49.10 Evaluation of Baseline Bowel Function in Patients Considering Surgery for Diverticular Disease

Posted on January 31, 2019

R. V. Lyn1, J. L. Goldwag2,3, S. J. Ivatury2,3  1Dartmouth College,Hanover, NH, USA 2Dartmouth Hitchcock Medical Center,Lebanon, NH, USA 3Geisel School of Medicine,Lebanon, NH, USA

Introduction:
Diverticular disease is common and many patients are sent for operative consideration. The aim of this study is to evaluate baseline bowel function for patients considering sigmoid colectomy for diverticular disease. 

Methods:
This is an observational study. We have collected bowel function patient reported outcomes using the Colorectal Functional Outcome Questionnaire (COREFO) questionnaire during each outpatient visit in our clinic. The COREFO is a validated bowel function questionnaire that assesses bowel function in five domains and a Total COREFO score. The scores range from 0 to 100, with a higher score indicating a poorer function. A score greater than 15 is considered symptomatic. We included all patients who were seen for diverticular disease, were considering surgery, and completed a COREFO questionnaire at their initial visit from May 2015 to July 2018. We excluded those that already had a sigmoid resection or those that did not complete their questionnaire. We evaluated the average scores of each domain and the Total COREFO score at baseline.

Results:
88 patients met criteria for inclusion in this study. The mean age was 57±11 years with 67% women. The median number of reported episodes of diverticulitis prior to the baseline visit was 4 (IQR: 2-5). The mean baseline scores for the domains and Total COREFO score are shown in Figure 1. The social impact, stool-related aspects, and need for medication domains were within the symptomatic range at baseline while the frequency and incontinence domains were in the asymptomatic range. The mean Total COREFO score at baseline was also in the symptomatic range. 

Conclusion:
Patients considering elective surgery for diverticular disease present with significant bowel dysfunction at baseline. Surgeons should be aware that this dysfunction lies primarily in the effect of bowel movements on a patient’s lifestyle (social impact), pain and bleeding with bowel movements (stool-related aspects), and the use of medication and foods to improve bowel movements (need for medication). 
 

49.09 Minimally Invasive Abdominoperineal Resection for Rectal Cancer: Does the Approach Matter?

Posted on January 31, 2019

D. T. Thompson1, P. Goffredo1, A. F. Utria1, I. Gribovskaja-Rupp1, J. Hrabe1, M. R. Kapadia1, I. Hassan1  1University Of Iowa,Iowa City, IA, USA

Introduction:
Laparoscopic and robotic platforms are commonly utilized minimally invasive approaches to perform abdominoperineal resections (APR) for rectal cancer (RC). There is however limited empiric evidence regarding the comparative effectiveness of these techniques with or without open assistance (OA). We hypothesized that in selected patients, differing minimally invasive approaches would not impact short-term outcomes. We therefore analyzed characteristics and perioperative outcomes of patients undergoing laparoscopic and robotic APR with or without OA for RC using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database Proctectomy Targeted Participant Use File (PUF).

Methods:
CPT code 45395 was used to identify patients from the 2016 ACS-NSQIP Proctectomy PUF database. Patients were analyzed if based on NSQIP definitions they underwent elective laparoscopic, robotic, laparoscopic with OA, or robotic with OA APR for RC. Patient disease and treatment characteristics, operation time (OT), length of stay (LOS), and perioperative clinical outcomes along with lymph node harvest (LNH) and circumferential margin (CRM) status were compared. Analyses were performed using chi-square tests, Fisher’s Exact tests, Student’s t-tests, Mann-Whitney U tests, and one-way ANOVA.

Results:
We identified 412 patients of which 128 (31%) were laparoscopic, 116 (28%) robotic, 107 (26%) laparoscopic with OA, and 61 (15%) robotic with OA. The characteristics of the cohort were as follows: mean age 65±13 years, 65% males, median BMI 28 kg/m2 (range 16-53), ASA ≥ 3 60%, neoadjuvant therapy 66%, locally advanced cancer 64%, and distal third of rectum tumor location 70%. There were no significant differences across the four groups for these variables (all p>0.05). Two-thirds of patients did not have complications and there were no reported mortalities. Short-term perioperative and measured oncologic outcomes were similar between groups (Table 1). A comparison of laparoscopic and robotic vs. OA approaches did not show a significant difference in LOS (median 6 vs. 6 days), OT (300 vs. 290 minutes), CRM (9% vs. 7% positive), LNH (16 vs. 16 nodes), or Clavien-Dindo grade ≥ 3 complications (7% vs. 7% positive) (all p>0.05).

Conclusion:
Patients undergoing laparoscopic or robotic APR are well selected and experience similar short-term clinical and oncologic outcomes regardless of minimally invasive technique. Further investigation into long term results is essential. Ultimately, surgeon preference and experience as well as system resources likely dictate which approach to utilize for APR in patients with rectal cancer.
 

49.08 Prevalence of Surgically Complex Diverticulitis in Young Hispanic Males in 2016

Posted on January 31, 2019

T. Gaglani1, C. H. Davis2, E. P. Askenasy1, M. V. Cusick1,2  1The University of Texas Health Science Center at Houston,Department Of Surgery,Houston, TEXAS, USA 2Houston Methodist Hospital,Department Of Surgery,Houston, TEXAS, USA

Introduction: The prevalence of diverticular disease has been increasing over the last 25 years in western society. While diverticulitis was traditionally viewed as a disease of older individuals, the incidence in patients ages 18 to 44 has increased by 82 percent over the last 20 years. Additionally, it has been observed that young Hispanic men are more likely to have severe diverticular disease. This study aims to ascertain a demographic correlation between age and ethnicity with severity of diverticular disease and required surgical intervention.

Methods:  Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients with primary diagnosis of diverticulitis undergoing surgical intervention in 2016 were identified. Severity of disease (as determined by ICD 10 code) and extent of intervention (as determined by CPT code) were then compared between Hispanic and non-Hispanic patients focusing on comparing young (age<50) Hispanic males to young non-Hispanic males using Fisher’s exact test.

Results: A total of 11,045 operations were performed on patients diagnosed with diverticulitis. Of these cases, 731(6.6%) were performed in Hispanic patients. The mean ages of the Hispanic and non-Hispanic patients were 52.7 and 59.4 years, respectively. Of all 5,010 male patients requiring surgery for diverticulitis, Hispanics were almost twice as likely than non-Hispanics to present at age <50 (53.1% vs. 30.4%, p<0.001). More young Hispanic males had perforated diverticulitis (143/310) compared to non-Hispanic males (844/2205), 46.1% vs. 38.3%, respectively (p=0.009). In terms of more invasive procedures, 42.6% of young Hispanic males underwent open operations vs. 33.8% of young non-Hispanic males (p=0.007; male and female combined, 39.7% vs 33.0%, respectively, p=0.021). More young Hispanics required a stay of 7 or more hospital days than young non-Hispanics (31.2% vs. 25.1%, respectively, p=0.015).

