Sun, Maxine

334 Background: Radical cystectomy (RC) represents the standard of care for patients with muscle-invasive urothelial carcinoma of the urinary bladder (UCUB). Alternative organ-conserving treatments such as chemotherapy and/or radiotherapy have gained interest. We sought to compare survival outcomes of patients according to treatment modalities, in a stage-for-stage analysis. Methods: We relied on the Surveillance, Epidemiology, and End Results Medicare-linked database to identify 12,950 patients diagnosed with T2–T4a N0/x M0 UCUB between years 1992 and 2009. Treatment types include RC (n=5207), chemotherapy/radiation (n=2,669), and surveillance (n=5,074). Following instrumental variable analysis, Cox- and competing-risks regression analyses were performed for prediction of overall survival (OS) and cancer-specific mortality (CSM), respectively. All analyses were stratified according to disease stage (T2, T3, T4a). Results: After adjusting for potential confounders, OS was more favorable for RC relative to chemotherapy/radiation (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.02–2.40) or surveillance (HR: 1.82, 95% CI: 1.20–2.78) in patients with T2 UCUB. For the same stage, CSM rates were lower in the surgery group compared to chemotherapy/radiation (HR: 2.05, 95% CI: 1.14–3.67) or surveillance (HR: 1.95, 95% CI: 1.09–3.48). When analyses focused on individuals with more advanced disease (T3–T4a), no statistically significant difference was observed between chemotherapy/radiation relative to RC for both OS and CSM. Conclusions: In the current retrospective population-based cohort, RC was associated with improved survival outcomes relative to its alternative treatment counterparts. However, this effect was only observable in patients with T2 disease. Conversely, no difference between chemotherapy/radiation vs. surgery was noted in patients with more advanced disease stage.

89 Background: Lymph node counts have been proposed as a quality metric for patients undergoing radical prostatectomy (RP) and pelvic lymph node dissection (PLND). It is unclear whether surgical approach and hospital characteristics independently determine the number of lymph nodes removed at PLND. Therefore, we assessed the variation in lymph node counts from a population-based cohort of patients undergoing surgery for intermediate and high-risk prostate cancer. Methods: Using the National Cancer Database, we identified all surgically treated patients diagnosed with pre-treatment intermediate or high-risk prostate cancer from 2010 to 2011. The primary outcome was the number of lymph nodes retrieved at the time of RP. Generalized estimating equations were used to assess for differences in the adjusted number of lymph nodes retrieved after accounting for patient and hospital characteristics and surgical approach. Results: Overall, 35,876 patients were diagnosed with intermediate (61.2%) and high-risk (38.8%) prostate cancer and underwent RP and PLND. On multivariable analysis, open radical prostatectomy (ORP) and high volume and academic hospitals were independently associated with greater lymph node counts compared to robotic-assisted radical prostatectomy (RARP) and medium/low and community hospitals, respectively (all p<0.001). After adjusting for patient and hospital variables, higher adjusted lymph nodes counts were observed for ORP compared to RARP (7.1 vs. 6.1; p<0.001). Adjusted counts were also higher for high volume compared to medium/low volume hospitals (7.8 vs. 5.9; p<0.001), and academic compared to community hospitals (7.3 vs. 5.6; p<0.001). Conclusions: Among patients with aggressive prostate cancer treated with RP and PLND, lymph node counts varied by surgical approach and hospital characteristics.

Purpose The role of adjuvant radiotherapy (aRT) in treating patients with pN1 prostate cancer is controversial. We tested the hypothesis that the impact of aRT on cancer-specific mortality (CSM) in these individuals is related to tumor characteristics. Methods We evaluated 1,107 patients with pN1 prostate cancer treated with radical prostatectomy and anatomically extended pelvic lymph node dissection between 1988 and 2010 at two tertiary care centers. All patients received adjuvant hormonal therapy with or without aRT. Regression tree analysis stratified patients into risk groups on the basis of their tumor characteristics and the corresponding CSM rate. Cox regression analysis tested the relationship between aRT and CSM rate, as well as overall mortality (OM) rate in each risk group separately. Results Overall, 35% of patients received aRT. At multivariable analysis, aRT was associated with more favorable CSM rate (hazard ratio [HR], 0.37; P < .001). However, when patients were stratified into risk groups, only two groups of men benefited from aRT: (1) patients with positive lymph node (PLN) count ≤ 2, Gleason score 7 to 10, pT3b/pT4 stage, or positive surgical margins (HR, 0.30; P = .002); and (2) patients with PLN count of 3 to 4 (HR, 0.21; P = .02), regardless of other tumor characteristics. These results were confirmed when OM was examined as an end point. Conclusion The beneficial impact of aRT on survival in patients with pN1 prostate cancer is highly influenced by tumor characteristics. Men with low-volume nodal disease (≤ two PLNs) in the presence of intermediate- to high-grade, non–specimen-confined disease and those with intermediate-volume nodal disease (three to four PLNs) represent the ideal candidates for aRT after surgery.

