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Objectives: We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US)., Background: The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown., Study Design: Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each., Results: Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups., Conclusions: Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Disparities in cancer outcomes for minoritized people and groups experiencing disadvantages with Stage IV cancer is largely unknown., Methods: Patients with Stage IV pancreatic, colorectal, lung, breast, and prostate cancer were identified from 2004 to 2015 in the National Cancer Database. Cox proportional hazard models were used to quantify how demographics and treatments received were associated with overall survival., Results: 903,151 patients were included. Patients who were younger, non-Hispanic White, had private insurance, higher income, or received care at an academic center were more likely to receive surgery, chemotherapy, and/or radiation therapy (p < 0.001). Black patients, those with Medicare, Medicaid, no insurance, and lower income had lower survival rates across all five cancer types (p < 0.001). On multivariable analysis, receipt of surgery, radiation, and chemotherapy attenuated but did not eliminate this worse survival (p < 0.001)., Conclusions: Survival for patients with Stage IV cancer differs by socioeconomic and self-reported racial classifications., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The Choosing Wisely Organization and the American College of Surgeons have issued recommendations for patients >70 with breast cancer involving screening and use of radiation therapy (RT) and sentinel lymph node biopsies (SNLB) in early stage tumors. This study evaluated compliance and implementation of these recommendations., Methods: A database of patients undergoing breast cancer surgery was retrospectively queried from 2002 to 2017. Patients were divided into cohorts before and after the year of each guideline publication., Results: The rate of presentation on mammography was not different before 2009 (65%) vs. after 2009 (66%). RT was given to 57% of patients with T1 ER + Her2-prior to 2013 vs. 27% after (p=<0.001). SLNB was performed in 91% of patients with T1, grade1/2, ER + Her2-tumors prior to 2016 vs. 56% after (p=<0.001)., Conclusion: Rates of mammography detected breast cancer have not decreased but adjuvant RT and SLNB are less frequently performed in low risk breast cancer in the elderly., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The majority of newly diagnosed breast cancers in the US are in women aged older than 65 years who can have additional comorbidities. Balancing the risks and benefits of treatment should take into account these competing risks of death., Study Design: The Surveillance, Epidemiology, and End Results Program-Medicare database was used to identify women with stage I breast cancer undergoing operations from 2004-2012. Using neural network analysis, comorbidities associated with mortality were grouped into clinically relevant categories. Cumulative incidence graphs and Fine and Gray competing risk regression analyses were used to study the association of age, race, comorbidity groupings, and tumor variables with 3 competing mortality outcomes: dead of disease (DOD), dead of other cancers (DOC), and non-cancer death (NCD)., Results: The overall cumulative incidence of mortality was 4.9% for DOD, 3.7% for DOC, and 21.3% for NCD for the 47,220 patients studied. For all patients, the 5- and 8-year probability of DOD was 3% and 4.7%, for DOC 1.9% and 3.5%, and for NCD 9.8% and 18.9%, respectively. The presence of any major comorbidity (eg cardiovascular or neurologic disorders) significantly increased the probability of NCD, and estrogen receptor status was the strongest predictor of DOD. Given patient age, comorbidity, and estrogen receptor status, an estimate of competing risks of death from DOD, DOC, and NCD can be calculated., Conclusions: To aid clinical decision making, we quantify competing risks of death in patients with stage I breast cancer by taking into account patient age, comorbidity, and estrogen receptor status., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)