Conclusion: These data indicate that diverticular disease often presents at an earlier age in the Hispanic population. Further, young Hispanic males had nearly double the rate of surgical intervention for diverticulitis. Additionally young Hispanic males had significantly longer length of stay suggesting a higher level of complexity. Further studies are needed to assess differences in operative technique and outcome. This study is limited as it only considered operative diverticulitis patients and not those managed non-operatively.
 

49.07 Quantitative Computed Tomography Image Analysis of Lateral Pelvic Lymph Node Status in Rectal Cancer

Posted on January 31, 2019

A. Usui1, K. Okita1, T. Nishidate1, K. Okuya1, E. Akizuki1, M. Ishii1, T. Satoyoshi1, I. Takemasa1  1Sapporo Medical University Hospital,Sapporo, Hokkaido, Japan

Introduction:
Lateral pelvic lymph node (LPLN) dissection in advanced lower advanced rectal cancer remains a subject of debate, and in order to justify this procedure, a reliable method of nodal characterization to assess preoperative nodal status is essential. Computed tomography (CT) of the pelvis is utilized to determine preoperative lymph node metastasis in rectal cancer, and morphological and internal structure of lymph nodes report to be promising factors. In this study, quantitative analysis of morphological and internal structure of LPLN in lower rectal cancer patients was performed to clarify the diagnostic value of these parameters in terms of metastasis.

Methods:
Data were retrospectively collected for 41 patients who had undergone total mesenteric excision with LPLN dissection for lower advanced rectal cancer from 2007 to 2014 at our institution. None of the patients had any treatment prior to surgery. All patients underwent preoperative enhanced CT. A single LPLN largest in short axis diameter was selected on the enhanced phase CT image for each patient, and the region of interest was manually drawn along the margin of the node. The number of voxels was calculated to determine the size of the lymph node and the mean signal intensity was recorded for the enhancement quality. Internal heterogeneity was quantified using kurtosis, skewness, and standard deviation of the pixel distribution histogram. All factors were compared between LPLN with and without metastasis pathologically proven with surgery.

Results:
An average of 16.9 LPLN was identified histopathologically for each patient (range: 2 to 39). Of the 41 patients, the LPLN detected on CT in 9 patients were too small for quantitative evaluation. Nine patients were histologically positive for LPLN metastasis. Compared to those without metastasis, the LPLN in these patients had a significantly increased number of voxels and significantly low mean signal intensity. Regarding heterogeneity, skewness was significantly higher and standard deviation was significantly lower in positive LPLN status. No significant difference was observed in kurtosis.

Conclusion:
LPLN with pathologically proven metastasis are presented on enhanced CT as larger in size, less enhanced, and CT enhancement was less heterogenous, compared to non-metastatic lymph nodes. Quantitative analysis with enhance CT using number of voxels, mean signal intensity, skewness, and standard deviation of the pixel distribution histogram are promising for discriminating metastatic lateral pelvic lymph nodes in lower rectal cancer.
 

49.06 Impact of Hospital Volume on Outcomes of Robotic versus Laparoscopic Resection for Rectal Cancer

Posted on January 31, 2019

N. Kim1, S. W. De Geus2, A. D. Geary2, S. Ng2, J. F. Hall1, J. F. Tseng2, U. Phatak1  1Boston Medical Center,Department Of Colorectal Surgery,Boston, MA, USA 2Boston Medical Center,Department Of General Surgery,Boston, MA, USA

Introduction: Robotic surgery for colorectal disease is rapidly gaining popularity. However, the impact of hospital volume on the outcomes of robotic surgery (RS) versus laparoscopic surgery (LS) remains unclear. This study investigates from the National Cancer Database whether hospital volume is a factor in determining the short- and long-term outcomes of RS versus LS for rectal cancer.

 

Methods:  Patients with stage I-III rectal cancer who underwent RS or LS between 2011 and 2014 were identified from the National Cancer Database. Institutions were defined as being either low-volume hospitals (LVH: 15 operations/year) or high-volume hospitals (HVH> 15 operations/year). Propensity-scores for the probability of undergoing RS were created within each volume group. Patients were matched based on propensity-score. Within each group, conversion rates, positive margin rates, readmission rates, 30-day and 90-day mortality, length of stay, number of lymph nodes dissected and overall survival were compared between patients who had RS vs LS. Survival analysis was performed using the Kaplan-Meier method.

Results: 8,235 patients underwent minimal invasive surgery for rectal cancer. Overall, 28.8% (n=2,374) of resections were performed robotically. Rectal cancer surgery at a HVH was associated with lower positive resection margins (5.0% vs. 6.3%; p=0.0080), lower rates of conversion to open (11.2% vs. 15.7%; p<0.0001), and 90-day (1.7% vs. 2.7%; p=0.0009) mortality. After matching, conversion rates were significantly lower after RS compared to LS (LVH: 10.1% vs. 18.8%; p<0.0001; HVH: 6.3 vs. 13.4; p<0.0001). There following factors were not significant for patients that received either RS or LS; positive margins rates (LVH: 5.5% vs. 6.9%; p=0.2014; HVH: 5.1% vs. 4.8%; p=0.7211), number of lymph nodes resected (LVH: 14 vs. 15 nodes; p=0.4129; HVH: 16 vs. 16 nodes; p=0.5739), median length of stay (LVH: 5 vs. 5 months; p=0.1324; HVH: 5 vs. 5 months; p=0.1324), readmission (LVH: 9.3% vs. 7.3%; p=0.0936; HVH: 8.9% vs. 8.9%; p=0.9460), 90-day mortality (LVH: 2.3% vs. 2.7%; p=0.5742; HVH: 1.2% vs. 1.9%; p=0.1567) and overall 3 year survival (LVH: 86.9% vs. 86.7%; log-rank p=9148; HVH: 88.6% vs. 88.6%; log-rank p=0.5114).

Conclusion: Although outcomes after major operations are influenced by various factors beyond hospital volume alone, the results of this study suggest that patients with rectal cancer are at higher risk of having positive resection margins, higher rates of conversion to open and 90-day mortality if they are treated at LVH as opposed to at HVH.  However, for both high- and low-volume hospitals, robotic resections of rectal cancer were associated with surgical and oncologic outcomes that were similar to those for laparoscopic operations. Although residual selection bias regarding RS vs LS must be acknowledged, our data suggest that robotic colorectal resections when feasible is a reasonable approach across hospital volume strata.

