31.09 Adjuvant Chemotherapy after Neoadjuvant Chemoradiation in Esophageal Cancer

Posted on January 18, 2018

C. Takahashi1, R. Shridhar2, A. Patel3, J. Huston4, K. Meredith3  1Midwestern University,Glendale, AZ, USA 2University Of Central Florida,Orlando, FL, USA 3Florida State University,Tallahassee, FL, USA 4Sarasota Memorial Hospital,Sarasota, FL, USA

Introduction:  Patients with locally advanced esophageal cancer (EC) have poor long-term survival despite improvements in multi-modality care. Neoadjuvant chemoradiation (NCR) followed by surgical resection remains standard of care. However, the utilization of adjuvant therapy continues to be debated. Our study reviews the effectiveness of adjuvant therapy after neoadjuvant therapy in resected EC.

Methods:  Utilizing the National Cancer Database (NCDB) we identified patients with esophageal cancer who underwent NCR followed by esophagectomy and received adjuvant therapy compared to those who did not. Propensity score matched (PSM) analysis was performed. Baseline univariate comparisons of patient characteristics were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test. All statistical tests were two-sided and α (type I) error <0.05 was considered statistically significant.

Results: We identified 1,816 patients from the NCDB with EC, 1,664 (91.6%) with adenocarcinoma and 134 (7.4%) with squamous cell carcinoma. Both the adjuvant therapy group and the no adjuvant group had 908 patients with a median age of 60 years (26-83). There were 1,596 (87.9%) males and 220 (12.1%) females. Location of the tumor was 121 (6.7%) middle, 1,267 (7.0%) lower, and 371 (20.4%) at the gastroesophageal junction. Univariate analysis revealed age, R0 resection, T-stage, N-stage, grade, <10 lymph nodes removed and adjuvant therapy were predictors of survival. All patients who received adjuvant therapy revealed greater median and overall survival, 36.4 months and 34.5% versus 30.9 months and 33.2%, p=0.02. Node negative patients did not show a significance in survival with adjuvant therapy 57.2 and 55.4 months respectively, p=0.4. However node positive patients demonstrated improved median and overall survival with adjuvant therapy 31.1 months and 27% respectively compared to the no adjuvant therapy group 25.7 months and 24.3%, p=0.03. Multivariate analysis revealed node positive patients T-stage (p=0.002), R0 resection (p<0.001), and number of lymph nodes removed (p<0.001) were predictors of survival. Adjuvant therapy failed to be a predictor of survival (p=0.2). However, PSM revealed that patients who received adjuvant therapy exhibited an improved median survival over those who did not 36.4 months and 30.9 months, p=0.02.

Conclusion: Adjuvant therapy in all EC patients after neoadjuvant therapy does show improved median and overall survival. Similar to other studies, R0 resection and T-stage continue to influence survival. However, node negative EC patients were found to have no survival benefit with the addition of adjuvant therapy.

 

31.10 Patterns of Disease Recurrence Following Neoadjuvant Therapy for Localized Pancreatic Cancer

Posted on January 18, 2018

C. Barnes1, M. Aldakkak1, K. Christians1, C. Clarke1, P. Ritch2, B. George2, M. Aburajab5, M. Griffin4, B. Erickson3, W. Hall3, D. Evans1, S. Tsai1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Hematology And Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 4Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 5Medical College Of Wisconsin,Department Of Gastroenterology And Hepatology,Milwaukee, WI, USA

Introduction: Among patients with pancreatic cancer (PC) who are treated with a surgery-first approach, median survival is approximately two years and over 20% have local disease as the first site of recurrence; likely related to the high rates of node positive (~60%) and margin positive (~40%) disease. In contrast, neoadjuvant therapy and surgery have been associated with median survival durations of greater than three years and decreased rates of lymph node and margin positivity. The improved survival implies a greater level of systemic disease control; the importance of local disease control is controversial largely due to a lack of available data.

Methods: Consecutive patients with localized PC who received neoadjuvant therapy and surgery underwent post-treatment radiographic surveillance at 3-4 month intervals for the first 2 years and at 6 month intervals thereafter. The first site(s) of failure was classified as local recurrence (LR) for peripancreatic or perivascular recurrences, regional recurrence (RR) for peritoneal or abdominal wall recurrences, and distant recurrence (DR) for all other recurrence sites.

Results: Neoadjuvant therapy and surgery was completed in 231 consecutive patients; 115 (50%) with resectable and 116 (50%) with borderline resectable PC. Neoadjuvant therapy consisted of chemoradiation (n=75, 32%), chemotherapy alone (37, 16%), or both (119, 52%). Of the 231 patients, 137 (60%) had node negative disease and 207 (90%) had margin negative resections. Postoperative adjuvant therapy was completed in 138 (60%) of the 231 patients, including 27 (12%) patients who received adjuvant chemoradiation. At a median follow-up of 24.3 months, disease recurrence was present in 128 (55%) of the 231 patients (the first site(s) of recurrence are summarized in Figure 1). Of the 231 patients, 221 (96%) received radiation and 10 (4%) did not. Isolated LR occurred in 3 (30%) of the 10 patients with no radiation and 16 (7%) of the 221 patients who received radiation (p=0.04). Median overall survival (OS) was 43 months; not reached, 31.5, 19.4, and 24.8 months for patients with no recurrence, isolated LR, any RR without DR, and any DR, respectively.

Conclusion: Patients who successfully complete all intended neoadjuvant therapy and surgery have a median OS greater than three years, and a greater than 50% reduction in isolated LR. Despite the increased length of survival observed with neoadjuvant therapy, LR rates have not increased. As survival duration increases, neoadjuvant chemoradiation may be an important treatment component in minimizing isolated LR, which may be a preventable cause of patient death. 

 

31.08 Online Information on Surgery for Pancreatic Cancer is Often Inadequate for Shared Decision-Making

Posted on January 18, 2018

C. Zhang1, A. Yang1, A. Halverson1  1Northwestern University,Chicago, IL, USA

Introduction:
Decision making regarding surgery for pancreatic cancer may be difficult for patients as surgery can improve survival but can also negatively impact quality of life. In order to more actively participate in decision making, patients often seek information on the Internet. The aim of this project was to assess the quality of publicly available online information regarding surgery for pancreatic cancer.

Methods:
This study was a cross-sectional survey of patient-centered websites that address surgery for pancreatic cancer. Two search engines (Google, Bing) were queried with the terms “pancreatic cancer treatment”, “pancreatic cancer surgery”, “Whipple procedure”, and “pancreaticoduodenectomy” to identify websites of interest. Each website was evaluated using the DISCERN instrument (www.discern.org.uk), a validated questionnaire developed to analyze written consumer health information on treatment choices. An additional questionnaire was used to evaluate website content specifically for pancreatic cancer surgical treatment. Two healthcare providers (surgeon, medical student) reviewed each website independently and inter-rater reliability (IRR) was calculated. In addition, one pancreatic cancer patient and one family member analyzed a randomly selected subgroup of study websites using the DISCERN instrument.

