27.02 Induction Chemotherapy versus Standard Treatment for Locally Advanced Rectal Cancer

Posted on January 18, 2018

C. Nganzeu1, J. J. Blank1, F. Ali1, W. Hall2, C. Peterson1, K. Ludwig1, T. Ridolfi1  2Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 1Medical College Of Wisconsin,Department Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
The standard treatment of stage II or III rectal adenocarcinoma is chemoradiation therapy (CRT) followed by surgical resection and adjuvant systemic chemotherapy. Recently there has been increased interest in the use of induction chemotherapy (IC), an approach that provides some or all systemic chemotherapy and CRT in the preoperative setting. Potential benefits of this treatment paradigm include tumor downstaging, early treatment of micrometastases, increased rate of sphincter preservation, decreased time with a diverting stoma, and patient compliance. However, little is known about this treatment strategy on a national level. The aims of this study were to define the frequency of IC use and evaluate treatment outcomes compared to standard CRT using the National Cancer Database.

Methods:
The National Cancer Database was queried for patients diagnosed with stage II or III rectal adenocarcinoma having received radiation, chemotherapy and surgical resection between 2004 and 2014. We compared patients with IC to patients having received standard combined CRT. Linear regression was performed to predict percent patients receiving IC by year. Propensity score matching was applied in a 1:10 fashion. A logistic model was fitted to obtain propensity scores. A greedy matching algorithm was then applied for predictor selection. Outcomes including downstaging, readmission, positive margins, and survival were evaluated.

Results:
A total of 33,480 patients met inclusion criteria. 96.4% of patients underwent standard CRT while 3.6% underwent IC. Of all patients diagnosed with stage II and III rectal cancer, only 2.8% received IC in 2004; this number rose to 4.4% in 2014. Propensity score matching yielded 10,531 patients receiving standard CRT and 1,073 patients who received IC for the analysis. The IC group had more tumor downstaging than standard CRT on surgical pathology (54% vs. 48.8%, p=0.006, respectively). This group also had significantly fewer 30-day readmissions after surgery (4.5% vs. 6.4%, p=0.021, respectively). There were no differences observed in 30-day or 90-day mortality (0.5% vs. 0.5%, p= 0.247 and 0.8% vs. 1.1%, P= 0.755, respectively), rate of positive margins (4.8% vs. 5.6%, p=0.398, respectively), or survival (p=0.587) between the two groups.

Conclusion:

The use of induction chemotherapy for patients with stage II and III rectal cancer increased significantly from 2004-2014. Induction chemotherapy was associated with improved downstaging before surgery and improved 30-day readmission rates after surgery without changing overall survival when compared to standard chemoradiation therapy.

 

26.09 Non-Home Discharge and Prolonged Length of Stay after Cytoreductive Surgery and HIPEC

Posted on January 18, 2018

D. Burguete1, A. A. Mokdad2, M. M. Augustine2, R. Minter2, J. C. Mansour2, M. A. Choti2, P. M. Polanco2  1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Division Of Surgical Oncology,Dallas, TX, USA

Introduction:  The ability to preoperatively anticipate prolonged length of stay (PLOS) or transition to an extended care facility (non-home discharge, i.e., NHD) may facilitate discussion of patient expectations and improve utilization of hospital resources. Predictive models for NHD after some major surgical procedures have already been proposed. No data has been reported on the rate and risk factors associated with NHD and PLOS in patients following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis. The aim of this study is to identify risk factors for NHD and PLOS following CRS/HIPEC in a national cohort of patients.

 

Methods:  The National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients who underwent CRS/HIPEC between 2011-2012. Patients designated as NHD and PLOS (>30d) were compared to the group of patients discharged to home within 30 days. Univariate analysis was used to compare patient demographics, preoperative labs, comorbidities, and intra and peri-operative variables among both groups. Multivariate analysis was used to identify independent predictors of NHD and PLOS.

 

Results: A total of 556 patients who underwent CRS/HIPEC were identified, of which 44 (7.91%) had a NHD/PLOS. From this group, 12 (27.2%) were discharged to a skilled care facility, 11 (25%) were discharged to a rehabilitation facility, and 21 (47.7%) remained hospitalized at 30 days. On univariate analysis, advancing age, chronic obstructive pulmonary disease, hypertension, low preoperative albumin and low preoperative platelets were identified as preoperative risk factors for NHD/PLOS (p values < 0.05). On multivariate analysis, age ≥ 65, pre-op albumin < 3.0 g/dL, and having a multi-visceral resection were identified as independent predictors of NHD/PLOS (Table 1.). If all three predictors are met, the probability of NHD/PLOS is 30.2%.

 

Conclusion: In this national cohort of patients, advanced age, hypoalbuminemia, and multi-visceral resection constituted the main risk factors for NHD/PLOS following CRS/HIPEC. Adequate identification of these risk factors may facilitate preoperative discussions with patients, and improve discharge planning and resource utilization. 

 

 

26.10 Molecular Profiling in Patients with Nodular verus Superficial Spreading Melanoma

Posted on January 18, 2018

M. Renzetti1, I. Solimon1, K. Loo1, E. Lamb1, H. Wu1, B. Luo1, H. Liu1, A. Olszanski1, S. Movva1, M. Lango1, S. Reddy1, J. Farma1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction: The use of next generation sequencing (NGS) molecular profiling has become increasingly important in characterizing cancers and their subtypes. Our institution has been using NGS to examine mutations in 50 cancer-related genes. It is well established that the nodular subtype of malignant melanoma (MM) tend to be more invasive, ulcerated, and have more mitoses than superficial spreading subtype (SS). Here we examine the use of molecular profiling of patients who presented with either SS or nodular type MM.

Methods:  Patients with either SS or nodular type MM were included in the study. Using NGS, we analyzed tissue samples for mutations in targeted regions of 50 cancer-related genes. Clinical and pathologic data were collected.

Results: We performed NGS on 179 patients with MM. Of these, 51 patients presented with nodular type MM, and 46 with SS type.  Median age at diagnosis was 64 for nodular and 59 for SS (range 22-81). 65.3% and 74% were male in nodular and SS respectively. Location of the primary included head and neck (8 nodular, 4 SS), upper extremity (15 nodular, 11 SS), lower extremity (11 nodular, 10 SS) and truncal (17 nodular, 21 SS).  At presentation, 2 nodular and 7 SS were stage I, 19 nodular and 7 SS were stage II, 26 nodular and 31 SS were stage III, and 4 nodular and 1 SS were stage IV.  Of the tissue tested, 53% (n=51) were from the primary tumor.  In the nodular type, 86 total mutations were identified over 43 unique genes, and in SS type, 73 mutations were identified affecting 35 unique genes (p = 0.34).