49.05 Risk Factors Associated with Recurrence Following Treatment for Stage ? Colon Cancer.

Posted on January 31, 2019

A. Obana1, K. Okada1, K. Kitamura1, T. Matsumura1, T. Suwa1, K. Karikomi1, M. Koyama1,2  1Kashiwa Kosei General Hospital,General Surgery,Kashiwa, CHIBA, Japan 2Hirosaki University for Cancer of The Colon and Rectum,Hirosaki, AOMORI, Japan

Introduction:

It is reported that the prognosis and response to chemotherapy for unresectable recurrent colon cancer are different according to the primary tumor location. This appears to be related to pathological and genetic aspects, which may have ramifications for both cancer surveillance and the adjuvant chemotherapy plan. We analyzed and compared the risk factors for recurrence of colon cancer classified as stage ?  between the right and left colon. 

Methods:

We reviewed 214 patients with stage ? colon cancer (including rectosigmoid) in multiple facilities from 1994 to 1997, 1999 to 2003, and performed histopathological evaluation retrospectively. All patients were classified by the primary tumor location, and the risk factors for recurrence were analyzed from clinical pathological aspects, including tumor depth, histology, lymph node metastasis, vascular invasion(ly,v), budding, extramural cancer deposition(EX), perineural invasion(PN), the number of dissected lymph nodes, and use of postoperative chemotherapy, as well as postoperative outcomes (recurrence rate, recurrence free survival rate). Chi-square test was used for univariate analysis, and multiple logistic regression analysis for multivariate analysis.

Results:
The 5 year disease-free survival rate (5Y DFS) was 66.1% for the right side of colon, and 66.7% for the left side. Multivariate analysis of right colon cancer cases showed that three independent factors associated with an increase in recurrence rate were tumor depth (T3:20.7%,T4:46.4%, P=0.010), lymph node metastasis (N1:25.7%,N2-3:51.4%,P=0.043), and perineural invasion (PN0:25.8%,PN1:46.5%,P=0.037). On the other hand, for the left colon, four independent factors associated with an increase in recurrence rate were tumor depth (T3:21.2%,T4:53.8%, P=0.021), lymph node metastasis (N1:22.5%,N2-3:55.9%,P=0.032), extramural cancer invasion (EX-:17.5%,EX+:52.1%, P=0.003), and histology (well-differentiated type:29.5%?other types:70.0%, P=0.008).

Conclusion:
Among patients with stage ? colon cancer, those with T4 and/or N2-3 have high recurrence rates after surgery. In addition, when the primary tumor is located on right side, patients with PN1 should be followed up carefully to detect early recurrence. On the other hand, when the primary tumor is located on left side, patients with EX+, mucinous carcinoma, or low differentiated adenocarcinoma should also undergo close follow-up.

49.04 Two-stage Complete Fistulotomy Approach for Horseshoe Fistula does not Affect Continence

Posted on January 31, 2019

A. Usui1, Y. Ishiyama1, A. Nishio1, M. Kawamura1, Y. Kono1, G. Ishiyama1  1Sapporo Ishiyama Hospital,Sapporo, HOKKAIDO, Japan

Introduction: Horseshoe fistulas are deep posterior anal fistulas which extend into the ischiorectal space in the shape of a horseshoe, involving muscle structure associated with continence. Surgical management is challenging due to its complex configuration and sphincter involvement. Failures in surgery for horseshoe fistulas often are attributed to insufficient drainage of the fistula or unsuccessful eradication of the fistula. These issues can be resolved with complete fistulotomy, which has been discredited for its high rate of incontinence, but recent studies have shown severance of the superficial external sphincter does not affect continence. We have chosen complete fistulotomy as the initial procedure of choice for horseshoe fistulas and divided the procedure in two stages to avoid impairment of sphincter function.

Methods: A retrospective review of 139 patients who underwent surgery for horseshoe fistula using this method between 2014 and 2017 was conducted. Incisions for the initial surgery were placed along the extended fistula arms so that the lateral tracts of the horseshoe were deroofed. The large open wound allowed a wider view enabling the eradication of fistula walls with a direct vision of the sepsis origin, as well as easier drainage. A loose seton was placed in the primary tract through the fistula origin which was laid open in the second surgery after the lateral wound was partially healed.

Results:

Fistula tracts extended into the supralevator space in 14 of the patients. An upward intersphincteric extension to the submucosa of the rectum was observed in 15. Twenty-one patients (15.1%) had undergone previous surgery intended to cure a lower anal fistula, implying the difficulty in accurate diagnosis for deep posterior anal fistulas.

All patients were followed up for a median of 22 months (range 3-53) and recurrence was observed in 12. In all but 1 patient, recurrence occurred as a superficial residual infection with the sepsis origin cured. Recurrence rate was 5.41% in those with tracts extending only to the ischiorectal fossa. Those with fistula extending higher intersphincterically had a significantly higher recurrence rate. Furthermore, patients who resided further than 50km from the hospital and could not visit the outpatient clinic frequently also had a significantly higher recurrence rate, indicating wound observation for premature closure is crucial in preventing recurrence. In regard to anal sphincter function, no patient had any continence issues including minor problems at the end of the follow up period.

Conclusion:Managing horseshoe fistula with the two-stage complete fistulotomy approach allows for complete eradication of the fistula tract without compromising anal sphincter function.
 

49.03 Impact of Primary Tumor Resection in Colorectal Cancer with Unresectable Metastasis

Posted on January 31, 2019

N. Ichikawa1, S. Homma1, T. Yoshida1, F. Kawamata1, T. Mitsuhashi2, H. Iijima3, S. Shibasaki1, H. Kawamura1, K. Ogasawara4, K. Kazui5, Y. Kamiizumi6, A. Taketomi1  1Hokkaido University,Department Of Gastroenterological Surgery 1,Sapporo, HOKKAIDO, Japan 2Hokkaido University Hospital,Department Of Surgical Pathology,Sapporo, HOKKAIDO, Japan 3Hokkaido University Hospital,Clinical Research And Medical Innovation Center,Sapporo, HOKKAIDO, Japan 4Kushiro Rosai Hospital, Japan Labour Health and Welfare Organization,Department Of Surgery,Kushiro, HOKKAIDO, Japan 5Hokkaido Hospital, Japan Community Healthcare Organization,Department Of Surgery,Sapporo, HOKKAIDO, Japan 6Iwamizawa Municipal Hospital,Department Of Surgery,Iwamizawa, HOKKAIDO, Japan

Introduction: The prognostic benefit of primary tumor resection in colorectal cancer patients with unresectable distant metastasis remains unclear. We aimed to assess whether palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is associated with improved survival.

