Search

Objective: To assess the effect of a practice-level preoperative frailty screening and optimization toolkit (OPTI-Surg) on postoperative functional recovery and complications in elderly cancer patients undergoing major surgery. Background: Frailty is common in older adults. It increases the risk of poor postoperative functional recovery and complications. The potential for a practice-level screening/optimization intervention to improve outcomes is unknown. Methods: Thoracic, gastrointestinal, and urologic oncological surgery practices within the National Cancer Institute Community Oncology Research Program (NCORP) were randomized 1:1:1 to usual care (UC), OPTI-Surg, or OPTI-Surg with an implementation coach. OPTI-Surg consisted of the Edmonton Frail Scale and guided recommendations for referral interventions. Patients 70 years old or above undergoing curative intent surgery were eligible. The primary outcome was 8 weeks postoperative function (kcal/wk). The key secondary outcome was complications within 90 days. Mixed models were used to compare UC to the 2 OPTISurg arms combined. Results: From July 2019 to September 2022, 325 patients were enrolled in 29 practices. One hundred ninety-nine (64 UC, 135 OPTI-Surg) and 279 (78 UC, 201 OPTI-Surg) were evaluable for primary and secondary analysis, respectively. UC and OPTI-Surg patients did not significantly differ in total caloric expenditure (2.2 UC, 2.0 OPTI-Surg) after adjusting for baseline function (P=0.53). UC and OPTI-Surg patients did not significantly differ in postoperative complications (25.6% UC, 35.3% OPTI-Surg, P=0.5). Conclusions: Frailty assessment was successfully performed, but the OPTI-Surg intervention did not improve postoperative function nor reduce postoperative complications compared with UC. Future analysis will explore practice-level factors associated with toolkit implementation and the differences between the coaching and noncoaching arms. [ABSTRACT FROM AUTHOR]

Melanoma is among the most commonly reported non-mammary primary tumors to metastasize to the breast. Unfortunately, evidence of melanoma metastasis to any site portends a poor prognosis. Imaging studies can be useful in the early detection of metastatic melanoma which is essential for appropriate management of this disease. There have been very few previous studies on the imaging findings of metastatic melanoma especially across multiple imaging modalities. This review aims to describe these imaging features seen on mammography, ultrasound, magnetic resonance imaging (MRI) and fluorodeoxyglucose-positron emission tomography computed tomography (FDG PET/CT) using three case examples. Our findings, consistent with previous studies, describe melanoma metastases to the breast as largely non-specific, round or oval masses with circumscribed margins and homogeneous internal enhancement. [ABSTRACT FROM AUTHOR]

Objective: We sought to evaluate local/regional recurrence rates after breast-conserving surgery in a cohort of patients enrolled in legacy trials of the Alliance for Clinical Trials in Oncology and to evaluate variation in recurrence rates by receptor subtype. Background: Multiple randomized controlled trials have demonstrated equivalent survival between breast conservation and mastectomy, albeit with higher local/regional recurrence rates after breast conservation. However, absolute rates of local/regional recurrence have been declining with multi-modality treatment. Methods: Data from 5 Alliance for Clinical Trials in Oncology legacy trials that enrolled women diagnosed with breast cancer between 1997 and 2010 were included. Women who underwent breast-conserving surgery and standard systemic therapies (n=4,404) were included. Five-year rates of local/regional recurrence were estimated from Kaplan-Meier curves. Patients were censored at the time of distant recurrence (if recorded as the first recurrence), death, or last follow-up. Multivariable Cox proportional hazards models were used to identify factors associated with time to local/regional recurrence, including patient age, tumor size, lymph node status, and receptor subtype. Results: Overall 5-year recurrence was 4.6% (95% CI=4.0-5.4%). Five-year recurrence rates were lowest in those with ER+ or PR+ tumors (Her2+ 3.4% [95% CI 2.0-5.7%], Her2- 4.0% [95% CI 3.2-4.9%]) and highest in the triple-negative subtype (7.1% [95% CI 5.4-9.3%]). On multivariable analysis, increasing nodal involvement and triple-negative subtype were positively associated with recurrence (P <0.0001). Conclusions: Rates of local/regional recurrence after breast conservation in women with breast cancer enrolled in legacy trials of the Alliance for Clinical Trials in Oncology are significantly lower than historic estimates. This data can better inform patient discussions and surgical decision-making. [ABSTRACT FROM AUTHOR]