 

Results:

We identified 93 distinct websites; 45 met inclusion criteria. Website affiliations included: health care organizations (44%), non-profit organizations (22%), open-access general information (22%), and government/professional websites (11%). Using DISCERN, the two healthcare providers identified that only 24% of the websites had clear aims, 31% had identifiable references, and 36% noted the publication date (Figure). Overall, 4 websites (9%) were identified as excellent, and nine (20%) were of poor quality. In regard to pancreatic cancer surgery, 62% of websites discussed postoperative complications, 56% addressed quality-of-life (QOL) issues, and 53% acknowledged the surgery volume-outcome relationship. IRR was 0.75 for the 2 professional assessors on the overall rating. DISCERN assessment by patient/family evaluators demonstrated 83% agreement with the results by medical professionals. Major areas of disagreement included QOL and website bias.

Conclusion:

The quality of patient-centered online information on pancreatic cancer treatment is highly variable. Websites frequently lack updated information and references, and often do not provide adequate information for patients to make well-informed treatment decisions. However, patients and family members demonstrated the ability to learn strategies to critically evaluate online health information.

31.06 Neutrophil to Lymphocyte Ratio is a Preoperative Risk Factor in Intrahepatic Cholangiocarcinoma

Posted on January 18, 2018

S. Buettner2, B. Groot Koerkamp2, M. Weiss3, S. Alexandrescu4, H. P. Marques5, J. Lamelas5, L. Aldrighetti6, T. Gamblin7, S. K. Maithel8, C. Pulitano9, T. W. Bauer10, F. Shen11, G. A. Poultsides12, J. Marsh13, J. N. IJzermans2, T. M. Pawlik1  1Ohio State University,Columbus, OH, USA 2Erasmus MC University Medical Center,Dept. Of Surgery,Rotterdam, ZUID-HOLLAND, Netherlands 3Johns Hopkins University School Of Medicine,Baltimore, MD, USA 4Fundeni Clinical Institute,Bucharest, ROMANIA, Romania 5Curry Cabral Hospital,Lisbon, PORTUGAL, Portugal 6Ospedale San Raffaele,Milan, ITALY, Italy 7Medical College Of Wisconsin,Milwaukee, WI, USA 8Emory University School Of Medicine,Atlanta, GA, USA 9University Of Sydney,Sydney, NSW, Australia 10University Of Virginia,Charlottesville, VA, USA 11Eastern Hepatobiliary Surgery Hospital,Shanghai, CHINA, China 12Stanford University,Palo Alto, CA, USA 13University Of Pittsburg,Pittsburgh, PA, USA

Introduction: Alterations in the Neutrophil-to-Lymphocyte ratio (NLR) may be indicative of host immune response to cancer. We sought to determine whether preoperative NLR was associated with long-term outcomes among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC).

Methods: Patients who underwent resection for ICC between 1990-2015 were identified from 12 major HPB centers. NLR was calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes. The Kaplan-Meier method and Cox regression models were used to evaluate factors, including NLR, that potentially were associated with overall survival. Factors associated with survival based on the multivariable Cox model were utilized to create a point-based preoperative score to predict prognosis. 

Results: Among 1,000 patients who underwent resection for ICC, the majority of patients had a solitary tumor (n=810, 82.6%) and median tumor size was 6.0 cm (interquartile range [IQR]: 4.3-9.0); 168 (19.5%) patients had lymph node metastases on preoperative imaging. Preoperative jaundice was present in 98 (9.8%) patients, while 27 (2.7%) patients had extrahepatic disease. Median NLR was 2.68 (2.05-4.00).  Overall survival at 1-, 3-, and 5- years was 78.7%, 61.5%, and 39.1%, respectively.  NLR was associated with prognosis as patients with a NLR ≥3 had a median survival of 31.3 months (95%CI: 23.9-38.8) compared with 53.1 months (95%CI: 37.1-69.2) among patients with a lower NLR (p<0.001).  In addition, 1-, 3-, and 5-year survival was 73.5%, 46.4%, and 38.8% versus 84.6%, 61.1%, and 47.8% among patients with NLR ≥3 versus NLR < 3, respectively (p<0.001).  Using backwards selection based on the Akaike Information Criterion, a preoperative risk score was derived. Specifically, on multivariable analysis, number of lesions (Hazard Ratio [HR]: 1.17; p<0.001), tumor size (HR: 1.04; p<0.001), preoperative lymph node metastases (HR: 1.32; p=0.022), preoperative jaundice (HR: 1.65; p<0.001) and extrahepatic disease (HR: 2.39, p<0.001) were each predictive of survival. After controlling for these competing risk factors, NLR remained independently associated with long-term survival (HR: 1.04, 95%CI: 1.02-1.07; p=0.001).  The combination of these preoperative factors into a prognostic model had fair discrimination to predict post-operative survival (area under the curve, 0.65).

Conclusion: Elevated NLR was an independent predictor of worse long-term outcomes among patients with ICC undergoing resection. NLR may be an important factor associated with survival and can help estimate postoperative survival when used in a preoperative predictive model.

 

31.07 Obstruction as a risk factor in the staging of colon cancer: a secondary analysis of the N0147 trial

Posted on January 18, 2018

F. S. Dahdaleh1, S. Sherman1, A. Benjamin1, E. Poli1, K. K. Turaga1  1The University Of Chicago Medicine,Section Of General Surgery/Surgical Oncology,Chicago, IL, USA

Introduction: Presentation with obstruction is frequent in patients with colon (non-rectal) cancer (CC). Large series have reported obstruction among “high-risk” features, yet data from prospective cohorts on its specific prognostic influence are lacking. We hypothesized that obstruction is an independent risk factor for poor prognosis in patients with stage III CC.

Methods: N0147 was a randomized trial conducted between 2004-09 including patients with Stage III CC randomized to adjuvant FOLFOX/FOLFIRI regimens with or without cetuximab. We obtained patient-level data for those in the control chemotherapy-only arms. Patient, tumor and treatment characteristics were abstracted. Disease-free and overall survival (DFS and OS) were estimated by the Kaplan-Meier method. Proportions were compared by Chi-square and Fisher-exact tests. Uni- and Multivariate survival analyses were performed using Cox-proportional hazards models.