Methods: The survival period of 123 colorectal cancer patients diagnosed from January 2010 to December 2015 in 4 Japanese hospitals was analyzed. Sixty-four patients with and 59 without primary tumor resection were compared, retrospectively. In the patients with primary tumor resection, the survival period of 39 patients with lymphocyte:monocyte ratio (LMR) increase after primary tumor resection (LMR-increase) and 25 patients with LMR decrease (LMR-decrease) was also compared.

Results: Eighty nine colon cancer and 34 rectal cancer patients were eligible for the analysis. The mean age was 63 years old and male to female ratio was 63: 60. In the resection group, more patients were accompanied by non-differentiated adenocarcinoma (36% vs 15%, p <0.01), obstructive symptom (80% vs 51%, p <0.01), high serum albumen (3.8 vs 3.6 mg/dL, p =0.02) and no lymph node metastasis (20% vs 2%, p <0.01) than the non-resection group. The patients who underwent primary tumor palliative resection had prolonged median survival compared with patients never resected (24.5 vs 14.5 months, p =0.01). Multivariate analysis identified possible independent prognostic variables as the pathology containing non-differentiated adenocarcinoma (Hazard Ratio, 3.7), non-resection of primary lesion (2.7), and no use of irinotecan (2.6). Moreover, in the patients with primary tumor resection, the median survival times of the LMR-increase and LMR-decrease groups were 27.3 and 20.8 months, respectively (p =0.02, Figure). The preoperative lymphocyte population and LMR in peripheral blood of the LMR-increase group were significantly less than those of LMR-decrease group. There were no differences in any other patient characteristics and the extent of metastases between the 2 groups. When assessed the resected specimen in available cases, there were more CD163+ and CD8+ cells invaded into tumor stroma, significantly. (n=5)

Conclusion: Palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is possibly associated with improved survival, especially in the case with lymphocyte:monocyte ratio  increase after primary tumor resection.

 

49.02 Chasing Zero Cuff: Robotic Distal Dissection Superior to Laparoscopy in Ileal Pouch Anal Anastomosis

Posted on January 31, 2019

A. W. Elias1, R. G. Landmann2  1Mayo Clinic – Florida,General Surgery,Jacksonville, FL, USA 2MD Anderson Cancer Center, Baptist Health,Colon & Rectal Surgery,Jacksonville, FL, USA

Introduction: Improved rectal dissection allows more distal transection and minimization of the rectal cuff during pouch procedures. Data is limited comparing robotic versus laparoscopic ileal J pouch-anal anastomosis (IPAA) procedures. Herein, we sought to compare robotic versus laparoscopic ileal pouch-anal anastomosis outcomes.

Methods: A prospectively maintained database was utilized to perform a retrospective matched cohort study. 44 consecutive patients who underwent ileal pouch-anal anastomosis between 2008-2017 at a US tertiary care hospital via robotic approach were matched to 72 laparoscopic controls by surgeon, age, gender, BMI, comorbidities, and operative history. Distal extent of dissection, intraoperative, and postoperative outcomes were analyzed.

Results: 116 patients (58% male) with median age 37.8 years [range 1716-68], BMI 24.5 [range 16.1-40.7], ASA score II [range I-III] underwent restorative ileal pouch-anal anastomosis (44 robotic, 72 laparoscopic), predominantly (90%) for ulcerative colitis. Distal extent of dissection (distance from dentate line) was significantly improved robotically (0 versus 1.3cm) (p<0.001). There were no significant differences in blood loss, complications, number of bowel movements at 30-days, 1 and 2 years, or use of pre-operative immunomodulators, steroids, ASA-derivatives, or TPN; however, more robotic patients utilized biologics (p = 0.007). Robotic procedure length was 20 minutes longer. Robotic median time to diet resumption was shorter (1 versus 2 days) (p<0.001). Despite equal medians, robotic admission length (4 days) and time until ostomy function (1 day) was significantly shorter (p = 0.02 and p=0.005, respectively). There were no reoperations or mortalities.

Conclusion: Robotic surgery enables superior total mesorectal excision and distal transection with elimination of the at-risk rectal cuff with improved postoperative outcomes in patients undergoing IPAA for ulcerative colitis and familial adenomatous polyposis. This technique can be applied to inflammatory and oncologic operations to improve negative margin rates and improve rates of sphincter preservation/intestinal continuity.

 

49.01 Robotic Natural orifice IntraCorporeal anastomosis and transrectal Extraction (NICE) procedure

Posted on January 31, 2019

R. O. Minjares-Granillo1, B. Dimas1, J. P. LeFave1,2, E. M. Haas1,2  1University of Texas Medical School at Houston,Department Of Surgery, Division Of Minimally Invasive Colon And Rectal Surgery,Houston, TEXAS, USA 2Houston Methodist Hospital,Division Of Colon And Rectal Surgery,Houston, TEXAS, USA

Introduction: Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures however technical challenges have limited this approach following conventional laparoscopic surgery.

The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided intracorporeal anastomosis, however, there are no reports involving more complex left-sided procedures such as for diverticulitis. Furthermore, there are no reports of natural orifice assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed thereby completely eliminating the need for an abdominal wall incision other than the port sites. 

We present a pilot study to investigate the safety, feasibility and short term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure.

Methods:  Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database.  All patients underwent the robotic NICE procedure.  Demographic data, intraoperative data and outcomes data were assessed and analyzed.  

Results: Ten patients (5 male and 5 female) underwent resection. The mean age, ASA and BMI was 56 (range 43-66), II (I-III) and 29 (21-35).  All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA.  The mean operative time was 198 min (146–338) and mean EBL was 35 ml (15 –50). Mean time to first flatus was 16 hours (10-22) and mean length of stay was 1.9 days (1.6 – 2.6).  There were no intraoperative or post-operative complications.  There were no unexpected ICU stay, reoperation or readmission. 

Conclusion:  Colorectal left-sided resections such as for diverticulitis can be safely accomplished using natural-orifice assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study.  The NICE procedure resulted in early return of bowel function, short length of stay and low complications. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

29.10 Insurance Coverage Trends for Breast Surgery in Cisgender Women, Cisgender Men, and Transgender Men

Posted on January 31, 2019

A. Almazan2, E. Boskey1, O. Ganor1  1Boston Children’s Hospital,Plastic And Oral Surgery,Boston, MA, USA 2Harvard Medical School,Boston, MA, USA

Introduction:  The criteria used to judge the medical necessity of a surgery can vary substantially between insurance providers and related procedures. Despite procedural similarities, insurance policies enforce different requirements for reimbursement of reduction mammoplasty (RM) in cisgender women, gynecomastia excision (GE) in cisgender men, and gender-affirming mastectomy (GAM) in transgender men. In this study, we examine how analogous procedures may be treated differently for patients of different genders, and we identify differences in coverage policies across insurance providers.