In nodular type, no mutations were found in 16% of patients (n=8), while 43% of patients (n=13) had one mutation, 24% (n=12) had 2 mutations, 14% (n=7) had 3 mutations, and 10% (n=5) had 4 or more mutations. The most frequently identified mutations included NRAS (33%, n=17), BRAF V600E (29%, n=15), TP53 (22%, n=11), CDKN2A (10%, n=5), and CTNNB1 (8%, n=4).

In SS type, no mutations were found in 2% of patients (n=1), while 61% of patients (n=28) had only one mutation, 24% (n=11) had 2 mutations, 7% (n=3) had 3 mutations, and 7% (n=3) had 4 or more mutations. The most frequently identified mutations were NRAS (35%, n=16), BRAF V600E (33%, n=15), TP53 (17%, n=8), BRAF V600R (11%, n=5), and PTEN (11%, n=5). There was no significant difference in the molecular profiles between nodular and SS types.

Conclusion:We found that the most frequent mutations in nodular melanomas were NRAS, BRAF V600E, TP53, CDKN2A, and CTNNB1, and the most frequent superficial spreading mutations were NRAS, BRAF V600E, TP53, BRAF V600R, and PTEN. It appeared to be more common to have no mutation in nodular melanoma. Future studies will further identify mutation patterns in MM subtypes and correlate them with treatment response.

26.07 Exon Mutational Analysis for GIST: Dissemination and Impact on Treatment

Posted on January 18, 2018

A. J. Bartholomew1, H. Dohnalek1, P. Prins2, H. S. Quadri3, L. B. Johnson3, N. G. Haddad4, J. L. Marshall2,5, W. B. Al-Refaie2,3,6,7  1Georgetown University Medical Center,School Of Medicine,Washington, DC, USA 2Georgetown University Medical Center,Lombardi Comprehensive Cancer Center, Ruesch Center For The Cure Of Gastrointestinal Cancers,Washington, DC, USA 3Georgetown University Medical Center,Surgery,Washington, DC, USA 4Georgetown University Medical Center,Gastroenterology,Washington, DC, USA 5Georgetown University Medical Center,Hematology/Oncology,Washington, DC, USA 6MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 7MedStar Health Research Institute,Hyattsville, MD, USA

Introduction:  Tyrosine kinase inhibitors (TKI) have become the guideline-recommended therapy for high-risk resected, recurrent, and metastatic gastrointestinal stromal tumors (GIST). Exon mutational analysis (EMA) is used to inform pre-therapy response to TKI and may predict overall prognosis. Despite these benefits, EMA remains underused, and its impact on TKI therapy decision-making remains unexplored. We sought to better characterize the use of EMA in GIST patients receiving TKI and to quantify the subsequent impact on treatment at a comprehensive cancer center.  

Methods:  A retrospective cohort was established from 104 patients who received treatment for pathologically confirmed, c-KIT-positive and -negative GIST from 2006 to Jan 2017. Variables collected included patient, tumor, and treatment characteristics. According to current National Comprehensive Cancer Network (NCCN) guidelines, EMA should be considered for all patients undergoing TKI therapy to identify genotypes that will, or will not, respond to treatment. We first tracked guideline-considered EMA use in GIST patients who received TKI over time. We then identified how the return of EMA results informed treatment decision-making across the study period. 

Results: Among the 104 GIST patients, 54 (52%) of patients received adjuvant or neoadjuvant TKI. Of these 54 patients, only 22 (41%) received EMA, as considered by NCCN guidelines. The use of EMA varied during our study course (Figure 1). Genotypes identified from EMA included 50% of patients with a mutation in KIT exon 11, 5% with KIT exon 9, 9% with PDGFRA exon 18, and 36% with wildtype GIST. Informed by these EMAs, TKI treatment decisions included 59% who continued on their original TKI regimen, 32% who switched to an alternative TKI treatment, and 9% who discontinued TKI treatment based on primary resistance. 

Conclusion: Less than half of patients receiving TKI therapy for GIST received EMA at a comprehensive cancer center. Despite this low uptake, when it was performed, EMA resulted in an alternative treatment decision in 41% of patients. Future interventions are needed to identify and mitigate barriers responsible for underuse of EMA prior to initiating TKI therapy for GIST. 

 

26.08 Consecutive Case Series of Melanoma Sentinel Node Biopsy for Lymphoseek Compared to Sulfur Colloids

Posted on January 18, 2018

C. Silvestri1, A. Christopher1, C. Intenzo2, J. Kairys1, S. Kim2, A. Willis1, A. C. Berger1  1Sidney Kimmel Medical College At Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Thomas Jefferson University Hospital,Nuclear Medicine/Radiology,Philadelphia, PA, USA

Introduction:
Sentinel lymph node biopsy (SLNB) is the current standard of care for patients diagnosed with melanoma >1mm. Preoperative lymphoscintigraphy with radiolabeled isotopes is essential to localize sentinel nodes for removal. Our study compared the effectiveness of Lymphoseek to standard sulfur colloids (SC) during lymphoscintigraphy in patients with melanoma undergoing SLNB.

Methods:
We queried our IRB-approved melanoma database at Thomas Jefferson University to identify 370 consecutive patients who underwent SLNB between 2012-2016 and at least one year of follow up. There were 185 patients who underwent SLNB with the standard SC, and 185 patients who underwent SLNB with Lymphoseek. Data points included primary characteristics of the melanoma (primary site, Breslow thickness, ulceration), lymphoscintigraphy (dosage of radiotracer, mapping time), and SLNB (number of sentinel nodes removed, number of positive sentinel nodes, and false negatives). Student’s t-test and Chi-Square were used to analyze the data with a p-value of <0.05 being considered significant.

Results:
Between the two groups, patients were equally matched in regard to age, sex, and primary characteristics of their melanoma including thickness, primary site, and presence of ulceration. In comparison to SC, Lymphoseek required lower radiation dosages (p<0.001), shorter mapping times (p=0.008), and decreased number of sentinel nodes removed (p=0.03). There was no difference in the number of patients with positive nodes (p=0.5). Additionally, there were no statistical differences between the two radioactive tracers in regard to average number of hot spots per basin, or the number of patients with false negative SLNB.

Conclusion:
Lymphoseek has the potential to decrease radioactivity and mapping time in patients who need SLNB. With a decrease in the number of nodes removed without loss of sensitivity, there is a potential to avoid unnecessary node removal and thus complications such as lymphedema. Longer follow-up will help to determine if there is any increase in false negative rates despite fewer nodes removed.
 