Results: Of 1,543 patients with stage-III CC, 250 (16.2%) presented with obstruction. Obstructive tumors were more likely to be K-ras mutant (35% vs. 30%, p=0.07) and poorly differentiated (28.8% vs. 24.6% vs. p=0.17) but these did not reach statistical significance. Obstructed patients were no less likely to complete 12 cycles of adjuvant chemotherapy (75.6% vs. 77.0% p=0.62). With median follow-up time of 30.1 months among survivors, 5-year overall and disease-free survival was significantly worse among obstructed patients (OS 67.7% vs. 78.0%, p<0.001; DFS 53.9% vs. 67.0%, p<0.0001, Figure). After adjusting for conventional AJCC staging variables including T and N-stage, high-grade histology, and host characteristics, obstruction remained significantly associated with worse survival (OS HR 1.61, 95% CI 1.16-2.24, p=0.005; DFS 1.54, 95% CI 1.21-1.98, p<0.001). This difference was more pronounced in the cohort receiving FOLFOX (HR 2.13, 95% CI 1.46-3.11, p<0.001).

Conclusion: In this prospectively-followed cohort of Stage-III CC patients treated with standard-of-care adjuvant chemotherapy, obstruction was significantly associated with worse survival. Moreover, this effect was independent of T- and N-stage, and histology. Conclusions from this secondary analysis of a randomized trial are less likely to be biased by diagnostic and therapeutic factors, and by disparities in access to care than retrospective series. Inclusion of obstruction in the AJCC staging system might help better stratify these patients at high risk of recurrence and death.

31.04 Clinical Fate of T0N1 Esophageal Cancer: Results from the National Cancer Database

Posted on January 18, 2018

C. Takahashi1, R. Shridhar2, A. Patel3, J. Huston4, K. Meredith3  1Midwestern University,Glendale, AZ, USA 2University Of Central Florida,Orlando, FL, USA 3Florida State University,Tallahassee, FL, USA 4Sarasota Memorial Hospital,Sarasota, FL, USA

Introduction:  The long-term survival for patients with locally advanced esophageal cancer (EC) remains poor despite improvements in multi-modality care. Neoadjuvant chemoradiation (NCR) followed by surgical resection remains pivotal in the management of patients with ECC.  However the outcomes of patients whose primary tumor exhibits a complete response with residual regional nodal disease (T0N1) remains unclear as well as the role for adjuvant therapy.

Methods:  Utilizing the National Cancer Database we identified patients with esophageal cancer who underwent NCR followed by esophagectomy who had subsequent pathology of T0N1.  Baseline univariate comparisons of patient characteristics were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test. All statistical tests were two-sided and α (type I) error <0.05 was considered statistically significant.

Results: We identified 7,116 patients diagnosed with EC (6,235 (87.6%) adenocarcinoma (AC), 881 (12.4%) squamous cell carcinoma (SCC) with a median age of 62 (21 – 88) years.  There were 6,031 (84.8%) males and 1,085 (15.2%) females. R0 resections were achieved in 6,668 (93.7%) patients and this correlated to improved survival, median survival 55.4 (RO) and 24.4 (R1) months respectively, p<0.001. The median nodes harvested were 13 (0-83) with a median positive LN’s of 1.4 (2.9%). Complete response (pCR) was achieved in 1,334 (18.7%), partial response (pPR) 2,812 (39.5 %) and non-response (pNR) 2,970 (41.7%).  There were 230 (3.2%) patients deemed as pathologic T0N1.  The median survival of patients with pCR was 61.7 months compared to 32.1 months in the T0N1 patients p<0.001. T0N1 patients did not demonstrate an improved survival over T1/2 patients who had a median survival of 30.5 months, p=0.77. However, T0N1 did reveal an improved survival over T3/4 patients who had a median survival of 24.6 months, p=0.02. Adjuvant chemotherapy in T0N1 did not provide a benefit in survival, median survival adjuvant versus no adjuvant 30.8 vs 32.1 months respectively, p=0.08. Multivariate analysis in T0N1 patients demonstrated only number of LN’s positive, histology SCC vs ACC, and margin as predictive of survival, HR 1.23 (1.10-1.36) p<0.001, HR 0.38 (0.22-0.67), p=0.001, HR 1.97 (1.7-2.27) p<0.001,respectively.

Conclusion: Patients with esophageal cancer who exhibit a pathologic T0N1 after NCR have oncologic fates similar to node positive patients.  Patients with pCR of the primary tumor and regional lymph nodes continue to demonstrate significant survival benefits over all remaining pathologic cohorts.

31.05 Total Neoadjuvant Therapy in Pancreatic Cancer

Posted on January 18, 2018

N. Goel1, A. Nadler1, W. H. Ward1, K. J. Ruth1, A. Karachristos1, J. P. Hoffman1, S. S. Reddy1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:

There is increasing interest in total neoadjuvant therapy (TNT) for pancreatic cancer. This entails systemic chemotherapy followed by chemoradiotherapy, and then definitive surgery as long as the disease remains localized. The perceived benefits are that all patients receive multimodality therapy, eradication of occult systemic disease, and the potential to downstage borderline resectable (BR) tumors for curative resection. This study evaluates whether TNT has an overall survival (OS) benefit compared to neoadjuvant chemoradiation therapy and upfront surgery. 

Methods:

This is a retrospective study of 182 pancreatic adenocarcinoma patients treated at our institution from 2000-2015 who underwent a pancreaticoduodenectomy (PD) or a total pancreatectomy. Patients undergoing distal pancreatectomy, those with macroscopic disease discovered at the time of surgery, and those with stage IV disease were excluded. 

Results:

The analytic cohort consisted of 66 patients in the TNT group, 29 in the neoadjuvant chemoradiation group, and 87 in the surgery first group. Median age at diagnosis was 67 in the TNT cohort, 72 in the neoadjuvant cohort, and 70 in the surgery first cohort. 46(69.7%) of the TNT patients were initially borderline resectable (BR) or unresectable and were clinically stage 2A or higher. 67(77%) of the upfront surgery patients were clearly resectable and were clinically stage 2A or lower. Ten(15.2%) of the TNT patients had a complete pathologic response. 55(83.3%) of the TNT patients had an R0 resection. On univariate analysis, treatment(p=0.0016), age(p=0.037), nodal status(p=0.01), and margin status(p=0.001) were statistically significant. On multivariate analysis, treatment(p=0.024), age(p=0.0014), and margin status(p<0.0001) remained significant. Surgery first had a statistically significant greater hazard ratio compared to the TNT group at 1.81. Median OS from date of diagnosis was 18 months in the upfront surgery group, 25 months in the neoadjuvant group, and 36.7 months in the TNT group (p=0.0019). The TNT group also had the greatest CA19-9 drop with 77% having at least a 50% response.