Methods: For each procedure, we examined the medical necessity criteria from the websites of the 9 largest national insurance networks that have national coverage guidelines, the 6 federal plans available through the Federal Employees Health Benefits plan, and 5 state plans for a large national network with state-based coverage policies. Plan policies were reviewed to determine coverage and identify standard medical necessity criteria for each procedure. For each plan, we recorded whether each procedure was covered and whether each medical necessity criterion was adopted.

Results: Coverage was highly variable between procedures. None of the plans excluded RM from coverage. 2 national networks, 2 federal plans, and 2 state plans excluded GE. 2 federal plans excluded GAM. Minimum age was the medical necessity criterion with the most variability between procedures. 5 of the 14 policies that cover GE explicitly required patients to be over the age of majority, compared to 10/20 RM policies and 16/18 GAM policies. GAM was the procedure with the most variable criteria between policies, with 10 different combinations of 5 criteria observed.

Conclusion: Insurance coverage and restrictiveness of medical necessity criteria for breast tissue removal are highly variable. Coverage for GE is fairly limited, and coverage exclusions for GAM exist despite the passage of transgender-specific insurance non-discrimination laws. Medical necessity criteria for RM and GE are somewhat inconsistent across insurers. Criteria for GAM are even more variable, despite the existence of published standards of care for transgender patients. Improving the consistency of insurance coverage for breast tissue removal, and streamlining procedure guidelines, has the potential to streamline the process of care.

29.09 Postoperative Analgesia after Iliac Crest Bone Graft Harvest using Liposomal Bupivacaine

Posted on January 31, 2019

R. Patel1, M. R. Borrelli1, K. Rustad1, B. Pridgen1, A. Momeni1, H. P. Lorenz1, S. Virk1, D. C. Wan1  1Stanford University,Palo Alto, CA, USA

Introduction: Bone grafting of alveolar clefts is routinely performed using cancellous bone harvested from the iliac crest. Graft site morbidity, however, is common, with many patients experiencing early post-operative pain. Conventional intraoperative use of local anesthetics such as Marcaine is often insufficient and requires additional opioid-based medications to achieve adequate postoperative analgesia. Marketed under the name Exparel®, liposomal bupivacaine has been demonstrated to provide significant improvement in post-operative pain for patients undergoing bunionectomy or hemorrhoidectomy, and this medication may similarly provide relief of donor site pain in patients requiring bone graft harvest. In this study we assessed the efficacy of a single dose of intraoperatively administered liposomal bupivacaine in children undergoing iliac crest bone graft harvest for repair of alveolar clefts.

Methods: 10 patients undergoing iliac crest bone graft from June 2017 to October 2017 were included in the study, which was performed under IRB approval. 5 patients underwent open iliac crest bone graft harvest, with administration of 0.25% Marcaine in Gelfoam at the hip donor site. The other 5 patients underwent open iliac crest bone graft harvest with direct infiltration of 1.3% liposomal bupivacaine around the osteotomy site. Post-operative measures included: patient-reported pain score, total narcotic use (in oral morphine equivalent) during hospitalization, length of stay, postoperative steps, as measured by a Fitbit Activity Tracker, and thigh numbness.

Results: There were no significant differences in age, weight, or distribution of clefts between the two groups. Patients receiving 0.25% Marcaine were discharged on average 1.4 ± 0.55 days after surgery and patients receiving Exparel discharged on average 1.2±0.45 days after surgery. However, differences were noted in average postoperative pain scores (4.25 ±2.15 vs. 2.50 ±1.51), oral morphine equivalents administered (7.08 ± 1.05 vs. 4.82 ± 1.55), and postoperative steps (498 ± 32 vs. 786 ± 157) for patients receiving 0.25% Marcaine vs. Exparel, respectively. Of note, two patients receiving liposomal bupivacaine did report transient thigh numbness lasting three days. No other complications were noted with these patients.

Conclusion: Liposomal bupivacaine may provide reliable and long-acting post-operative analgesia which contributes to a reduction in pain scores and need for additional narcotic administration. This is also reflected in improved post-operative activity, as measured by patient steps. Importantly, there are no recommendations for pediatric dosing of Exparel, and no studies exist in the literature describing use in this patient population. Nonetheless, safe use was observed in this study, highlighting the promise of this analgesic to improve postoperative pain management in children undergoing alveolar bone grafting.

 

29.08 Shared Decision-making for Unilateral Breast Cancer Patients Choosing between CPM and UM

Posted on January 31, 2019

J. Huang1, A. Chagpar1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction:

Choosing between contralateral prophylactic mastectomy (CPM) and unilateral mastectomy (UM) is a personal decision, but the patient’s surgeon may influence this. We sought to determine how different patient-doctor communication strategies play into the decision-making process.

Methods:

Female unilateral breast cancer patients who had a mastectomy at a large academic institution were approached to participate in a survey regarding patient-physician communication and their decision between CPM and UM. Patient satisfaction with decision was measured using the 5-point Satisfaction with Decision (SWD) scale (higher = more satisfied). Non-parametric statistics were performed using SPSS version 24.

Results:

100 (91.7%) of 109 patients approached completed the survey and were included in this cohort; the median age was 49.5 years (range 29-82). 54 patients chose to undergo CPM (54%). 33 patients (33%) reported being recommended UM, 6 patients (6%) reported being recommended CPM, and 61 patients (61%) reported that their doctors employed shared decision-making (SDM), i.e., made no strong recommendation either way. The majority of patients who stated their doctors recommended UM chose UM (78.8%); similarly, 83.3% of those who stated their doctors recommended CPM chose CPM. Of the 39 patients whose doctors recommended a surgery, 8 patients (20.5%) did not follow their doctor’s advice. These patients were equally as satisfied with their decision as those who did follow their doctor’s advice (p=0.441). Compared to patients that followed their doctor’s advice, patients who did not tended to use a 2nd physician’s opinion (38.7% vs. 0%, p=0.042) as well as photos of cosmetic results (37% vs. 6.5%, p=0.049) in their decision-making process. There was no difference in age, race, education, insurance type, or income between patients who followed their doctor’s advice versus those who did not (p>0.05). Patients who reported engaging in SDM tended to choose CPM (68.3% vs. 30.8%, p<0.001). The mean SWD score of the entire cohort was 4.80 out of 5.00 (range 3.17-5.00). Patients who did not engage in SDM were similarly satisfied with their decision as those who did engage in SDM (mean SWD score 4.77 vs. 4.83, p=0.286). In terms of patient reported preferences for patient-physician communication, 12 patients (12%) preferred the doctor to provide a recommendation, 7 (7%) preferred to make the decision on their own, and 81 (81%) preferred to engage in SDM. Race, education, insurance type, income, and age did not differ between types of preferred communication strategies (p>0.05).