26.05 Perioperative Chemotherapy Use for High Grade Truncal Sarcomas May Not Improve Survival

Posted on January 18, 2018

P. Y. Yu1, E. W. Beal1, L. Suarez-Kelly1, R. Shelby1, T. M. Hughes1, C. G. Ethun2, T. B. Tran3, G. Poultsides3, J. Charlson4, T. C. Gamblin4, J. Tseng5, K. K. Roggin5, K. Chouliaras6, K. Votanopoulos6, B. A. Krasnick7, R. C. Fields7, R. E. Pollock1, V. Grignol1, K. Cardona2, J. H. Howard1  1Ohio State University,Columbus, OH, USA 2Emory University School Of Medicine,Atlanta, GA, USA 3Stanford University,Palo Alto, CA, USA 4Medical College Of Wisconsin,Milwaukee, WI, USA 5University Of Chicago,Chicago, IL, USA 6Wake Forest University School Of Medicine,Winston-Salem, NC, USA 7Washington University,St. Louis, MO, USA

Introduction:  The benefit of perioperative chemotherapy (CTX) for treatment of truncal soft-tissue sarcoma (STS) is not well established. Our aim was to determine the effect of CTX on the outcomes of patients with surgically resected primary truncal STS.

Methods:  Adult patients with high grade truncal STS who had primary resection for curative intent from 2000-2016 at 7 U.S. institutions were evaluated retrospectively. Patients with well-differentiated liposarcoma, dermatofibrosarcoma protuberans, desmoid tumors, low-grade sarcomas or palliative resections were excluded. Patients were stratified by receipt of CTX. Categorical variables were compared using chi-square or Fisher exact test. Continuous variables were compared using two-sample t-tests or Mann-Whitney U test. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) and recurrence-free survival (RFS). Logistic regression models were used to evaluate characteristics associated with OS.

Results: Of patients with high grade truncal STS, 235 received curative intent resections. The most common histology was undifferentiated pleomorphic sarcoma and mean tumor size was 7.8 cm. Thirty percent of the patients received CTX (n=70): 10% (n=24) neoadjuvant CTX, 13% (n=31) adjuvant CTX and 6% (n=15) neoadjuvant and adjuvant CTX. Patients who received CTX were younger (48 vs 59 yrs, p<0.001), less likely to have hypertension (30% vs 50%, p<0.01), more likely to have deep tumors (86 vs 73%, p<0.05), radical resections (87 vs 72%, p<0.05), chest wall/rib resections (43 vs 24%, p<0.01), solid organ invasion (14 vs 3%, p<0.01), longer operative time (228 vs 142 min, p<0.01) and radiation (51 vs 34%, p<0.05). On univariate analysis patients who received CTX had significantly worse OS (p<0.01) and a trend towards worse RFS (p=0.08) (Fig 1). Margin status was the only variable associated with OS on multivariate analysis (OR 4.36, 95% CI 1.56, 12.13, p<0.01).

Conclusion: In this multi-institutional retrospective analysis of high grade truncal STS undergoing curative resection, microscopically-negative margin status was the only independent factor associated with better survival. The receipt of perioperative CTX was not associated with improved OS which may be explained by selection bias. Treating physicians at high-volume sarcoma centers can predict patients likely to have poor outcomes based on clinical and surgical findings. This results in a higher likelihood to administer CTX to patients with worse tumor biology. Our findings emphasize the importance of margin-negative resection as the foundation of optimal sarcoma treatment as well as the need for a better biologic understanding of truncal STS to help guide clinical decision making.

26.06 Preoperative Immunonutrition for Axillary or Inguinal Lymphadenectomy: Tolerability and Outcomes.

Posted on January 18, 2018

D. B. Porter1, K. M. McMasters1, C. R. Scoggins1, R. C. Martin1, M. E. Egger1, P. Philips1  1University Of Louisville,Louisville, KY, USA

Introduction:
Axillary and inguinal lymphadenectomy for melanoma is associated with a high infectious complication rate and lymphedema. There are conflicting data on the efficacy of preoperative immunonutritional supplementation in reducing infectious complication rates mostly after abdominal surgery. The aim of this study is to assess the tolerability and efficacy of preoperative immunonutrition in reducing infectious complications after inguinal and axillary lymphadenectomy.

Methods:
Thirty-nine patients who underwent inguinal/axillary lymphadenectomy for melanoma, between 2014-2017, received 5 days of immunonutritional supplement (3 cans of Impact AR®, Nestle® containing arginine, omega-3 fatty acids, nucleotides) preoperatively and perioperative outcomes were compared with thirty-nine patients from 2011-2017 who did not receive nutritional supplementation from a prospective melanoma database. All patients underwent nutritional assessment using the MUST (Malnutrition Universal Screening Tool) score and malnourished patients (score >1) were excluded from this study.  High-grade infectious complications were defined as infections requiring intervention or hospitalization (CTCAE V4.03, Grade 3 or higher). 

Results:
Immunonutrition group and control group had similar comorbidities (diabetes: 6 vs. 7, p=0.6572, tobacco use: 15 vs. 15), primary site (truncal 18 vs. 19, extremity 21 vs. 20, p=0.748) and lymphadenectomy site (groin 16, axillary 23 each). Median lymph node yields were similar between both groups for axillary (19, IQR 13, 23.5 vs. 18, IQR 13.5, 23.5, p=0.872) and inguinal lymphadenectomy (15 IQR 10, 21 vs. 15, IQR 11.5, 20, p=0.853). Overall compliance was good with 31 (79.5%) patients completing the 5-day course and 8 (20.5%) completing at least 3 days. Reasons for poor compliance were dislike of the supplement flavor in 5 and bloating in 4. No significant difference was noted between the two groups with respect to postoperative seroma rate, prolonged drainage, length of hospital stay and lymphedema rates. Overall complication rates were similar (19, 48.7% vs. 24, 61.5%, p=0.2513) but the immunonutrition group had a lower total number of patients with infectious complications (7 vs. 14, p=0.0035) and fewer high-grade infections (3 vs. 8, p=0.0027). 

Conclusion:
Preoperative immunonutrition with Impact AR® was well tolerated and in well-nourished patients demonstrated a significant decrease in infectious complications. A larger randomized trial is needed to further investigate this finding. 
 