Surgeon-scientists provide critical perspectives to academic medicine, both as lead scientists and as collaborators. Successfully applying for and obtaining funding is critical to sustain a research program; however, significant challenges exist. It is imperative to be aware of and consider all funding sources available to surgeons during the evolution of one's career. Additionally, a deep understanding of intramural and extramural nonfinancial resources, such as mentorship relationships, grant writing, and career development courses, and research infrastructure are required. In this article, we present a set of recommendations and guidelines for surgeon-scientists to leverage funding resources with active planning longitudinally during their careers to sustain their research programs and provide their unique perspectives on surgical disease to the scientific community. [ABSTRACT FROM AUTHOR]

Background: Cancer-related financial hardship is associated with poor care outcomes and reduced quality of life for patients and families. Scalable intervention development to address financial hardship requires knowledge of current screening practices and services within community cancer care. Methods: The NCI Community Oncology Research Program (NCORP) 2017 Landscape Assessment survey assessed financial screening and financial navigation practices within U.S. community oncology practices. Logistic models evaluated associations between financial hardship screening and availability of a cancer-specific financial navigator and practice group characteristics (e.g., safety-net designation, critical access hospital, proportion of racial and ethnic minority patients served). Results: Of 221 participating NCORP practice groups, 72% reported a financial screening process and 50% had a cancer-specific financial navigator. Practice groups with more than 10% of new patients with cancer enrolled in Medicaid (adjOR = 2.81, P = 0.02) and with less than 30% racial/ethnic minority cancer patient composition (adjOR = 3.91, P < 0.01) were more likely to screen for financial concerns. Practice groups with less than 30% racial/ethnic minority cancer patient composition (adjOR = 2.37, P < 0.01) were more likely to have a dedicated financial navigator or counselor for patients with cancer. Conclusions: Most NCORP practice groups screen for financial concerns and half have a cancer-specific financial navigator. Practices serving more racial or ethnic minority patients are less likely to screen and have a designated financial navigator. [ABSTRACT FROM AUTHOR]

Purpose: Annual low-dose CT (LDCT) for lung screening in high-risk individuals decreases both lung cancer-specific mortality and all-cause mortality. Community oncology practice networks constituting the National Cancer Institute Community Oncology Research Program (NCORP) conduct clinical trials across the cancer spectrum. The authors report access to and characteristics of LDCT screening for lung cancer in these community oncology practices.Methods: A landscape capacity assessment was conducted in 2017 across the NCORP network. The primary outcome was the proportion of adult oncology practice groups offering LDCT lung screening on site. The secondary outcomes were the proportion of those screening services (1) with radiologist participation in service management and (2) offered at ACR Designated Lung Cancer Screening Centers.Results: Fifty-two percent of components and subcomponents responded to at least some portion of the assessment, representing 217 practice groups. Analyzing the 211 adult oncology practice groups responding to the primary question, 73% offered lung screening services on site. Radiologists participated in managing 69% of these services. Forty-seven percent were offered in ACR Designated Lung Cancer Screening Centers. Minority and underserved practice groups were less likely to offer lung screening; however, this association dissipated when analyses focused on practices within the United States. Safety net and Critical Access Hospital designation increased the likelihood of screening availability.Conclusions: The majority of community oncology practice groups within the NCORP offered lung screening on site, although radiologist participation in service management and ACR Lung Cancer Screening Center designation, markers of service quality, were more variable. [ABSTRACT FROM AUTHOR]

Comparative effectiveness research (CER) is especially applicable to surgical oncology because of the numerous challenges associated with conducting surgical randomized controlled trials, and the opportunity to apply various CER methodologies to answer surgical questions. In this article, several past randomized trials or attempted trials are described to demonstrate challenges related to feasibility, patient selection and generalizability, and timeliness trial results to inform clinical practice. Thus, there is a gap between these “efficacy” studies (ie, randomized trials) and “effectiveness” research, which is performed in a less controlled setting (not randomized) but is able to examine patient outcomes in the “real world.” Retrospective analyses and pragmatic trials are other important methods for answering CER questions in surgical oncology, with examples of these studies being conducted in prostate, breast, and rectal cancers. Multiple current initiatives by the American College of Surgeons and the Alliance for Clinical Trials in Oncology continue to expand the infrastructure for CER in surgical oncology. [Copyright &y& Elsevier]