Conclusion:

When the physician provides an initial recommendation between UM and CPM, patients tend to follow it, while patients who engaged in SDM tend to choose CPM. While most patients state that they prefer to have physicians engage in SDM, patients were equally as satisfied with their surgical decision whether they engaged in SDM or not.

29.07 Increased APOBEC3C-H Gene Expression is Associated with Improved Outcome in Breast Cancer

Posted on January 31, 2019

M. Asaoka1,2, S. K. Patnaik1, A. L. Butash1, E. Katsuta1, T. Ishikawa2, K. Takabe1,2  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA 2Tokyo Medical University,Department Of Breast Surgery And Oncology,Shinjuku, Tokyo, Japan

Introduction:

APOBEC enzymes are known as strong mutagenic factors, particularly in breast cancer. APOBEC3B (A3B) gene expression is significantly increased in breast cancer and associated with tumor mutation load and intra-tumor heterogeneity. The relevance of the other APOBEC3s (A3A, C-H) is not yet clear in breast cancer. Therefore, we analyzed these genes, looking at their association with survival, mutations, and immune activity.

Methods:

We collected gene expression data for primary tumors (1091) and adjacent normal tissues (113) from The Cancer Genome Atlas (TCGA). Patients were divided into 3 equal groups by gene expression to compare high and low expressors. Tumor immune features like cytolytic activity and T cell receptor (TCR) diversity were quantified from gene expression data. Data for some of these features, mutation-related aspects, and survival were obtained from TCGA publications. Gene expression data for 55 breast cancer cell-lines was from Cancer Cell Line Encyclopedia. Cox regression and Spearman methods were used for survival and correlation analyses, resp. Welch t test was used for group comparison, with P <0.05 deemed significant. Hallmark gene-sets were used for enrichment analysis.

Results:

A3B and A3C represented 91% of A3 gene expression in breast cancer cell-lines. In patients, expression of A3B was higher in tumors compared to normal tissue (4.5x), while that of A3C was lower (0.5x). A3B or A3A levels had no effect on overall (OS) or disease-specific survival (DSS). But, higher expression for each of A3C-H was significantly associated with improved OS (HR, 0.45-0.66) or DSS (0.43-0.61). The prognostic value of high A3C-H expression was validated in two gene expression meta-datasets (KMPlot and SurvExpress). A3A and A3B expression levels correlated with both tumor mutation burden and neoantigen load (ρ = 0.28-0.34), which resp. were 2.0-2.9x more in high expressors. There was no association of tumor mutation burden or neoantigen load with A3C-H. A3C-H expression levels correlated positively with both total immune cell and lymphocyte populations in tumor (ρ = 0.29-0.70 & 0.20-0.50, resp.), whereas the correlations were poor for A3B (0.10 & -0.01, resp.). Expression of genes related to immune function like interferon response and complement activation was enriched in high A3C-H expressors, which also had significantly more CD4 and CD8 T cells, and TCR diversity (2.3-4.0x, 2.1-5.4x & 1.3-2.1x, resp.). Concordantly, for each of A3C-H, expression correlated with tumor immune cytolytic activity (ρ = 0.31-0.79), which was increased 3.1-7.9x in high expressors.

Conclusion:

APOBEC3s are DNA mutators. However, unlike A3B, whose expression is associated with poor survival, increased expression of A3C-H confers a survival benefit. Further studies are warranted to explore if the increased A3C-H expression reflects a heightened anti-cancer immune response, and if A3C-H can be used as prognostic biomarkers.

29.06 Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcomes and Delineation of Risk Factors

Posted on January 31, 2019

K. P. Nealon1, R. E. Weitzman1, N. Sobti1, A. S. Colwell1, W. G. Austen1, E. C. Liao1  1Massachusetts General Hospital,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Breast cancer is among the most common cancers diagnosed in women, affecting 1 in 8 women per year. Immediate implant-based breast reconstruction is the leading technique for post-mastectomy reconstruction, trending toward direct to implant (DTI) as the preferred method when compared to the traditional tissue expander method. Although implants are generally placed beneath the pectoralis major muscle, recent developments have allowed for implant placement above the muscle in a pre-pectoral plane. This study compares the safety endpoints and risk factors in prepectoral vs. subpectoral DTI breast reconstruction cohorts. We hypothesize that prepectoral DTI breast reconstruction is a safe alternative to subpectoral DTI breast reconstruction.

Methods:  Retrospective chart review at a tertiary academic medical institution identified 107 patients who underwent prepectoral DTI reconstruction and 158 patients who underwent subpectoral DTI reconstruction. Univariate analysis was performed to compare patient characteristics between both cohorts. A penalized logistic regression identified relationships between postoperative complications and covariate variables in each group.

Results: A binomial regression model revealed that prepectoral DTI breast reconstruction is associated with lower risk of surgical site infection (p = 0.011) and lower risk of revision (p = 0.015) when compared to subpectoral DTI breast reconstruction. Prepectoral DTI breast reconstruction is also associated with lower risk of capsular contracture, trending towards significance (p = 0.064). Rates of overall complication, explant, skin necrosis and hematoma were comparable between groups.

Conclusion: This study compares the safety outcomes and risk factors in prepectoral versus subpectoral DTI breast reconstruction cases. Prepectoral DTI breast reconstruction is associated with lower rates of surgical site infection, revision, and capsular contracture. It is speculated that the significant difference in surgical site infection may be due to decreased procedure time of the prepectoral procedure, or less dissection and devascularization of the soft tissue surrounding the implant. Fewer overall complications in the prepectoral group also resulted in a decreased number of revisions. Due to lack of manipulation of the pectoralis major muscle, prepectoral implant placement reported decreased rates of capsular contracture. These results demonstrate that prepectoral DTI reconstruction is a safe alternative when compared to subpectoral DTI reconstruction. 