Conclusion:

Although limited data exist on the utility of TNT, our review, which is one of the largest to date, shows a statistically significant improvement in OS for the TNT group, despite more advanced disease. We achieved a median OS of 36.7 months and 5 year OS 31.5% with TNT in a patient population that was more advanced, including both BR and unresectable patients. TNT therefore offers favorable short- and long-term outcomes, as well as the benefit of optimally selecting patients for surgery based on fitness for TNT and tumor biology.

 

31.01 Functional Assessment of TILs in Rectal Cancer

Posted on January 18, 2018

J. C. Kong1,2, G. R. Guerra1,2, R. M. Millen1,2, S. K. Warrier1,2, W. Phillips1,2, A. C. Lynch1,2, R. Ramsay1,2, A. G. Heriot1,2  1Peter MacCallum Cancer Centre,Division Of Cancer Surgery,Melbourne, VIC, Australia 2The University Of Melbourne,Sir Peter MacCallum Department Oncology,Melbourne, VIC, Australia

Introduction

 

Currently there are no reliable methods that can adequately predict response to neoadjuvant chemoradiotherapy (NACRT) in locally advanced rectal cancer. However tumour infiltrating lymphocytes (TIL) have gained significant prominence in predicting response and survival outcome in rectal cancer. The aim of this study was to assess whether a novel functional cytotoxic immune assay measuring the kinetics of TIL killing predicts pathological tumour response after NACRT accurately.

 

Methods

 

Treatment naïve fresh rectal cancer biopsies from each patient was processed to cultivate organoids and TIL. An immune cytotoxic assay comprising of patient-matched TIL and organoids were co-cultured for 48 hours. A fluorescence microscope was utilitised to measure organoid death, by an automated computer algorithm that calculates the mean fluorescence intensity.

 

Results

 

A total of 17 consecutive rectal cancer patients were recruited. In each cytotoxic assay, a total of 15,000 organoids were measured, with organoid to TIL ratio of 1:10,000. The mean fluorescence intensity for each response group were; complete response=27982 (n=6), partial response=16663 (n=5) and no response=8933 (n=6) (p-value<0.001). This demonstrates that by measuring the kinetics of TIL killing, it can predict response to NACRT accurately before surgery. This was further validated by measuring the IFN-Y production of cytotoxic (CD8+) T cell, which was significantly higher in complete/partial response TIL compared to no response TIL (mean 1969 pg/ml and 76 pg/ml respectively, p-value=0.02).

 

Conclusion
 

A functional immune assay can predict rectal cancer response to NACRT. This has the potential both to modify clinical management and opens the door for novel therapeutic approaches. 

31.02 A Comparison of Colon versus Rectal Adenocarcinoma using Molecular Profiling

Posted on January 18, 2018

J. Purchla1, W. H. Ward1, F. Lambreton1, N. Nweze1, T. Li2, N. Goel1, S. Reddy1, E. Sigurdson1, J. M. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Philadelphia, PA, USA

Introduction: The role of molecular profiling (MP) in the evaluation and management of colorectal adenocarcinoma continues to grow. In conjunction with standard genotyping for disease-related mutations, MP provides a genetic blueprint of the analyzed colorectal tumors. Although similar histologically, the clinical behavior and treatment of colon and rectal cancers can be quite dissimilar. The purpose of this investigation is to compare the colon and rectal MPs.

Methods: A retrospective study was performed using MP data of colorectal patients of any stage who were treated at our tertiary cancer center between 2006 and 2017, and underwent a Targeted Cancer Panel and/or specific single gene tests. Those who did not undergo molecular profiling were excluded. Demographic, clinical, and pathological data were collected and analyzed. The Wilcoxon test and Chi-square test were used for statistical analysis.

Results: 355 colon cancers underwent MP, and 66.5% had a mutation affecting 42 different genes. 126 rectal cancers underwent MP and 79.4% has a mutation affecting 45 different genes (P=0.007). In the colon group, 53.2% were male, and in the rectal group, 63.5% were male (P=0.04). Additionally, in the colon group, 80.6% were white, and in the rectal group, 89.7% were white (P=0.02). Stage IV colon cancer patients comprised 45.0% of the cohort, and stage IV rectal cancer patients comprised 48.8% (P=0.6). KRAS mutation was seen in 43.4% of colon and 46.1% of rectal (P=0.65), BRAF mutation in 11.6% of colon and 5.0% of rectal (P=0.06), P53 mutation in 57.4% of colon and 62.6% of rectal (P=0.4), APC mutation in 47.4% of colon and 58.2% of rectal (P=0.08), SMAD4 mutation in 10.0% of colon and 13.7% of rectal (P=0.3), PIK3CA mutation in 17.0% of colon and 7.3% of rectal (P=0.02), and defective mismatch repair/microsatellite instability (dMMR/MSI) in 12.6% of colon and 1.6% of rectal (P=0.0004). No mutations were seen in 33.5% of colon and 20.6% of rectal tumors, 1 mutation was seen in 20.9% of colon and 23.8% in rectal, 2 mutations were seen in 20.9% of colon and 13.5% of rectal, and 24.8% of colon and 42.1% of rectal had more than 3 mutations (P=0.0005). In colon cancer patients with mutations: 41.5% were located in the right colon, 10.9% in the transverse colon, 10.0% in the left colon, 37.6% in the sigmoid/recto-sigmoid colon, and 7 patients were unreported.

Conclusions: In colon and rectal patients who underwent MP had mutations affecting more than 40 unique genes. Colon tumors had higher rates of BRAF and PIK3CA mutation, and dMMR/MSI in comparison to rectal cancers. Based on this descriptive analysis, further investigation with a larger sample size is needed to affirm these patterns and may affect future treatment decision making. 

31.03 Neoadjuvant Therapy Response in Esophageal Cancer Predicts Survival vs. Up-Front Esophagectomy

Posted on January 18, 2018

G. S. Chevrollier1, D. Giugliano1, F. Palazzo1, E. L. Rosato1, N. R. Evans1, A. C. Berger1  1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA

Introduction:
Despite advances in care, survival for patients with locally advanced esophageal cancer (EC) remains poor. It is known that patients who undergo neoadjuvant chemoradiation (nCRT) and have poor or no response (non-responders) have worse survival compared to those who respond. We sought to evaluate survival of patients who underwent nCRT compared to similarly-staged patients who underwent esophagectomy without nCRT (primary esophagectomy).