26.04 The Prognostic Significance of Tumor-Infiltrating Lymphocytes for Primary Melanoma Varies by Gender

Posted on January 18, 2018

A. J. Sinnamon1, C. E. Sharon1, Y. Song1, M. G. Neuwirth1, D. E. Elder2, X. Xu2, D. L. Fraker1, P. A. Gimotty3, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,Endocrine And Oncologic Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Pathology,Philadelphia, PA, USA 3University Of Pennsylvania,Biostatistics, Epidemiology And Informatics,Philadelphia, PA, USA

Introduction:
The immune response to melanoma, manifested locally by tumor-infiltrating lymphocytes (TILs), has gained increasing attention in the era of effective immunotherapies. Men and women are known to have varying patterns of immunity, yet gender-specific prognostic implications of TILs have not been explored.

Methods:
Patients with clinically localized primary melanoma ≥0.76mm who underwent sentinel lymph node (SLN) biopsy were identified within our institutional melanoma database. Association between TILs (categorized as absent, nonbrisk, and brisk) and SLN positivity was evaluated using logistic regression. The possibility of interaction between gender and TILs on the rate of SLN positivity was assessed using the Wald test. Overall survival estimates were obtained using the Kaplan-Meier method and Cox regression with separate analyses performed by gender.

Results:
Among 1,367 patients identified, 794 (58%) were men. TILs were brisk in 143 (10%) lesions, nonbrisk in 903 (66%), and absent in 321 (23%); this distribution did not vary by gender (p=0.71). Among men, SLN positivity rate was significantly associated with TILs (brisk 3.8%, nonbrisk 16.9%, absent 26.6%, p<0.001). In contrast, there was no significant relationship between TILs and SLN status in women (see figure; p=0.49). Significant interaction between brisk TILs and female gender on SLN status was identified (p=0.029). This interaction remained significant in multivariable analysis adjusting for clinicopathologic factors (p=0.043). Among men, presence of brisk TILs was associated with prolonged overall survival (brisk HR 0.43, p=0.038; nonbrisk HR 0.84, p=0.34). This association was no longer significant after adjustment for SLN status (brisk HR 0.72, p=0.42; nonbrisk HR 1.05, p=0.79). In contrast, no association between TILs status and overall survival was observed among women (brisk HR 0.97, p=0.95; nonbrisk HR 1.06, p=0.85).

Conclusion:
The negative prognostic implications of absent TILs on SLN status and thus on survival appear to be stronger among men than women. This may provide some basis for better melanoma-specific prognosis among women.

26.02 Tumor Mitotic Rate: A Strong, Independent Predictor of Survival for Localized Melanoma

Posted on January 18, 2018

J. L. Evans1, R. J. Vidri1,2, D. C. MacGillivray1, T. L. Fitzgerald1  1Tufts University School Of Medicine – Maine Medical Center,Surgery,Portland, ME, USA 2St. Mary’s Regional Medical Center,Surgery,Lewiston, ME, USA

Introduction:
The prognostic significance of tumor mitotic rate (TMR) for patients with localized melanoma has engendered significant controversy. Although several small studies have validated TMR as a prognostic marker for this disease, TMR is no longer incorporated in the AJCC staging paradigm. To better define TMR as an independent predictor of disease-specific survival for localized melanoma, we performed a cohort study utilizing an administrative cancer database.

Methods:
Patients diagnosed with localized cutaneous melanoma from 2010 to 2014 were identified from the SEER registry. TMR was then categorized into three groups based on the number of mitoses:  0-3 mitoses/mm2 (Group 1), 4-10 mitoses/mm2 (Group 2), and >10 mitoses/mm2 (Group 3). Five-year disease-specific survival for stage and TMR category were calculated using the Kaplan-Meier method, groups were compared using the log-rank test. Multivariate analysis was performed using Cox proportional hazards model. (Using JMP 13. Cary, NC: SAS Institute Inc.)

Results:
A total of 71,235 patients were included; the majority were white (94.7%), male (58.5%), and had Stage I disease (79.0%). When analyzed both as a categorical and a continuous variable, TMR was associated with disease-specific survival for all TNM stages.   Univariate analysis demonstrated that 5-year disease-specific survival decreased with increasing TMR in Groups 1, 2, and 3 for Stage I (98.31%, 90.90%, 79.74%; p<0.0001), Stage II (86.07%, 74.17%, 72.85%; p<0.0001), and Stage III melanoma (72.52%, 58.58%, 49.65%, p<0.0001).  Multivariate analysis controlling for age, race, sex, primary site, ulceration, and Breslow thickness revealed an increased mortality risk for those melanoma with 4-10 mitosis/mm2 and more than 10 mitosis/mm2, when compared to those with 0-3 mitosis/mm2: Stage I (RR=3.00 and 6.90 p<0.0001), Stage II (RR=1.37 and 1.63, p=0.0002), and Stage III disease (RR=1.33 and 1.46 p=0.0004).  When analyzed as a continuous variable in this model, each unit increase in TMR increased the risk of death by 22% in Stage I (p<0.0001), 5% in Stage II (p<0.0001), and 4% in Stage III melanoma (p<0.0001).

Conclusion:
This retrospective cohort study, the largest to date; suggests that tumor mitotic rate is a strong, and independent predictor of disease-specific survival in melanoma. While the literature has previously demonstrated the prognostic value of TMR in Stage I disease, the present study expands upon this knowledge by demonstrating a similar relationship in Stage II and III melanoma.
 

26.03 A Multi-institutional Analysis of Elderly Patients Undergoing Resection for Retroperitoneal Sarcomas.

Posted on January 18, 2018

K. H. Wilkinson1, C. G. Ethun2, M. Hembrook1, M. Bedi5, J. Charlson4, H. Mogal1, K. K. Christians1, T. B. Tran3, G. Poultsides3, V. Grignol6, J. H. Howard6, J. Tseng7, K. K. Roggin7, K. Chouliaras8, K. Votanopoulos8, D. Cullinan9, R. C. Fields9, S. Weber10, T. C. Gamblin1, K. Cardona2, C. N. Clarke1  1Medical College Of Wisconsin,Division Of Surgical Oncology,Milwaukee, WI, USA 2Winship Cancer Institute, Emory University,Department Of Surgery,Atlanta, GA, USA 3Stanford University,Department Of Surgery,Palo Alto, CA, USA 4Medical College Of Wisconsin,Department Of Medical Oncology,Milawuakee, WI, USA 5Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 6The Ohio State University,Department Of Surgery,Columbus, OH, USA 7University Of Chicago,Department Of Surgery,Chicago, IL, USA 8Wake Forest University,Department Of Surgery,Winston-Salem, NC, USA 9Washington University,Department Of Surgery,St. Louis, MO, USA 10University Of Wisconsin,Department Of Surgery,Madision, WI, USA

Introduction: Little is known about the postoperative outcomes of elderly (≥70yrs) patients undergoing radical resection of retroperitoneal sarcomas (RPS).  We hypothesize that biological age impacts outcomes and prognosis after surgical resection in patients with RPS.

