Wasif, Nabil

131 Background: Research demonstrating a volume-outcome relationship has resulted in regionalization of complex cancer surgery to high volume hospitals. A simultaneous national trend towards improved surgical outcomes brings into question whether the potential benefits of regionalization are still relevant. We hypothesize that the difference in adjusted post-operative mortality between low and high volume hospitals has decreased over time. Methods: The National Cancer Database (NCDB) was used to identify patients with colon, esophageal, and pancreatic cancer undergoing curative intent surgery from 2003-2011. Hospitals were divided into low ( < 25th percentile), medium (25th-75th) and high ( > 75thpercentile) volume groups depending on annual volume of cancer-specific surgery. Year-specific hospital averaged observed/expected (O/E) ratios were calculated for 90-day mortality. Poisson regression was used to model hospital averaged O/E ratios over time. Results: Our study population included 343,929 patients with colon (88%), esophageal (5%) and pancreatic (7%) cancer. There were significant (p < 0.05) improvements in adjusted 90-day mortality from 2003 and 2011 for all volume categories and cancer types, except in high volume hospitals for esophageal cancer. In 2003, high volume hospitals had significantly better outcomes compared to low volume hospitals for all cancer types, as suggested by lower O/E ratios for 90 day mortality (p < 0.05). However, by 2011 the difference in O/E ratios for 90 day mortality was no longer significantly lower for high compared to low volume hospitals (p > 0.05); this was true for all three cancer types (Figure1). Conclusions: During the period of our study, 90-day mortality following gastrointestinal cancer surgery improved in low, medium and high volume hospitals. However, by 2011 the difference in adjusted post-operative mortality between low and high volume hospitals was not significantly different, likely due to global improvements in operative and peri-operative care. This attenuation of the volume-outcome curve has important implications for policy pertaining to regionalization of cancer care in the US.

109 Background: Hospital readmissions following surgery are a focus of quality improvement efforts nationwide. Although some reflect appropriate care, others are potentially preventable readmissions (PPRs). We aim to describe the burden, timing, and factors associated with PPRs after complex cancer surgery. Methods: The National Readmissions Dataset (2013) was used to select patients undergoing a complex oncologic resection (defined as esophagectomy/gastrectomy, hepatectomy, pancreatectomy, colorectal resection, lung resection, and cystectomy). All Readmissions occurring within 30 days from discharge were analyzed. Causes for readmissions were categorized in eleven diagnostic groups and tabulated. ICD-9 primary diagnosis codes were reviewed to identify PPRs. Logistic regression analyses were used to identify demographic, clinical and hospital factors associated with PPRs. Results: We analyzed 60,970 patients with 92,260 admissions. A 30 day readmission occurred in 14% of patients, and was highest following cystectomy (25%) and lowest for lung resections (9%). Of all readmissions 82% were deemed to be PPRs. Half of PPRs occurred within the first 10 days of discharge. Infections, gastrointestinal complications and respiratory conditions accounted for 59% of PPRs. Other common causes included dehydration/electrolyte deficiencies (11%), exacerbation of comorbidity (9.2%), bleeding (5%), thromboembolism (3.5%), and wound complications (3.2%). Factors associated with an increased likelihood of PPRs include Medicaid compared with private insurance (OR 1.24, 95%CI 0.8-1.7), higher comorbid conditions (OR 1.44, 95%CI 1.32, 1.59), and discharge to a facility (OR 1.9, 95%CI 1.7-2.1). Patients with a prolonged hospital stay or a major complication during the index admission had a 34% (OR 1.34, 95%CI 1.3-1.4), and 64% (OR 1.64, 95%CI 1.5-1.7) higher likelihood of a PPR respectively. Conclusions: Most 30 day readmissions after complex cancer surgery are potentially preventable and occur within 10 days of discharge. We identify common causes of readmission and high risk populations to help physicians, administrators and policy makers develop strategies to decrease PPRs.