Methods:
Using our IRB-approved institutional esophagectomy database, we retrospectively identified all patients who underwent open or minimally invasive esophagectomy at our institution between January 1994 and June 2015. We separated patients into two groups: those who underwent nCRT (n=235) and those who underwent up-front esophagectomy with pathologic stage II or greater (primary esophagectomy, n=53). The neoadjuvant group was further separated into patients who were downstaged (responders, n=133) and those whose pathologic stage was the same or higher than their pre-nCRT clinical stage (non-responders, n=102). Overall and 5-year survival were compared between these three groups using Kaplan Meier survival curves and log-rank statistics, with significance set at p<0.05.

Results:
We identified 288 patients who met our inclusion criteria with an average age of 62 years. 53% of patients were male and 61% underwent open esophagectomy. The majority had adenocarcinoma (82%, n=236). Serious complication rates (grade 3 or higher according to the modified Clavien scale) were 28.4%, 26.3%, and 24.5% for non-responders, responders, and primary esophagectomy, respectively (p=NS).  The primary esophagectomy and non-responder groups had equal numbers of stage II (49% vs. 53%) and stage III (42% vs. 45%) cancers. Median survival was 36.2 months in the downstaged group (95% CI 27.2-42.6 months), 19.3 months in the non-responder group (95% CI 15-23.3 months), and 27.1 months in the primary esophagectomy group (95%CI 21.6-54.7 months) (p= 0.029). Five-year survival was 42% in the downstaged group, 25.8% in the non-responder group (HR 1.5), and 32.1% in the primary esophagectomy group (HR 1.2) (p=0.029).

Conclusions:
Patients with EC who fail to respond to nCRT have decreased survival compared to those who respond and those who undergo up-front esophagectomy. Neoadjuvant therapy in non-responders may delay definitive therapy in the form of esophagectomy, and may also expose patients to unnecessary morbidity and increased costs associated with nCRT. Further research is needed to identify potential non-responders with advanced resectable EC in order to provide more individually tailored treatment and avoid potentially harmful neoadjuvant therapy and delayed time to esophagectomy.

30.09 The Economics of Private Practice Versus Academia in Surgery: an Analysis of Sub-Specialization.

Posted on January 18, 2018

M. Baimas-George1, B. Fleischer1, J. R. Korndorffer1, D. Slakey1, C. DuCoin1  1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction:  In the surgical field, residents often make career decisions regarding future practice without adequate knowledge or exposure to the realities of professional life, particularly private practice. Currently there is a paucity of comparable data regarding the economic differences between practice models.  This study seeks to illuminate the financial disparities of surgical sub-specialties between academic and private surgical practice.

Methods:  Data was collected from the Association of American Medical College (AAMC) and the Medical Group Management Association’s (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for eight comparative surgical sub-specializations, and regional data was combined for a national average. Fixed time of practice was set at 30 years. Assumptions for the calculation of lifetime revenue in academia included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. The formula utilized is as follows: (average yearly salary) x [years of practice (30 yrs – fellowship/research yrs)] + ($50,000 x yrs of fellowship/research) = total adjusted lifetime revenue.

Results: As a full professor, academic surgeons in all sub-specialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners respectively. Plastic surgery and general surgery are the only two disciplines that have similar lifetime revenues to private practitioners, earning only 2% and 6% less than their counterparts’ lifetime revenue respectively.  Surgical oncology is the only sub-specialty that regardless of practice model (academic vs private) or academic status (assistant, associate, or professor) grossed less lifetime revenue than general surgery.

Conclusion: Academic surgeons in all surgical sub-specialties examined earn less lifetime revenue compared to those in private practice.  This difference in earnings decreases but remains substantial as an academic surgeon advances from assistant to associate to full professor.  With limited exposure to the diversity of possible professional arenas, residents must be aware of this considerable discrepancy. 
 

30.10 Unnecessary Use of Plain Abdominal Radiographs in Patients of Acute Abdomen

Posted on January 18, 2018

D. Soares1, K. M. Pal1  1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan

Introduction:
Acute abdomen accounts for 5-10% of visits to the ER. An early and accurate diagnosis is essential in the management of these patients. Usually the first radiological investigation performed is an abdominal X-ray. However in most cases an abdominal X-ray is unable to reach a diagnosis and the patient then has to undergo further investigations. In our study, we wished to establish in how many patients presenting to the ER with acute abdominal pain was an abdominal X-ray done unnecessarily and did not lead to a final diagnosis. 

Methods:
This was a cross-sectional study conducted at the Department of Surgery at Aga Khan University Hospital over a 6 month period from April to October 2016. Patients aged 16 to 60 years of any gender, who presented to the ER with non-traumatic abdominal pain, lasting more than 2 hours and less than 5 days in duration, and which measured more than 5 on the VAS were included in the study. The patients who presented with acute abdomen and undergoing an abdominal X-ray were followed. The principal investigator then reviewed how helpful the X-ray was in the diagnosis, and calculated the proportion of X-rays that were done unnecessarily. Data was analysed using SPSS version 19. 

Results:

A total of 110 patients were included in the study.

The initial diagnosis was intestinal obstruction in 47.3% (n=52), followed by acute pancreatitis in 15.5% (n=17), peritonitis in 9.1% (n=10), constipation in 8.2% (n=9), acute cholecysitis 5.5% (n=6) and acute appendicitis in 4.5% (n=5). 

The x-ray findings included a non-specific bowel gas pattern in 50% (n= 55). Significant findings included dilated small bowel loops in 23.6% (n=26) and fecal loading in 19.1% (n=21); air fluid levels, calcific opacity in the right lumbar region, dilated large bowel loops in 1.8% respectively; and diffuse haziness in the abdomen and a foreign body in 1 patient respectively.

The most common final diagnoses were intestinal obstruction (27.3%), acute pancreatitis (14.5%) and constipation (10%). 

The proportion of unnecessary X-rays was found to be 69.1% (n=76) with only 30.9% (n=34) actually leading to a final diagnosis.

We stratified different variables on the basis of the necessity of the x-ray. The location of pain (p = 0.007), the x-ray findings (p = 0.000) and the final diagnosis (p = 0.000) was found to be significantly associated with the unnecessary use of x-rays. Abdominal x-ray was found to have some usefulness in intestinal obstruction, ureteric caluclus, foreign body and constipation in geriatric patients. It was also found that the visual analog scale had a significant association with the use of unnecessary x-rays. On further analysis, it was found that patients with a VAS of 8 and above were more likely to have an unnecessary x-ray as opposed to patients with a VAS of 6-7. 

Conclusion:

The abdominal X-ray for acute abdomen was done unnecessarily in 69% of the patients presenting with acute abdomen.