Methods: Three hundred and nine patients undergoing surgical resection for primary or recurrent RPS between 2000 and 2015 at participating US Sarcoma Collaborative institutions were identified. Patient demographics, perioperative morbidity, mortality, length of stay (LOS), discharge to home, disease specific survival (DSS) and disease free-survival (DFS) were compared between elderly (≥70yrs, n=69) and non-elderly (<70yrs, n= 240) patients.

Results: Median age at time of surgery for  elderly and non-elderly patients was 76yrs (IQR=7) and 55yrs (IQR=18), respectively . Elderly patients had a median ASA of 3 (IQR =1) while non-elderly had a median of 2 (IQR =1). Median tumor size was larger in the elderly group (12 cm [IQR=15] vs. 9 cm [IQR=8], p =0.004). There was no difference in median operative time (183 mins [IQR 114] vs. 214 mins [IQR 191], p= 0.06) or estimated blood loss (300 mL [IQR 650] vs. 300mL [IQR 900], p= 0.22) between elderly and non-elderly patients. Thirty-two (39%) elderly patients underwent bowel resection, 7 (8.5%) nephrectomy, 4 (4.9%) pancreatic resection, 2 (2.9%) liver resection, and 3 (4.3%) major vascular resection. Incidence of total and major complications was comparable between groups (elderly vs. non-elderly: 42.0% vs. 38.8%; p = 0.62 and 24.6% vs. 20.0%; p = 0.41).  LOS was similar with a median of 8 days (IQR 6) in the elderly group and 6 days (IQR 5) in the non-elderly group, p= 0.64. There was no difference in 30-day readmission rates between elderly and non-elderly patients (11.6% and 10.8%, p= 0.86). 61 (88.4%) elderly patients were discharged to home, 2 (2.9%) to subacute rehab facilities and 5 (7.2%) to skilled nursing facilities. Perioperative mortality was comparable in both groups (elderly vs. non-elderly, 0% vs 0.2% p= 0.28). There was no difference in three-year DFS between the elderly and non-elderly patients (18.8% vs 21.6% p=0.61) however elderly patients had lower three-year DSS (25.1% vs 56.1% p< 0.001) (Figure).

Conclusion: Elderly patients undergoing resection for retroperitoneal sarcoma at high-volume academic centers demonstrated analogous perioperative morbidity and mortality when compared to their younger counterparts. Three-year DFS was similar between groups however, elderly patients are more likely to die from their disease after recurrence as evidenced by lower DSS compared with younger patients.

 

21.09 Scholarly Activity in Academic Plastic Surgery: The Gender Difference

Posted on January 18, 2018

S. E. Sasor1, J. A. Cook1, S. P. Duquette1, T. A. Evans1, S. S. Tholpady1, M. W. Chu1, L. G. Koniaris1  1Indiana University,Plastic Surgery,Indianapolis, IN, USA

Purpose:

The number of women in medicine has grown rapidly in recent years. Women constitute over 50% of medical school graduates and hold 38% of faculty positions at U.S. medical schools. Despite this, gender disparities remain prevalent in most surgical subspecialties, including plastic surgery. The purpose of this study is to analyze female authorship trends to identify factors that affect scholarly output and professional advancement in academic plastic surgery.

 

Methods:

A cross-sectional study of all academic plastic surgeons was performed. Data was collected on gender, degrees, titles, and affiliation residency programs from department websites and online resources. National Institute of Health (NIH) funding was determined using the Research Portfolio Online Reporting Tools database. Number of published manuscripts, citations, and h-index were obtained from Scopus (Elsevier Inc., New York, NY). Statistical analysis was performed in SPSS.

 

Results:

A total of 814 plastic surgeons were identified from 91 training programs in the US. Mean years in practice was 15.3 and the majority were male (83.2%). Average number of published manuscripts, citations, and h-index were 45.5, 974.9, and 11.6, respectively.

 

Compared to male surgeons, female surgeons had significantly fewer years in practice (9.9 vs. 16.4, p<0.001), held lower academic ranks (57.3% vs. 33.9% assistant professor, p<0.001 compared to 6.6% vs. 29.0% full professor, p<0.001), and published less (20.0 vs. 50.2 manuscripts, p<0.001, and 7.3 vs 12.6 h-index, p<0.001). Females with titles of assistant or associate professor had significantly fewer years in practice than males with the same title (6.1 vs. 9.0 years, p<0.001 assistant and 13.5 vs. 15.8 years p=0.01 associate). The trend continued for full professors but was not significant. Males published more manuscripts, had more citations and higher h-indexes than female surgeons at each academic rank but the findings were not statistically significant beyond the level of assistant professor.

 

Seven of 136 female surgeons (5.1%) and 46 of 678 male surgeons (6.9%) received an NIH grant during their career (p=0.57). Mean number of awards and total amount of funding was 10.3/$2,996,734 for women and 8.0/$1,853,345 for men (p=0.469 and p=0.57, respectively). NIH-funded surgeons of both sexes published more than non-funded surgeons (119.5 vs. 40.3 publications, p<0.001 and 24.7 vs. 10.7 h-index, p<0.001). There was no gender difference in scholarly output amongst NIH-funded surgeons.

 

Conclusion:

Research productivity is a metric for promotion in academic medicine. This study identifies significant gender disparities in scholarly productivity amongst plastic surgeons in academia. Differences are most apparent at junior ranks, suggesting that women who remain in academic medicine may later overcome publishing barriers faced earlier in their careers. 

 

21.08 Should Sentinel Lymph Node Biopsy Be Recommended to All Intermediate Thickness Melanoma Patients?

Posted on January 18, 2018

A. Hanna1, A. J. Sinnamon1, R. Roses1, R. Kelz1, D. Elder1, X. Xu1, B. Pockaj2, D. Fraker1, G. Karakousis1  1University Of Pennsylvania,Philadelphia, PA, USA 2Mayo Clinic,Phoenix, AZ, USA

Introduction:

Sentinel lymph node (SLN) biopsy is routinely recommended for patients with intermediate (1.01 – 4.00 mm) thickness melanoma. Prior institutional data from our group,however, suggested significant variation in the risk for SLN metastasis for these patients and we therefore sought to identify subgroups within this cohort with low risk for SLN positivity using a large national data set.