 

29.05 Non-Discrimination Laws and Medical Necessity Criteria for Gender Affirmation Surgery

Posted on January 31, 2019

A. Almazan1, O. Ganor1, E. Boskey2  1Harvard Medical School,Boston, MA, USA 2Boston Children’s Hospital,Department Of Plastic And Oral Surgery,Boston, MA, USA

Introduction:  A recent movement to pass state-based non-discrimination laws has led to mandatory coverage for gender-affirming surgical care in many private insurance plans. However, it is unclear whether these laws have improved access to treatment for transgender patients. While more plans may cover gender affirmation surgery, restrictive medical necessity criteria used by insurers to decide reimbursement can still delay treatment or preclude access to surgery for many patients. In this study, we examine how coverage and medical necessity criteria for gender affirmation surgeries vary between states that do and do not have laws protecting coverage of gender-affirming medical care in private insurance.

 

Methods: Medical coverage guidelines for surgical treatment of gender dysphoria were taken from the websites of the largest insurer in each state by market share.

Expansiveness of coverage for each insurer was assessed by examining whether each plan offered any of the following procedures: FTM phalloplasty, MTF vaginoplasty, FTM mastectomy, MTF augmentation mammoplasty, electrolysis, and laryngoplasty.

Restrictiveness of medical necessity criteria was assessed by examining whether each plan mandated any of the following prerequisites for gender affirmation chest surgeries: proof of social transition, documentation of hormone therapy for FTM mastectomy and MTF augmentation mammoplasty, documentation of legal name change, and proof of employment/schooling/community involvement.

Each state was labeled according to whether it had a law protecting insurance coverage of gender affirmation surgery. The number of covered procedures and number of chest surgery prerequisites were compared between states that did and did not have transition-related protections.

 

Results: The mean number of procedures covered in states with legal protections is 4.81, compared to 3.92 in states without protections (t=-2.32, p=0.013). The mean number of pre-requisites for chest reconstruction surgeries in states with legal protections is 0.88, compared to 0.92 in states without protections (t=0.10, p=0.46).

 

Conclusion: Insurers in states with non-discrimination laws protecting transition-related insurance coverage tend to cover more gender-affirming surgical procedures. However, the number of requirements that must be fulfilled to deem a chest reconstruction medically necessary is effectively identical between insurers in states that do and do not have non-discrimination laws. Transition-related insurance protections are associated with enhanced coverage of gender affirmation surgery. However, they are not associated with improvements in the restrictiveness of medical necessity criteria, which may still act as a barrier to care even when coverage is nominally increased in accordance with these laws.
 

29.04 Radiation Following Autologous Breast Reconstruction – Is It Safe Practice?

Posted on January 31, 2019

L. A. Gamble1, S. Sha2, J. L. Kelly1, L. A. Jarvis4, G. L. Freed3, K. M. Rosenkranz1, C. V. Angeles1  2Stony Brook University,School Of Medicine,Stony Brook, NEW YORK, USA 3Dartmouth-Hitchcock Medical Center,Plastic Surgery,Lebanon, NEW HAMPSHIRE, USA 4Dartmouth-Hitchcock Medical Center,Radiation Oncology,Lebanon, NEW HAMPSHIRE, USA 1Dartmouth-Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:  The incidence of immediate breast reconstruction (IBR) following mastectomy for breast cancer has steadily been on the rise while the indications for post mastectomy radiation therapy (PMRT) have broadened. Current literature demonstrates conflicting data regarding surgical complications and timing of PMRT, while the safety of PMRT following autologous breast reconstruction (ABR) is still considered controversial. We sought to investigate the safety of PMRT in breast cancer patients who undergo ABR.

Methods:  Retrospective chart review was performed on all patients treated with mastectomy between 2000-2006 at a single, academic institution. Data collected included patient demographics, PMRT, and postoperative complications including seroma, infection, fat necrosis, and contracture documented from the time of surgery until one year post surgery. Median follow-up was 6.19 years. Chi-square analysis was performed with significance set at p <0.05.

Results: 592 patients underwent mastectomy for breast cancer treatment or prophylaxis. Only half of these patients (49%; 292/592) underwent reconstruction. The majority (83%; 240/292) received ABR, and 95% (228/240) were done at the time of mastectomy (IBR). The most common flap performed was the transverse rectus abdominis (TRAM) flap at 72.1%, followed by 24.2% latissmus dorsi (LD), and 3.7% other flaps (including superior and inferior gluteal artery perforators, and transverse upper gracilis). Of the immediate ABR patients, 57/228 received PMRT. Of these, 54% (31/57) suffered any surgical complication and 23% (13/57) were classified as Clavien-Dindo grade IIIb (CD IIIb). Comparatively, 171/228 patients did not receive PMRT with almost half (84/171) having complications, but only 26% (45/171) were classified as CD IIIb. There was no statistically significant difference in overall complication rate or CD IIIb complications between ABR patients with or without PMRT (p=0.742 and p=0.357, respectively). Additionally, we found no significant difference in overall complication rate in patients who underwent PMRT when comparing between those who had no reconstruction versus those who had ABR (p=0.0623).

Conclusion: Our data shows no statistically significant difference in the complication rate between breast cancer mastectomy patients who received PMRT after ABR versus no reconstruction.  Additionally, there is no difference in the rate of complications between ABR patients who did or did not receive PMRT. This study supports the idea that it is safe to radiate a reconstructed breast.

 

29.03 Adhering to Surgical and Oncologic Standards Improves Survival in Breast Cancer Cohorts

Posted on January 31, 2019

B. Zhao1, C. Tsai1, K. K. Hunt2, S. L. Blair1  2University Of Texas MD Anderson Cancer Center,Breast Surgical Oncology,Houston, TX, USA 1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:
The American College of Surgeons Clinical Research Program published evidence-based surgical and oncologic standards for breast cancer in the Operative Standards for Cancer Surgery.  Recommended standards include surgical resection with negative margins, removal of all sentinel lymph nodes (SLN) and removal of >10 lymph nodes (LN) for complete axillary dissection (ALND), and the use of adjuvant therapy after surgical resection. However, the rates of adherence to these standards nationwide is unknown. 

Methods:
Using the National Cancer Database from 2004-2015, we selected distinct cohorts of breast cancer patients who underwent surgical resection: clinical T1N0M0 under age 70 (CT1), clinical T2N0M0 or T3N0M0 (CT2/3), and clinical M0, pathologic N2 or N3 (PN2/3). For CT1 and CT2/3 patients, we considered patients with negative margins, any form of adjuvant therapy, and ³2 LNs examined as meeting standards. For PN2/3 patients, we considered those with negative margins, any form of adjuvant therapy, and ³10 LNs examined as meeting standards. We compared outcomes of those who met standards versus those who did not for all cohorts. We performed Kaplan-Meier analysis with log-rank test to compare survival for patients based on achieving standards and Cox proportional hazards model for individual predictors of improved survival while controlling for patient comorbidities. 