30.08 Functional Status vs. Frailty in GI Surgery: Are They Comparable in Predicting Short Term Outcomes?

Posted on January 18, 2018

S. Y. Chen1, M. Stem1, S. L. Gearhart1, B. Safar1, S. H. Fang1, J. E. Efron1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Functional dependence and frailty are important factors in assessing preoperative risk. No studies to date have compared functional dependence with frailty as predictors of surgical outcomes. We sought to compare the impact of functional dependence and frailty on early outcomes after gastrointestinal (GI) surgery, including readmission.

Methods:
Patients who underwent GI surgery were identified using the ACS-NSQIP database (2012-2015). Functional dependence is defined by NSQIP as “partial or total assistance with performing activities of daily living (bathing, feeding, dressing, toileting, and mobility) in the 30 days prior to surgery.” The 5-item modified frailty index (mFI) consists of: history of severe chronic obstructive pulmonary disease, congestive heart failure, functional status, hypertension requiring medication, and diabetes. Propensity score matching analysis was used to separately match dependent and independent patients, and patients with mFI<3 and mFI≥3 on baseline characteristics. Multivariable logistic regression analysis was utilized. Postoperative outcomes and reasons for readmission were compared. A subgroup analysis of colectomy patients was also performed.

Results:
Of 765,082 patients, 1.71% were dependent, and 1.49% had mFI≥3. Similar outcomes were observed in matched cohorts for dependent and mFI≥3 patients: readmission (15.61% dependent; 5.75% mFI≥3), overall morbidity (37.91%; 34.81%), serious morbidity (19.06%; 17.06%), mortality (6.73%; 5.43%), and reoperation (7.01%; 6.48%). Dependent and mFI≥3 patients had similar and increased odds of outcomes on adjusted multivariable logistic analysis (TABLE) and shared three of the top five indicators for readmission: complication of surgical procedure (11.46% dependent; 11.23% mFI≥3), intestinal obstruction (10.70%; 7.65%), and organ space surgical site infection (7.93%; 8.65%). Comparable outcomes and reasons for readmission were also obtained for dependent and mFI≥ 3 colectomy patients: overall morbidity (51.14% dependent; 49.03% mFI≥ 3), serious morbidity (25.12%; 23.11%), mortality (8.83%; 8.08%), reoperation (8.60%; 7.98%), and readmission (17.79%; 17.75%) Colectomy patients shared four of the top five reasons for readmission: 1) intestinal obstruction without hernia (13.06% dependent; 9.06% mFI≥ 3 ), 2)  complications of surgical procedure (9.44%; 10.40%), 3) organ/space SSI (8.06%; 9.40%), and 4) respiratory complications (6.94%; 8.39%).

Conclusion:
Functional dependence and frailty are comparable in predicting outcomes including readmission after GI surgery. Functional dependence should be considered an acceptable and practical alternative for preoperative risk stratification in a clinical setting.
 

30.07 M&M Combined with Critique Algorithm-Based Database Reliably Evaluates Quality of Surgical Care

Posted on January 18, 2018

A. C. Antonacci1, S. Dechario1, J. Nicastro1, G. Coppa1, C. Antonacci2, M. Jarrett1  1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA 2Tulane University School Of Medicine,New Orleans, LA, USA

Introduction:

Collection and critique of actuarial complication data following surgery has been a historically difficult endeavor. Weekly Morbidity and Mortality conference (MMC) review combined with a standardized critique algorithm as part of a relational database can provide valuable cumulative data useful for evaluation of surgical quality.

 

Methods:

From January 2014 to July 2017,  62,377 general surgery operative procedures were performed at two major university based medical centers within our health system. We collected weekly Morbidity/Mortality reports from a total of 741 cases comprising 1714 adverse events (2.75% complication rate) and 194 deaths (0.31% mortality rate).  Approximately 250 cases were presented in detail at MMC. However, all cases were analyzed for adverse event incidence, Clavien-Dindo risk profile, error assessment (i.e., diagnostic, judgment, technical, communication and system), management and high-risk surgery.  Management evaluation was  determined by a small group of senior surgeons not involved with individual cases. Reports were reviewed at the department and provider level, and used to guide quality improvement processes.    

Results: 

The overall mortality rate for the study group was 0.31%. Yet,  the mortality rate for patients sustaining an adverse event was 25.9% (194/741), or 11.3% (194/1714) of adverse events.  Patients without mortality sustained an average of 1.7 complications per case and patients who expired sustained an average of 2.84 complications per case. There were no statistically significant differences in the management of survivors vs. non-surviviors.  Returns to the operating room (RTOR), death, intrabdominal abcess, return to interventional suite (RTIS), and hemorrhage requiring transfusion were the most common adverse events reported overall.  Technical (60%), judgment (20.1%), system (13.1%) and diagnostic (6%) errors occurred with equal frequency between both campuses. Denominator adjusted complication and mortality rates in high-risk surgical procedures  ranged from 6.5% to 23.5%, and as high as 2.8%, respectively. Over eighty-five percent (85%)  of  reported cases had Clavien Dindo scores between Grade IIIa and Grade V, confirming that  post-operative RTIS, RTOR, ICU care for systemic disease and death were important features of the complication profile.

 

Conclusion:

 Denominator adjusted morbidity and mortality rates are elevated well beyond reported overall rates. The number of complications following surgery are statistically associated with mortality, and  patients who sustain a complication  have an eleven percent (11%) risk of death. This methodology has implications not only for focused quality improvement, but for teaching a logical approach to self-assessment in the context of residency training. This project describes the feasibility of combining MMC  with a standardized critique algorithm-based database to provide accurate risk-adjusted data useful for comprehensive assessment of  surgical quality.

 

 

30.04 Geriatric Syndromes Predict the Timing of Early Postoperative Do-Not-Resuscitate (DNR) Orders

Posted on January 18, 2018

M. A. Hornor1,2, R. A. Rosenthal1,3,5, T. N. Robinson1,4,6  1American College Of Surgeons,Chicago, IL, USA 2Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OH, USA 3Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 4University Of Colorado Anschutz Medical Campus,Department Of Surgery,Aurora, CO, USA 5Veterans Affairs Connecticut Health Care System,New Haven, CONNECTICUT, USA 6Veterans Affairs Eastern Colorado Health Care System,Aurora, COLORADO, USA

Introduction:  The timing of and risk factors for new DNR orders following surgery in older adults are not well defined. The goal of this study was to investigate the timing of new postoperative DNR orders and to determine if identifiable geriatric syndromes are associated with early postoperative DNR.

Methods:  We performed a retrospective cohort study using data from the American College of Surgeons’ (ACS) National Surgical Quality Improvement Project (NSQIP) Geriatric Surgery Pilot Project that collects an additional 20 geriatric and palliative care-specific variables at 26 hospitals.  Patients aged ≥ 65 who underwent an inpatient operation were included. The timing of postoperative DNR orders was determined and univariate and multivariate analyses were performed to examine the association between patient factors and early postoperative DNR orders, defined as a new DNR order placed on postoperative day 0-2.