Methods:

Patients with intermediate thickness melanomas who underwent SLN biopsy from 2010 to 2013 were identified using the National Cancer Database. Clinical and pathologic variables associated with SLN positivity were analyzed using logistic regression. Classification and Regression Tree (CART) analysis was used to risk-stratify patients for SLN positivity.

Results:

Of the 23,440 study patients with intermediate thickness melanoma, 14.7% (95% CI, 14.2% – 15.1%) were found to have a positive SLN. Most (59.9%) patients were male and the median age was 62 years (IQR, 51 – 72 years old). In multivariate logistic regression, increased age (OR = 0.89/10 years, 95% CI 0.88 – 0.90), female gender (OR = 0.85, 95% CI 0.79 – 0.93), absence of lymphovascular invasion (LVI) (OR = 0.31, 95% CI 0.27 – 0.36), absent mitoses (OR = 0.61, 95% CI 0.54 – 0.70), a H&N, upper extremity, or shoulder primary site (OR = 0.55, 95% CI 0.49 – 0.63), decreased thickness (OR = 1.55/mm, 95% CI 1.48 – 1.63), and absent ulceration (OR = 0.74, 95% CI 0.68 – 0.81) all were significantly associated with having a negative SLN. In CART analysis, absent LVI, thickness < 1.7 mm, age < 56, and primary site were significant branch points (Figure 1). In patients 56 years of age or older with absent LVI and intermediate thickness lesions < 1.7 mm (29% of all patients analyzed), the rate of SLN positivity was < 5%.

Conclusion:

Despite a SLN positivity rate of 14.7% overall, there exists significant heterogeneity in the risk for SLN metastasis in patients with intermediate thickness melanoma. In a sizable group of patients (nearly 30% undergoing the procedure), the risk for SLN metastasis approximates that seen in lower risk thin melanomas, where the procedure is offered selectively. For these patients (56 years or older with lower depth intermediate lesions and absent LVI) careful consideration should be made weighing the risks and benefits of the SLN procedure.

21.03 Editorial (Spring) Board?: Gender Composition in High-Impact General Surgery Journals

Posted on January 18, 2018

C. A. Harris1, T. Banerjee7, M. Cramer4, S. Manz6, S. Ward5, J. B. Dimick3, D. A. Telem2  1University Of Michigan,Division Of Plastic Surgery, Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Michigan Women’s Surgical Collaborative,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 4Cornell University,Ithaca, NY, USA 5University Of Michigan,Division Of Cardiac Surgery, Department Of Surgery,Ann Arbor, MI, USA 6University Of Michigan,Ann Arbor, MI, USA 7University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA 8University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA

Introduction: Serving on an editorial board is an important step in many surgeons’ careers; however, evidence suggests that access to these positions may differ based on gender. Analyses of medical journals indicate although women’s representation is improving, they remain a clear minority. Whether similar trends exist in surgery and whether women surgeons face different qualification thresholds for appointment remains unknown. To address this knowledge gap, we quantify the current gender composition of ten high-impact surgery journals, evaluate qualification metrics by gender, and delineate how board composition has changed over time.

Methods: Ten prominent general surgery journals were selected for inclusion based on impact factor. Editor characteristics were assigned using faculty websites, Scopus profiles, and the American Board of Surgery certification database. We performed cross-sectional analyses of editorial board composition by gender for 1997, 2007, and 2017 using univariate and logistic regression analysis. Variation in qualifications by gender was assessed by comparing H-index, academic rank, and number of additional degrees. Gender-based differences in editorial board member turnover and multiple board positions were evaluated for each time interval.

Results: Over 20 years, women’s editorial presence has increased from 5% to 19%. Initial univariate analysis demonstrated significant qualification differences. Compared to women, men had higher mean H-indices (39.1 vs 21.9; p<0.001) and more full professorships (70.2% vs 55.8% p=0.02); whereas, a higher percentage of women had additional degrees (36.1% vs 21.9% p=0.004). Following logistic regression controlling for length of time since board certification, these associations became non-significant (degrees p= 0.051; academic rank p=0.56; H-index p=0.35). Both women and men were equally likely to hold multiple board positions (1997 p=0.74; 2007 p=0.42; 2017 p=0.69). Journals retained higher proportions of men in each time interval (1997-2007 p=0.003; 2007-2017 p= <0.001; 1997-2017 p=0.01) and retention rates increased over time (Figure 1).

Conclusion: Women surgeons have a small but growing presence on surgical editorial boards, and any qualification differences by gender are likely attributable to practice length. Although this suggests improved gender parity, gaps remain, and may be perpetuated by inequitable retention. More importantly, rising retention rates may limit next-generation surgeons' opportunities regardless of gender. Strategies such as imposing term limits or instituting merit-based performance reviews may help balance the need for high-level expertise with efforts to ensure that editorial boards capture the field’s changing demographics.

 

20.08 Lymph Node Ratio Does Not Predict Survival after Surgery for Stage-2 (N1) Lung Cancer in SEER

Posted on January 18, 2018

D. T. Nguyen2, J. P. Fontaine1,2, L. Robinson1,2, R. Keenan1,2, E. Toloza1,2  1Moffitt Cancer Center,Department Of Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Health Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Stage-2 nonsmall-cell lung cancers (NSCLC) include T1N1M0 and T2N1M0 tumors in the current Tumor-Nodal-Metastases (TNM) classification and are usually treated surgically with lymph node (LN) dissection and adjuvant chemotherapy.  Multiple studies report that a high lymph node ratio (LNR), which is the number of positive LNs divided by total LNs resected, as a negative prognostic factor in NSCLC patients with N1 disease who underwent surgical resection with postoperative radiation therapy (PORT).  We sought to determine if a higher LNR predicts worse survival after lobectomy or pneumonectomy in NSCLC patients (pts) with N1 disease but who never received PORT.

Methods:   Using Surveillance, Epidemiology, and End Results (SEER) data, we identified pts who underwent lobectomy or pneumonectomy with LN excision (LNE) for T1N1 or T2N1 NSCLC from 1988-2013.  We excluded pts who had radiation therapy, multiple primary NSCLC tumors, or zero to unknown number of LNs resected.  We included pts with Adenocarcinoma (AD), Squamous Cell (SQ), Neuroendocrine (NE), or Adenosquamous (AS) histology.  Log-rank test was used to compare Kaplan-Meier survival of pts who had LNR <0.125 vs. 0.125-0.5 vs. >0.5, stratified by surgical type and histology.