Background: Use of neoadjuvant chemotherapy for breast cancer is increasing. The objective was to examine risk of postoperative wound complications in patients receiving neoadjuvant chemotherapy for breast cancer. Methods: Patients undergoing breast surgery from 2005 to 2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were included if preoperative diagnosis suggested malignancy and an axillary procedure was performed. We performed a stepwise multivariable regression analysis of predictors of postoperative wound complications, overall and stratified by type of breast surgery. Our primary variable of interest was receipt of neoadjuvant chemotherapy. Results: Of 44,533 patients, 4.5% received neoadjuvant chemotherapy. Wound complications were infrequent with or without neoadjuvant chemotherapy (3.4% vs 3.1%; P = .4). Smoking, functional dependence, obesity, diabetes, hypertension, and mastectomy were associated with wound complications. No association with neoadjuvant chemotherapy was seen (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.78–1.32); however, a trend was observed toward increased complications in neoadjuvant patients undergoing mastectomy with immediate reconstruction (OR, 1.58; 95% CI, 0.98–2.58). Conclusion: Postoperative wound complications after breast surgery are infrequent and not associated with neoadjuvant chemotherapy. Given the trend toward increased complications in patients undergoing mastectomy with immediate reconstruction, however, neoadjuvant chemotherapy should be among the many factors considered when making multidisciplinary treatment decisions. [Copyright &y& Elsevier]

Background: In an era of proliferating systems of quality assessment, surgeon confidence in metric tools is essential for successful initiatives in quality improvement. We evaluated surgeons'' awareness and attitudes about ACS-NSQIP, which is the only national, surgeon-developed, risk-adjusted, system of surgical outcome assessment. Methods: A 33-item survey instrument was constructed and content validity established through content expert review; test-retest reliability was assessed (weighted-kappa = 0.72). Survey administration occurred in three institutions with varying ACS-NSQIP experience. Summary statistics were generated and subgroup analyses performed (Fisher''s exact test). Results: One-hundred and eight surgeons participated. Practice experience varied (27% residents, 33% < 10, 12% 10–20, and 28% > 20 years). Seventy-two percent had fellowship training. Surgeons were familiar with ACS-NSQIP structure, including prospective datacollection (70%), case-sampling (63%), and reporting as observed/expected ratios (83%). Surgeons knew some collected data-points but misidentified EKG-findings of MI (67%), surgeon case-experience (41%), and anastomotic dehiscence (79%). Most felt ACS-NSQIP would improve quality of care (79%) and identify areas for improvement (92%). Surgeons were less confident regarding utility at an individual level, with only 46% believing surgeon-specific outcomes should be reported. Few thought ACS-NSQIP data should be available publicly (45%), used for marketing (26%), or direct pay-for-performance (24%). Reservations were most pronounced among surgeons with institutional ACS-NSQIP experience. Conclusion: While surgeons accept ACS-NSQIP at an institutional level, skepticism remains surrounding measurement of individual outcomes and public reporting. Surgeons at institutions with a longer duration of experience with ACS-NSQIP tended to be more cynical about potential data applications. Ongoing education and assessment of surgeons'' perceptions of quality improvement initiatives is necessary to ensure surgeons remain engaged actively in determining how quality of care data is measured and utilized. [Copyright &y& Elsevier]

The incidence of anal canal squamous-cell carcinoma is increasing. Limited data exist on predictors of treatment failure. This study was designed to identify predictors for relapse/persistence after first-line therapy. Using one database, we identified 131 Stages I-III patients treated for primary anal canal squamous-cell carcinoma at our institution from December 1986 to August 2006, with minimum six-month follow-up. Demographic, pathologic, treatment, and outcome data were extracted. Treatment failure was defined as biopsy-proven persistence or relapse (local and/or distant). Univariate, bivariate, and multivariate survival analyses were performed. Of 131 patients (median age, 58.3 years; median follow-up, 2.9 (range, 0.6–11.2) years), 66 percent were females, 43.5 percent were Stage II, and 11 (8 percent) were HIV-positive. Surgery only (local excision) was uncommon (6.9 percent, n = 9). One hundred twenty-two patients (93.1 percent) received radiotherapy; two required preradiotherapy diversion. Although 114 (93.4 percent) completed radiotherapy, most required treatment breaks, making total duration of radiotherapy longer than planned. Almost all patients undergoing radiotherapy (96.7 percent, 118/122) also had chemotherapy: 118 (100 percent, Stages I-III) had concurrent chemotherapy: (98 (83.8 percent) mitomycin/5-fluorouracil, 12 (10.2 percent) cisplatin/5-fluorouracil, 8 (6.8 percent) 5-fluorouracil alone); 35 of 46 (76 percent) Stage III patients received induction chemotherapy (34 (97.1 percent) cisplatin/5-fluorouracil, 1 (2.8 percent) 5-fluorouracil alone). Many (44 percent Stages I/II, 48.9 percent Stage III) required dose adjustments. Thirty-seven patients (28.2 percent) failed first-line therapy. There were no differences between patients with relapse (n = 22) or persistence (n = 15) of disease. Bivariate analyses demonstrated that T stage ( P = 0.0019), completion of radiotherapy, and total radiotherapy dose ( P = 0.03) were all significantly associated with treatment failure. On multivariate analyses, disease stage ( P = 0.05) and completion of radiotherapy ( P = 0.01) remained significant predictors of relapse-free survival. Tolerance of chemoradiation seems to be an important predictor of treatment success. Effective therapies with less acute toxicity must be identified. [ABSTRACT FROM AUTHOR]