Results: Of the 29,864 patients included in the study, 717 (2.4%) patients had a DNR order placed postoperatively, 329 (1.1%) of which were classified as early. Over half of the patients with early postoperative DNR’s underwent emergency surgery (58.1%). In the adjusted multivariate model, preoperatively identifiable geriatric syndromes were significantly associated with early postoperative DNR [Table 1].  

Conclusion: Early postoperative DNR orders are highly associated with preoperative geriatric syndromes and emergency operation status. The consideration of geriatric syndromes such as cognitive and functional status in shared decision making conversations prior to surgery may better inform advance care planning and surgical decision making. 

 

30.05 Influence of English Proficiency on Patient Provider Communication and Shared Decision Making

Posted on January 18, 2018

A. Z. Paredes1, J. Idrees1, E. W. Beal1, Q. Chen1, E. Cerier1, V. Okunrintemi1, G. Olsen1, S. Sun1, T. M. Pawlik1  1Ohio State University,General Surgery,Columbus, OH, USA

Introduction: The proportion of Hispanic and Asian persons in the United States is expected to increase over the next 50 years. In turn, the number of patients who speak a language other than English will also continue to increase. The effect of English proficiency on health care outcomes has been poorly studied, yet may be important. Therefore, we sought to define the impact of English proficiency on self-reported patient provider communication and shared decision-making.

Methods: The 2013-2014 Medical Expenditure Panel Survey database was utilized to identify respondents who spoke a language other than English and who had self-rated their proficiency in English. Patient provider communication (PPC) and Shared Decision Making (SDM) were characterized into three categories using a composite score that ranged from 4 to 12 (score 4-7: “poor," 8-11: “average,” and 12 “optimal”). The relationship between PPC, SDM and English proficiency was analyzed using regression analysis.

Results: 13,880 respondents spoke a language other than English and self-rated their English proficiency. Most respondents were white (n=10,281, 75%), age 18-39 years (n=6,677, 48%), male (n=7,275, 52%), middle income (n=4,125, 30%), born outside of the United States (n=9,125, 65%), and currently lived in the Western region of the United States (n=5,812, 42%). English proficiency was rated as “very well” (n=7,221, 52%), “well” (n=2,378, 17%), “not well” (n=2,820, 20%) or “not at all” (n=1,463, 10%). Among individuals who self-reported English proficiency as “not at all,” 81% had the medical interview conducted completely in the patient’s native language with or without the use of translator (“well” 38% vs. “not well” 72%  p=<0.001). On multivariable analysis, compared with “very well,” patients who self-reported English proficiency as “well” (OR 1.21, CI 1.033–1.42) or “not well” (OR 1.21, CI 1.04–1.43) were more likely to report "poor" PPC (both p<0.02). Similarly, SDM was more commonly self reported as “poor” among patients who reported English proficiency as “not well” (OR 1.31, CI 1.04–1.65, p=0.02). Compared with patients with “very well” English proficiency, individuals who reported “not at all” English proficiency had comparable PPC (OR 1.0, CI 0.82–1.23) and SDM (OR 0.96, CI 0.72–1.28) scores (p>0.05, both). Of note, the majority of patients who reported “poor” PPC had self-reported their proficiency as “well” and therefore had their interview conducted in English (n=413, 72%).

Conclusion: Decreased English proficiency was associated with worse self-reported PPC and SDM. Among patients for whom English was a second language, PPC was “poor” even among patients who reported English proficiency as “well” when the interview was conducted in English. Attention to the patient language needs is critical to patient satisfaction.

30.06 MELD Underestimates Morbidity and Mortality in Cirrhotic Patients for General Surgical Procedures.

Posted on January 18, 2018

M. Fleming1, F. Liu2,4, Y. Zhang2,3, K. Pei1  1Yale School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Sciences,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, BEIJING SHI, China

Introduction:
Ascites and the Model for End-Stage Liver Disease (MELD) score independently predict surgical morbidity and mortality. However, MELD, unlike other scoring systems for chronic liver disease such as the Child’s-Turcotte-Pugh, does not include the presence of ascites. Recently, MELD score has been shown to underestimate morbidity and mortality for cirrhotic patients undergoing colectomy for diverticulitis. We sought to ascertain whether this previously reported underprediction was generalizable to cirrhotic patients with ascites across a multitude of general surgery procedures.

Methods:
We performed an analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 through 2014 to calculate risk adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing the following common surgical procedures including both open and laparoscopic approaches: inguinal hernia repair, adhesiolysis for small bowel obstruction, cholecystectomy for acute cholecystitis, and ventral hernia repair. Stratification was performed by MELD score and presence of ascites. Patients with and without ascites were compared within each MELD stratum (low, moderate, and high) utilizing low MELD and no ascites as a reference group.

Results:
Overall there were 30,391 procedures included of which 19,311 (63.54%) were open and 11,080 (36.46%) were laparoscopic. Compared to the low MELD strata with no ascites, each group had increased risk for complications (all p < 0.0001) and within each MELD stratum the presence of ascites portends increased risk for complications (low MELD with ascites adjusted OR 3.22 CI 2.00-5.18, moderate MELD no ascites adjusted OR 1.72 CI 1.55-1.90, moderate MELD with ascites adjusted OR 3.70 CI 2.64-5.19, high MELD without ascites adjusted OR 2.93 CI 2.53-3.39, high MELD with ascites adjusted OR 6.38 CI 4.39-9.26). The same findings hold true when evaluating mortality (all p < 0.0001, low MELD with ascites adjusted OR 9.40 CI 3.53-25.01, moderate MELD without ascites adjusted OR 3.22 CI 2.36-4.40, moderate MELD with ascites adjusted OR 15.24 CI 8.17-28.45, high MELD without ascites adjusted OR 7.01 CI 4.90-10.05, high MELD with ascites adjusted OR 28.56 CI 15.43-52.88).  These trends hold true for all 4 general surgical procedures when adjusted morbidity and mortality were analyzed by procedure.

Conclusion:
Ascites increases the risk of perioperative morbidity and mortality across a myriad general surgery procedures in chronic liver disease patients when stratified by MELD score. These findings suggest that ascites plays a critical physiologic and predictive role for surgical patients that is not incorporated into MELD. Further studies should attempt to prospectively validate a novel clinical score inclusive of ascites that may predict outcomes with better accuracy.
 