Results:  Of 3,452 pts, 2666 (77.2%) had lobectomy and 786 (22.8%) had pneumonectomy.  There were 1935 AD pts (56.1%), 1308 SQ pts (37.9%), 67 NE pts (1.9%), and 141 AS pts (4.1%).  When comparing all 3 LNR groups for the entire cohort, 1082 pts (31.3%) had LNR <0.125, 1758 pts (50.9%) had LNR 0.125-0.5, and 612 pts (17.7%) had LNR >0.5.  There were no significant differences in 5-yr survival among all 3 LNR groups for the entire population (p=0.551).  After lobectomy, 854 pts (32.0%) had LNR <0.125, 1357 (50.9%) pts had LNR 0.125-0.50, and 455 pts (17.1%) had LNR >0.5.  After pneumonectomy, 228 pts (29.0%) had LNR <0.125, 401 pts (51.0%) had LNR 0.125-0.5, and 157 pts (19.9%) had LNR >0.5.  There was no significant difference in 5-yr survival among all 3 LNR groups in either lobectomy pts (p=0.576) or pneumonectomy pts (p=0.212).  When stratified by histology, we did not find any significance in 5-yr survival among all 3 LNR groups in AD pts (p=0.284), SQ pts (p=0.908), NE pts (p=0.065), or AS pts (p=0.662).  There were no differences in 5-yr survival between lobectomy vs. pneumonectomy pts at LNR <0.125 (p=0.945), at LNR 0.125-0.5 (p=0.066), or at LNR >0.5(p=0.39).

Conclusion:  Patients with lower LNR did not have better survival than those with higher LNR in either lobectomy or pneumonectomy pts.  Lower LNR also did not predict better survival in each histology subgroup.  These findings question the prognostic value of LNRs in NSCLC patients with N1 disease after lobectomy or pneumonectomy without PORT and suggest further evaluation of LNRs as a prognostic factor.

20.09 Induction Chemotherapy versus Standard Treatment for Locally Advanced Rectal Cancer

Posted on January 18, 2018

C. Nganzeu1, J. J. Blank1, F. Ali1, W. Hall2, C. Peterson1, K. Ludwig1, T. Ridolfi1  2Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 1Medical College Of Wisconsin,Department Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
The standard treatment of stage II or III rectal adenocarcinoma is chemoradiation therapy (CRT) followed by surgical resection and adjuvant systemic chemotherapy. Recently there has been increased interest in the use of induction chemotherapy (IC), an approach that provides some or all systemic chemotherapy and CRT in the preoperative setting. Potential benefits of this treatment paradigm include tumor downstaging, early treatment of micrometastases, increased rate of sphincter preservation, decreased time with a diverting stoma, and patient compliance. However, little is known about this treatment strategy on a national level. The aims of this study were to define the frequency of IC use and evaluate treatment outcomes compared to standard CRT using the National Cancer Database.

Methods:
The National Cancer Database was queried for patients diagnosed with stage II or III rectal adenocarcinoma having received radiation, chemotherapy and surgical resection between 2004 and 2014. We compared patients with IC to patients having received standard combined CRT. Linear regression was performed to predict percent patients receiving IC by year. Propensity score matching was applied in a 1:10 fashion. A logistic model was fitted to obtain propensity scores. A greedy matching algorithm was then applied for predictor selection. Outcomes including downstaging, readmission, positive margins, and survival were evaluated.

Results:
A total of 33,480 patients met inclusion criteria. 96.4% of patients underwent standard CRT while 3.6% underwent IC. Of all patients diagnosed with stage II and III rectal cancer, only 2.8% received IC in 2004; this number rose to 4.4% in 2014. Propensity score matching yielded 10,531 patients receiving standard CRT and 1,073 patients who received IC for the analysis. The IC group had more tumor downstaging than standard CRT on surgical pathology (54% vs. 48.8%, p=0.006, respectively). This group also had significantly fewer 30-day readmissions after surgery (4.5% vs. 6.4%, p=0.021, respectively). There were no differences observed in 30-day or 90-day mortality (0.5% vs. 0.5%, p= 0.247 and 0.8% vs. 1.1%, P= 0.755, respectively), rate of positive margins (4.8% vs. 5.6%, p=0.398, respectively), or survival (p=0.587) between the two groups.

Conclusion:

The use of induction chemotherapy for patients with stage II and III rectal cancer increased significantly from 2004-2014. Induction chemotherapy was associated with improved downstaging before surgery and improved 30-day readmission rates after surgery without changing overall survival when compared to standard chemoradiation therapy.

 

20.10 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.

 

20.06 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.
 

20.07 Improvements in Surgical Mortality: The Roles of Complications and Failure to Rescue

Posted on January 18, 2018

B. T. Fry1,2, J. R. Thumma2, J. B. Dimick2,3  3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Surgical mortality has declined considerably over the last decade. While most hospitals have reduced mortality to some degree, much can be learned from how hospitals with the largest reductions achieved their improvement. Specifically, the roles of reducing complications and improving rescue from complications once they occur (known as failure to rescue or FTR) remain unclear. This study sought to understand which of these factors plays a larger role in reducing surgical mortality.

Methods: Using Medicare Provider Analysis and Review files, we performed a retrospective, longitudinal cohort study of patients who underwent abdominal aortic aneurysm (AAA) repair, pulmonary resection, colectomy, and pancreatectomy. We then calculated hospital-level risk- and reliability-adjusted rates of 30-day mortality, serious complications, and FTR for these patients in two time periods: 2005-2006 and 2013-2014 (n=699,771 patients). Serious complications were defined as the presence of one or more of eight complications plus a procedure-specific length of stay of greater than the 75th percentile. FTR was defined as death occurring in a patient with at least one serious complication. Hospitals were stratified into quintiles by change in mortality over time with average rates of 30-day mortality, serious complications, and FTR reported for each quintile. Variance partitioning was used to determine the relative contributions of differences in complication and FTR rates to the observed changes in hospital-level surgical mortality between time periods.

Results: After stratifying by reductions in mortality from 2005-2014, the top 20% of hospitals had decreased mortality rates by 3.4% (8.9 to 5.5%, p<0.001), decreased complication rates by 1.8% (15.2 to 13.4%, p<0.001), and decreased FTR rates by 7.4% (25.8 to 18.4%, p<0.001). In contrast, the bottom 20% of hospitals had actually increased mortality rates by 1.1% (6.9 to 8.0%, p<0.001), increased complication rates by 0.9% (14.6 to 15.5%, p<0.001), and increased FTR by 0.6% (22.1 to 22.7%, p<0.001). When examining the factors most associated with reductions in mortality, we found that decreased FTR explained 69% of the improvement in hospitals’ mortality rates over time, whereas decreased complication rates accounted for only 6% of this improvement. 