Prophylactic surgery decisions are difficult. Supplemental information improves patients’ knowledge, promoting active participation in decision-making. Our objective was to examine internet information regarding prophylactic surgery for familial adenomatous polyposis to determine its adequacy in facilitating patient participation in surgical decision-making. We searched the internet for information on surgery for familial adenomatous polyposis, using an intentionally simple strategy to represent patients’ searches. We examined the first 50 sites from each search, assessing each for content by using predefined criteria. Every site was evaluated by two investigators (kappa 0.71) by using the DISCERN criteria, a tool for evaluating quality of health information. Search-efficiency was calculated. Searches revealed 307,138 “hits”; 20 sites met inclusion criteria. GOOGLE™ demonstrated the highest search-efficiency (28 percent). Sites were maintained by general health pages (35 percent), hospitals (30 percent), professional organizations (15 percent), familial adenomatous polyposis registries (10 percent), and government (10 percent). Only 40 percent had been developed and/or updated within two years. Most included basic information regarding risk, symptoms, diagnosis, as well as discussion of familial adenomatous polyposis-associated diseases and surveillance (80–100 percent). Although 90 percent of sites presented surgical treatment options, only 60 percent provided details. Few provided information regarding postoperative bowel function (40 percent), sexual function (20 percent), or fertility (5 percent). Seven (35 percent) were identified as being of “good/excellent” quality. Only four were patient-oriented; variable information was provided. Internet information regarding surgical treatment of familial adenomatous polyposis is sparse, and insufficient to support active patient participation in decision-making. Despite the time and financial commitment required, development of high-quality internet resources may be justified given the lack of adequate patient-oriented information currently available. [ABSTRACT FROM AUTHOR]

Background: The National Comprehensive Cancer Network and American Society of Clinical Oncology recommend consideration of the use of echocardiography 6 to 12 months after completion of anthracycline-based chemotherapy in at-risk populations. Assessment of BNP (B-type natriuretic peptide) has also been suggested by the American College of Cardiology/American Heart Association/Heart Failure Society of America for the identification of Stage A (at risk) heart failure patients. The real-world frequency of the use of these tests in patients after receipt of anthracycline therapy, however, has not been studied previously.Methods and Results: In this retrospective study, using administrative claims data from the OptumLabs Data Warehouse, we identified 31 447 breast cancer and lymphoma patients (age ≥18 years) who were treated with an anthracycline in the United States between January 1, 2008 and January 31, 2018. Continuous medical and pharmacy coverage was required for at least 6 months before the initial anthracycline dose and 12 months after the final dose. Only 36.1% of patients had any type of cardiac surveillance (echocardiography, BNP, or cardiac imaging) in the year following completion of anthracycline therapy (29.7% echocardiography). Surveillance rate increased from 37.5% in 2008 to 42.7% in 2018 (25.6% in 2008 to 40.5% echocardiography in 2018). Lymphoma patients had a lower likelihood of any surveillance compared with patients with breast cancer (odds ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). Patients with preexisting diagnoses of coronary artery disease and arrhythmia had the highest likelihood of cardiac surveillance (odds ratio, 1.54 [95% CI, 1.39-1.69] and odds ratio, 1.42 [95% CI, 1.3-1.53]; P<0.001 for both), although no single comorbidity was associated with a >50% rate of surveillance.Conclusions: The majority of survivors of breast cancer and lymphoma who have received anthracycline-based chemotherapy do not undergo cardiac surveillance after treatment, including those with a history of cardiovascular comorbidities, such as heart failure. [ABSTRACT FROM AUTHOR]

A correction to the article "Squamous-cell Carcinoma of the Anal Canal: Predictors of Treatment Outcome," that was published in the previous issue is presented.