30.02 Gender Disparities in Retention and Promotion of Academic Surgeons: A Prospective National Cohort

Posted on January 18, 2018

N. Z. Wong1, J. S. Abelson1, M. Symer1, H. L. Yeo1,2  1Weill Cornell Medicine,Surgery,New York, NY, USA 2Weill Cornell Medicine,Healthcare Policy And Research,New York, NY, USA

Introduction: Women comprise 38.3% of general surgery residents in the U.S., but only 9.8% of full professors in academic general surgery. Previous studies have identified factors contributing to the underrepresentation of women in academic surgery, but no study has quantified the rates of retention and promotion of early and mid-career female academic surgeons.  As a result, we used data from the American Association of Medical Colleges (AAMC) Faculty Roster to track a national cohort of academic surgeons over time to evaluate gender disparities in retention and promotion.

Methods: Data were extracted from the AAMC Faculty Roster for all first-time appointments of full-time assistant and associate professors of surgery starting their academic careers between January 1, 2003 and December 31, 2006; these faculty were individually followed over 10 years to determine if they stayed in full time academic practice (retained) or were promoted.  Cumulative counts of retained or promoted faculty at the end of the 10-year follow up period were compared using Fisher’s exact test. The impact of gender on retention and promotion during the study period was analyzed with survival analysis by log-rank test.

Results: The analysis included retention and promotion data for 3,966 early and mid-career (assistant and associate professors) academic surgeons. Over the 10-year follow up, there were no differences in retention rates between women and men for assistant professors (50% vs. 46%, p=0.10) or associate professors (39% vs. 35%, p=0.27). Survival analysis did not demonstrate a significant difference in retention rates by gender for either academic level (assistant/associate). However, when comparing rates of promotion, women both at the assistant (29% vs 34%, p=0.02) and associate (32% vs. 42% p=0.01) level were promoted at significantly lower rates compared to their male collogues. Furthermore, 10-year survival analysis demonstrated a significant difference in promotion rates in full-time academic surgery for both assistant and associate professors (log-rank p=0.03 and p=0.03, respectively).

Conclusion: This study is the first to quantify gender disparities in retention and promotion rates among U.S. academic surgeons using a comprehensive and prospective national database. Findings suggest that academic surgery retention rates are similarly low between women and men, while promotion rates are significantly lower for women faculty. These findings demonstrate that women surgeons are at increased likelihood of non-promotion in academia, likely contributing to decreased gender diversity at the full professor level. We should consider strategies to improve retention of junior faculty (both men and women) over time.  Additional research on the relationship between gender and promotion will be critical to effectively increasing and maintaining workforce diversity.
 

30.03 Medicare's HAC Reduction Program Disproportionately Affects Minority-Serving Hospitals

Posted on January 18, 2018

C. K. Zogg1,2, J. R. Thumma2, A. M. Ryan2, J. B. Dimick2  1Yale University School Of Medicine,New Haven, CT, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: In FY2015, Medicare began reducing payments to hospitals with high adverse-event rates. Termed the Hospital Acquired Condition (HAC) Reduction Program, concern has been expressed that HAC penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. The objective of this study was to examine the extent to which a hospital’s percentage of minority patients associates with FY2017 a) overall/domain-specific HAC scores and b) HAC penalty receipt. Differences in socioeconomic status (SES) and hospital receipt of DSH payments (a marker of safety-net status) were also assessed.

Methods:  Older adult (≥65y) inpatients presenting for eight common surgical conditions were identified using 2013-2014 100% Medicare fee-for-service claims. Records were matched to risk-adjusted FY2017 HAC scores/penalties and hospital-level data from Medicare Hospital Impact files and the AHA Annual Survey Database. Differences were compared using multilevel logistic regression and calculation of absolute percentage-point change. Restricted analyses addressed the possibility that marginal changes among the most vulnerable (likely to be penalized) institutions could be driving the differences observed.

Results: As a hospital’s percentage of minority patients increased, climbing from 1.0 to 25.1%, average HAC scores also increased, rising from 5.8 to 6.3 (higher values indicate worse scores). Increases in penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of minority-serving extent (45.7 vs 36.7%; OR[95%CI]: 1.45[1.42-1.47])—absolute difference +8.9% (Figure). Similar patterns were seen for safety-net (1.44[1.42-1.47]) and low SES-serving (1.38[1.35-1.40]) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated differences in penalties when limiting hospitals to those at highest risk (more residents-to-beds, more severe)—absolute differences +13.9% and +20.5%. Restriction to high operative volume, in contrast, reduced the penalty difference—absolute difference +6.6%.

Conclusion: Minority-serving hospitals are being disproportionately affected by the HAC Reduction Program. While scores followed a stepwise increase, disparities in penalty allocation were isolated to hospitals with the largest minority-serving extent—a finding which became more pronounced among hospitals with an already heightened risk of penalty receipt. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions in order to ensure that disparities do not increase.

 

30.01 Domestic responsibilities for physician mothers across specialties.

Posted on January 18, 2018

H. G. Lyu1, R. E. Scully1, J. S. Davids2, N. Melnitchouk1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University Of Massachusetts Medical School,Surgery,Worcester, MA, USA

Introduction: Despite an increase in women in medicine, there are disproportionately few in academia and leadership positions. We hypothesized that early career physician mothers face greater burnout and career dissatisfaction due to unequal domestic responsibilities.

Methods: Data from 2,360 U.S. physician mothers were gathered via an anonymous, IRB-approved online survey. Univariate analysis was performed using Chi-squared tests.

Results: The majority of respondents (97.7%) were married or partnered. Physician mothers reported having sole responsibility for the majority of domestic needs, compared to their significant other, including routine childcare plans  (56.8% vs 12.0%), back-up childcare plans (44.0% vs 26.7%), cooking (43.0% vs 25.6%), groceries (45.1% vs 24.7%), shopping for clothing (85.0% vs 2.9%), vacation planning (50.0% vs 15.6%), helping with homework (21.6% vs 3.6%), and laundry (46.6% vs 14.1%). By contrast, physician mothers reported that their significant others were more likely than them to have sole responsibility for home repairs (62.7% vs 12.0%), finances (45.7% vs 30.0%), and automobile maintenance (57.4% vs 11.3%). Compared to physician mothers whose significant other was a stay-at-home parent, those whose significant other was a physician were significantly more likely to be solely responsible for routine child care plans, (72.5%% vs 8.9%, p<0.001); this was even more pronounced for the subset with surgeon spouses, (80.8% vs 8.9%, p<0.001). Female physicians who report having an unsupportive significant other are more likely than those with supportive significant others to report burnout or desire to switch careers (8.3% vs 4.2%, p<0.001).

Conclusions: Female physicians continue to carry more domestic responsibility than their significant others, even when they are both physicians. Increased domestic responsibility correlated with having an unsupportive partner, as well as a desire to switch to a less demanding career or specialty.

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