Conclusion: Hospitals with the largest reductions in surgical mortality achieved these improvements largely through reducing FTR rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue from serious complications.  

20.03 Impact of ‘Take the Volume Pledge’ on Access & Outcomes for Gastrointestinal Cancer Surgery

Posted on January 18, 2018

R. C. Jacobs1, S. Groth1, F. Farjah2, M. A. Wilson3, L. A. Petersen4,5, N. N. Massarweh1,4  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2University Of Washington,Division Of Cardiothoracic Surgery,Seattle, WA, USA 3VA Pittsburgh Healthcare System,Department Of Surgery,Pittsburgh, PA, USA 4Michael E. DeBakey Veterans Affairs Medical Center,VA HSR&D Center For Innovations In Quality, Effectiveness, And Safety,Houston, TX, USA 5Baylor College Of Medicine,Department Of Medicine,Houston, TX, USA

Introduction: The “Take the Volume Pledge” (TVP) initiative aims to regionalize complex cancer resections to hospitals meeting established annual volume thresholds. There is little data describing the potential impact on patient access if this initiative were broadly implemented or the relationship between TVP volume thresholds and quality of oncologic care.

Methods:  Hospitals performing esophagectomy (n=968), proctectomy (n=1,250), or pancreatectomy (n=1,068) in the National Cancer Data Base (2006-2012) were categorized into four groups based on frequency meeting TVP thresholds: always low volume (LV); low annual average and intermittently low volume (ILV); high annual average and intermittently high volume (IHV); always high volume (HV). Multivariable generalized estimating equations were used to evaluate the association between hospital TVP category and multimodality therapy (MMT) use, margin positive (R+) resection, and 30-day mortality.

Results: Over the study period, few hospitals met annual TVP thresholds (HV or IHV)—esophagectomy 1.6%; proctectomy 19.7%; pancreatectomy 6.6%. The majority of esophagectomy (77.8%) and pancreatectomy (53.4%) and 48.1% of proctectomy patients received care at hospitals not meeting annual TVP thresholds (LV or ILV). While unadjusted MMT, R+ resection, and 30-day mortality rates were better at ILV, IHV, and HV relative to LV hospitals, there were no consistent differences between non-LV (ILV, IHV, and HV) hospitals. The odds of receiving MMT was not different across TVP categories for esophagectomy or pancreatectomy (Table). For proctectomy, MMT use was significantly more likely (relative to LV hospitals) at ILV, IHV, and HV hospitals. For all three procedures, the odds of a R+ resection were lower (relative to LV hospitals) at IHV and HV hospitals (and at ILV hospitals for esophagectomy). However, there were no differences in R+ resection rates between ILV, IHV, and HV hospitals. The odds of 30-day mortality after esophagectomy was not different in any TVP category, except at HV (relative to LV) hospitals (OR 0.63 [0.42-0.94]). The odds of mortality were significantly lower (relative to LV hospitals) at ILV, IHV, and HV hospitals after proctectomy and pancreatectomy. But, there were no mortality differences comparing ILV, IHV, and HV hospitals.

Conclusion: Few hospitals meet TVP cancer resection volume thresholds with little difference in outcomes across non-LV hospitals. A policy to shift surgical care only to hospitals meeting TVP could compromise patient autonomy, limit access if patients are unable or unwilling to travel, and may not necessarily establish objective benchmarks for ensuring high-quality outcomes.

20.04 The Affordable Care Act’s Medicaid Expansion and Utilization of Discretionary Inpatient Surgery

Posted on January 18, 2018

A. B. Crocker3, A. Zeymo2,3, D. Xiao3, L. B. Johnson4, T. DeLeire5, N. Shara2,4, W. B. Al-Refaie1,2,3  1MedStar-Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 4Georgetown-Howard Universities Center For Clinical And Translational Science,Washington, DC, USA 5Georgetown McCourt School Of Public Policy,Washington, DC, USA

Introduction: Pre-Affordable Care Act (ACA) Medicaid expansion has preferentially increased utilization of elective inpatient procedures. However, the impact of the ACA on such elective and preference-sensitive procedures (also known as discretionary procedures) vs. clinically essential and time-sensitive non-discretionary procedures remains unknown. We hypothesize that the ACA’s expansion led to increased utilization of inpatient discretionary procedures (DP) relative to non-discretionary surgical procedures (NDP) in expansion vs. non-expansion states. As such, we performed hospital-level quasi-experimental evaluations to measure the state-by-state differential effects of the ACA’s Medicaid expansion on utilization of DP vs. NDP.

Methods:  The State In-Patient Database (2012-2014) yielded 476 hospitals providing selected DP or NDP procedures performed on 275,131 non-elderly, adult patients (ages 18-64 years) across three expansion states (Kentucky, Maryland, and New Jersey) vs. two non-expansion control states (Florida and North Carolina). DP included non-emergent total knee arthroplasty and total hip arthroplasty, while NDP included a cohort of nine cancer surgeries. Mixed Poisson interrupted time series (ITS) analyses were performed to determine the impact of ACA’s Medicaid expansion on the number of DP vs. NDP provided: 1) across expanded versus non-expanded states overall, 2) among non-privately insured patients (Medicaid and uninsured payers).

Results: Substantial reductions in the number of uninsured DPs were observed in both expansion (-73%) and non-expansion states (-45%). While the number of Medicaid insured DPs in expansion states nearly doubled, the number of privately insured DPs in non-expansion states increased by 10%.  Observing no overall differential increase in the utilization of DPs in expansion and non-expansion states after 2014 (2.2% per quarter and 2.8% per quarter), subsequent analysis on the mean number of non-privately insured DP and NDP was performed. Mixed ITS estimated a differential increase in DP (+17.7% vs -3.5%) and NDP (+4.7% vs -5.0%) in expansion states compared to non-expansion states.  Additionally, a substantially larger increase in utilization of DP vs NDP was detected within expansion states after 2014 (Figure).

Conclusion: In this multi-state evaluation, ACA’s Medicaid expansion has preferentially increased utilization of DP in expansion vs non-expansion states among non-privately insured patients. This expansion has also differentially increased utilization of DP relative to NDP in expansion states. These preliminary findings suggest that expansion coverage increased use of inpatient surgery. Further research is merited to expand on these early results.

 

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