541 Background: A long wait-time for colectomy for colon cancer should theoretically affect survival but, to date, the association between delay to colectomy and survival remains unresolved. Methods: We studied 4,692 patients who underwent colectomy for colon cancer between 1990 and 2012. Wait-time was defined as the number of days between diagnosis and colectomy. Cox regression models were used to estimate all-cause mortality across wait-time categories. Multivariable analyses were controlled for clinicopathologic variables and Charlson comorbidity index. Results: The number of patients in the wait-time group of 1-28 days was 3,950 (84.2%), 29-84 days was 681 (22.7%), and >84 days was 61 (1.3%). A wait-time of 29-84 days was not associated with an increased risk of death (HR=1.13; p=0.056) when compared to a wait-time of 1-28 days. Though a wait-time >84 days represented a small group, it was associated with an increased risk of death (HR=1.60; p=0.013). For patients with stage I and II disease, wait-times of 29-84 days (HR =1.44; p=0.0001) and >84 days (adjusted HR=2.24; p=0.0007) were associated with an increased risk of mortality. Conclusions: A wait-time for colon cancer surgery of up to 12 weeks is likely safe for most patients. However, those suspected to have early-stage colon cancer may benefit from less of delay. These data provide a framework to address concerns over prolonged wait-times and can direct efforts for timely surgical intervention in patients with colon cancer. [Table: see text]

178 Background: Soft tissue sarcoma is a rare disease requiring multidisciplinary care for effective treatment. The National Comprehensive Cancer Network has developed guidelines for surgical resection and adjuvant therapy based on best available evidence. We sought to examine variance from these guidelines in treatment across the United States. Methods: The Surveillance, Epidemiology and End Results cancer registry was queried to identify patients undergoing surgery for extra-abdominal soft tissue sarcoma from 2004-2009. Coded variables signifying radical excision (RE) and the use of radiation therapy (RT) were correlated with stage of the primary tumor. Patients with metastatic disease, unknown size and unknown grade were excluded. Results: A total of 5,600 patients were identified with a median age of 61. Median tumor size was 8cm and most tumors were high grade (57% G3). Stage specific breakdown was as follows; Stage I 24%, Stage II 37% and Stage III 39%. Overall, 54% of patients underwent RE and 50% received RT, mostly in the post-operative setting (83%). The amputation rate was 4%. Although routine radiation therapy is not recommended for Stage IA and IB patients, 24% still underwent RT, whereas only 49% of Stage I patients were noted to have undergone a RE. Even though routine RT is recommended for Stage II and III tumors, 42% of patients did not undergo any RT, and only 58% underwent RE. On multivariate analysis predictors of RE were age <50 (OR 1.3, 95% CI 1.1-1.6), lower extremity tumor (OR 2.2, 95% CI 1.6- 2.8), Stage III, (OR 2.1, 95% CI 1.7- 2.6), and white race (OR 1.4, 95% CI 1.2- 1.8). Variance from guidelines was seen in 64% of patients. Conclusions: Significant heterogeneity and variation in the contemporary treatment for soft tissue sarcoma in the United States exists. Although low rates of RE may be related to coding discrepancies, rates as low as 54% are still a cause for concern. Overuse, and more importantly, underuse of RT is seen for a significant proportion of patients. If these trends are confirmed by further study, more effort will have to be directed towards compliance with appropriate treatment recommendations, perhaps by regionalizing sarcoma care.

