old (50.0% vs. 32.9%, p=.012). Preference also varied according to malignancy type (Figure1).

Conclusion: While many patients preferred to receive “normal” surveillance results via MyChart/secure-email, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.

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