Objective To evaluate the relationship between partial nephrectomy ( PN ) and hospital availability of robot‐assisted surgery from a population‐based cohort in the USA . Methods After merging the Nationwide Inpatient Sample ( NIS ) and the A merican Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy ( RN ) for renal cell carcinoma ( RCC ). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN . Results We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN , respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [ OR ] 2.77; P < 0.001), urban centres ( OR 3.66; P < 0.001) and A merican College of Surgeons ( ACOS )‐designated cancer centres ( OR : 1.10; P < 0.05) compared with non‐academic, rural and non‐ ACOS ‐designated cancer centre hospitals, respectively. Robot‐assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability ( OR 1.28; P < 0.001). Conclusions Although academic and urban locations are establi s hed factors that affect the receipt of PN for RCC , the availability of robot‐assisted surgery at a hospital was also independently associated with higher use of PN . Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN .

Objective To determine the association between peri‐operative blood transfusion ( PBT ) and oncological outcomes in a large multi‐institutional cohort of patients undergoing radical cystectomy ( RC ) for urothelial carcinoma of the bladder ( UCB ). Patients and Methods We conducted a retrospective analysis of 2895 patients treated with RC for UCB . Univariable and multivariable C ox regression models were used to analyse the effect of PBT administration on disease recurrence, cancer‐specific mortality, and any‐cause mortality. Results Patients' median (interquartile range [ IQR ]) age was 67 (60, 73) years and the median ( IQR ) follow‐up was 36.1 (15, 84) months. Patients who received PBT were more likely to have advanced disease ( P < 0.001), high grade tumours ( P = 0.047) and nodal metastasis ( P = 0.004). PBT was associated with a higher risk of disease recurrence ( P = 0.003), cancer‐specific mortality ( P = 0.017), and any‐cause mortality ( P = 0.010) in univariable, but not multivariable, analyses ( P > 0.05). In multivariable analyses, pathological tumour stage, pathological nodal stage, soft tissue surgical margin, lymphovascular invasion and administration of adjuvant chemotherapy were independent predictors of disease recurrence, cancer‐specific mortality and any‐cause mortality (all P values <0.002). Conclusions Patients with UCB who underwent RC and received PBT had a greater risk of disease recurrence, cancer‐specific mortality and any‐cause mortality in univariable, but not multivariable, analysis. Although the greater need for PBT with more advanced disease is probably caused by a number of factors, including surgical and cancer‐related factors, the present analysis showed that the disease characteristics rather than need for PBT led to worse outcomes.

BACKGROUNDApproximately 1.7 million individuals per year are affected with health care‐associated infections (HAIs) in the United States. The authors examined trends in the incidence of HAI after major cancer surgery (MCS) and risk factors for HAI to describe the effects of HAI on mortality after MCS.METHODSPatients undergoing 1 of 8 MCS procedures within the Nationwide Inpatient Sample between 1999 and 2009 were identified (n = 2,502,686). Generalized linear regression models were used to estimate the impact of the primary predictors (procedure type, age, sex, race, insurance status, Charlson comorbidity index, hospital volume, and hospital bed size) on the odds of HAI and in‐hospital mortality. Trends in incidence were evaluated with linear regression.RESULTSOverall, MCS‐associated HAI incidence increased 2.7% per year (P < .001), whereas mortality decreased 1.3% per year (P < .001). Male gender (odds ratio [OR], 1.12, 95% confidence interval [CI], 1.10‐1.14), advancing age (OR, 1.02; 95% CI, 1.02‐1.02), black race (OR, 1.26; 95% CI, 1.21‐1.31), ≥1 comorbidities (OR, from 1.08 [95% CI, 1.04‐1.13] to 1.31 [95% CI, 1.27‐1.35]), and nonprivate insurance (OR, from 1.18 [95% CI, 1.15‐1.22] to 1.67 [95% CI, 1.59‐1.76]) were associated with an increased odds of HAI on multivariable analysis. Conversely, increasing hospital volume was associated with lower odds of HAI (OR, 0.999; 95% CI, 0.99‐0.99). Patients with MCS‐associated HAI had increased odds of mortality (OR, 8.66; 95% CI, 8.51‐8.82).CONCLUSIONSBetween 1999 and 2009, the incidence of MCS‐associated HAI events increased; however, HAI‐associated mortality decreased. That said, significant disparities exist in the hospital and demographic attributes associated with MCS‐associated HAI, with attendant health policy implications. Moreover, HAI remains detrimentally linked to mortality during hospitalization. Cancer 2013;119:2317–2324. © 2013 American Cancer Society.