Results:
We identified 318,853 (65.0%) CT1 patients, 164,593 (67.3%) CT2/3 patients, and 77,626 (67.7%) PN2/3 patients who met surgical and oncologic standards. Survival data is shown in the table. For PN2/3 patients, the median survival for those who met standards was significantly longer than those who did not meet standards (109.34 months versus 72.97, p<0.001). Patients were significantly more likely to meet standards if they were treated at an academic center (p<0.001 for all cohorts). For CT1 and CT2/3 patients, ³2 LNs examined, endocrine therapy, radiation therapy, and negative margins were predictors of improved survival. For CT1 patients, chemotherapy was a predictor of worse survival, but was a predictor of improved survival in CT2/3 patients. For PN2/3 patients, ³10 LNs examined, endocrine therapy, chemotherapy, radiation therapy, and negative margins were predictors of improved survival. 

Conclusion:
Approximately a third of patients are not receiving evidence-based minimal standards as part of their surgical and oncologic treatment for breast cancer.  Adhering to surgical and oncologic standards improves survival in CT1, CT2/3, and PN2/3 breast cancer patients.  Efforts to improve knowledge of, and adherence to, these surgical and oncologic standards should be emphasized. 
 

29.02 Underinsurance and Healthcare Utilization among Working-Age Breast Cancer Patients

Posted on January 31, 2019

S. Obeng-Gyasi1, L. Timsina1, O. Bhattacharyya3, S. E. Severance1, C. S. Fisher1, D. A. Haggstrom2  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2VA HSR&D Center for Health Information and Communication,Indianapolis, IN, USA 3Indiana University Purdue University,Department Of Economics,Indianapolis, IN, USA

Introduction: Breast cancer is the most common female cancer in the United States. For working-age patients, a cancer diagnosis can be financially devastating secondary to disease related reduction in work productivity, loss of employment, and subsequent increased economic burden. The objective of this study is to understand out-of-pocket costs (OOP), health care utilization costs (outpatient visits, office-based visits, ambulatory care, prescription medication cost), and the rate of underinsurance among working age breast cancer patients. 

Methods: The study data was obtained using the Medical Expenditure Panel Survey data from 2008-2012.  Self-responding patients ages 18-64 with an age at diagnosis of breast cancer within two years of the survey interviews were included. The data was divided into three groups based on insurance:  private, Medicaid, and other public.  The other public includes patients with Non-Medicaid state or local insurance or other federal programs. Bivariate intergroup analysis was conducted. A multivariable logistic regression model tested variables associated with underinsurance. Underinsurance was defined as spending at least 10% of the household income on breast cancer related OOP.

Results:The study cohort included 14,586 patients. The groups differed significantly by marital status (p=0.004), race/ethnicity (p=0.0002), education (P <0.0001), percent below the poverty level (p<0.0001), family income (P <0.0001) and employment (P<0.0001).   Mean total annual OOP costs were $2006.0 (95% CI 1705.5, 2305.5) for the privately insured, $991.0 (95% CI -160.1, 2142.3) for Medicaid, and $7420.0 (95% CI 1722.8, 13117) for other public insurance. The majority of OOP cost were on prescriptions, $706.0 (95% CI 557.7, 854.6), and office-based visits, $779. 0(95% CI 641.7, 916.3). Patients with other public insurance spent the most OOP costs on prescriptions $3258.0 (95% CI 2047.2, 4467.8) and office-based visits $3258.0 (95% CI 2047.2, 4467,8). Being divorced (OR 5.6, p=0.029), living in the Midwest (OR 18.6, p=0.001) or South (OR 7.49 p=0.015) compared to the Northwest and having other public insurance (OR 12.2, p=0.012) were all associated with an increased rate of underinsurance. Conversely, employment (OR 0.21, p=0.011) and having Medicaid (OR 0.09, p= 0.006) were associated with a reduced rate of underinsurance.

Conclusion:Breast cancer patients spend most of their OOP costs on prescriptions and office-based visits. Since Medicaid was protective against underinsurance and higher OOP costs, future longitudinal studies should monitor whether Medicaid policy changes continue to reduce the economic vulnerability among cancer patients. Fifteen states in the South and Midwest have not expanded Medicaid, and this public policy decision appears to expose breast cancer patients to substantially greater financial burdens. Medicaid expansion should be considered to mitigate financial burden among working age women with breast cancer.

 

29.01 Impact of Global Migration on Asian Breast Cancer: A Comparison between US and Taiwan

Posted on January 31, 2019

J. Wu1,2, Y. Hung2, S. M. Stapleton2, Y. Hsu2, S. T. Oseni2, C. Huang1, D. C. Chang2  1National Taiwan University Hospital,Surgery,Taipei, Taiwan 2Massachusetts General Hospital,Surgery,Boston, MA, USA

Introduction:

More than half of the Asian Americans with breast cancer were born in Asia, however it is unknown whether their disease patterns are different from Asians born in the US. We hypothesize that nativity status may have an impact on the onset and the presentation of breast cancer in the Asian population.

Methods:

A retrospective analysis was performed for Asian females³ 20 years old in the US Surveillance, Epidemiology, and End Results (SEER) Program database, and as a convenience sample from Asia, in the Taiwan Cancer Registry (TCR) for the years 2004-2010. The primary end point was proportion of patients who had early-onset breast cancer, defined as breast cancer age at onset before 50. Secondary outcome was the proportion of advanced breast cancers, defined by American Joint Committee on Cancer staging III to IV. Three groups of patients were compared: Native Asian in Taiwan (TW), Asia-born Asian American (AAA), and US-born Asian American (USAA).

Results:

We identified 13,404 patients (2,743 USAA & 10,661 AAA) in SEER and 49,322 TW in TCR. TW presented at an earlier age than AAA (median age 51vs 56) and USAA (median ­­­­­­61). TW had the highest proportion of early-onset breast cancer (44.3% vs 31.7% AAA and 23.7% USAA, p < 0.001). In addition, both TW and AAA had significantly higher rates of advanced cancer at presentation than USAA (22.8% and 17.2% vs 13.8%, respectively, p < 0.001).

Conclusions:

Recent immigrants to the US may be at increased risk of earlier and more aggressive breast cancers. Future studies should determine whether these differences are due to biomedical factors, access to healthcare, or poor healthcare quality affecting immigrant communities. The impact of immigration on health and disease remains an under-appreciated but important way through which we can further understand the interaction between social and biomedical factors on disease onset and progression.

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