13 Background: A Memorial Sloan Kettering Cancer Center (MSKCC) nomogram predicts disease−specific survival (DSS) following R0 resection for gastric adenocarcinoma using patient and tumor factors, with predictive ability superior to that of the current AJCC staging system. However, validation has only been performed in high−volume, specialized institutions. The goal of this study is to compare nomogram-predicted survival with actual survival by using a population database with the largest sample size reported to date. Methods: A retrospective review of all gastric cancer patients from Surveillance, Epidemiology and End Results (SEER) registry data from 1988 to 2000 was conducted. Data for patient age, tumor size, gender, primary location of tumor, Lauren histology, depth of tumor invasion, and % (+) and (-) lymph nodes was entered into the nomogram calculator for each patient. Nomogram-derived 5−year DSS was compared with actual DSS survival using Cox proportional hazards regression and Kaplan-Meier estimates. Results: 4,700 patients were identified. Mean patient age was 68.7 years (SD 12.3), and mean tumor size was 4.8 cm (SD 2.7). The commonest tumor location was the body/middle third of stomach (1519, 32%), followed by the gastro−esophageal junction (1381, 29%) and the antrum (1376, 29%). The majority of patients (76%) had intestinal histology. The estimated proportion of patients surviving 5 years was 23%, 48%, 58%, and 82% for survival groups defined by nomogram likelihoods of 5−year DSS of 0−25%, 26−50%, 51−75%, and 76−100%, respectively. Relative to patients in the 76−100% 5−year nomogram group, patients in the 0−25%, 26−50%, and 51−75% group had significantly higher likelihood of death with hazard ratios of 7.0 (95% CI 6.1−8.0), 3.3 (95% CI 2.8−4.0), and 2.6 (95% CI 2.2−3.0), respectively (all p<0.001). Median follow-up was 9.1 years (range, 0−18). The concordance index (c−index) for the 5−year nomogram score was 0.68 (95% CI 0.67−0.69). Conclusions: There is good discrimination of survival between nomogram-predicted survival groups. Our results validate the use of the MSKCC nomogram in the setting of the general population, outside of specialized institutions, for predicting DSS following resection of gastric adenocarcinoma.

96 Background: In the last decade there has been an increase in the incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer. Although many factors have been proposed to explain this trend, the impact of breast reconstruction on the decision to undergo CPM has not been extensively studied. Methods: A retrospective review of breast cancer patients from Surveillance, Epidemiology and End Results (SEER) registry data (2004-2008) was conducted. Characteristics of patients undergoing CPM were evaluated. Results: 71,176 patients with a diagnosis of stage I-III infiltrating ductal or lobular breast cancer underwent mastectomy for their primary lesion. Among these, 10,558 patients (15%) underwent a CPM. A significantly higher proportion of women undergoing CPM had reconstruction performed (44%) than those patients not undergoing CPM (13%), p<0.001. On multivariate analysis (Table), significant variables predicting CPM included age <50 years (OR 10.12), breast reconstruction (OR 3.58), and lobular histology (OR 1.41), all p<0.001. Of the 12,466 patients (18%) who underwent reconstruction, 4,636 (37%) had implant reconstruction, 4,498 (36%) had tissue reconstruction, and 1,122 (9%) had combined tissue/implant reconstruction (no data for 18%). On multivariate analysis, predictors of reconstruction included age <50 years (OR 20.5; CI 18.5-22.7), year of surgery (2008 vs. 2004; OR 1.60; CI 1.49-1.71), low tumor grade (OR 1.19; CI 1.13-1.25) and ER+ status (OR 1.16; 95% CI 1.10-1.23). The use of radiation therapy was associated with a lower likelihood of pursuing reconstruction (OR 0.61; CI 0.58-0.65). Conclusions: Apart from age, the factor most strongly associated with CPM is the decision to have reconstructive surgery performed. This suggests that CPM may not be purely associated with risk-reduction but also with treatment factors such as cosmesis. [Table: see text]

Background Cardiovascular disease (CVD) is an important driver of mortality after kidney transplantation. Its broader impact on posttransplant health care utilization in US hospitals is unknown. Methods We used administrative claims data from the Nationwide Inpatient Sample and the American Hospital Association Annual Survey to identify hospitalizations for kidney transplant patients with a cardiovascular diagnosis from 2005 to 2011. CVD hospitalizations were stratified by transplant hospital status to characterize patterns in inpatient health care utilization and outcomes. Based on these analyses, the domestic burden of treatment for posttransplant CVD (myocardial infarction, stroke, congestive heart failure, dysrhythmia, cardiac arrest, malignant hypertension) was estimated. Results The total domestic burden of post-kidney transplant hospitalization between 2005 and 2011 is estimated at 389 138 of which 26.5% of episodes were related to CVD (n = 103 118). CVD was responsible for a growing proportion of post-transplant hospitalizations over time (24.4%-30.4%, P < 0.001). Compared with nontransplant hospitals, transplant hospitals had similar length of stay (median length of stay, 3.7 days), higher median costs per hospitalization (US $10 364 vs US $8606, overall US $9324), and lower adjusted mortality (3.2% vs 3.9%, overall 3.6%; P = 0.003). Conclusions Inpatient CVD care is increasing over time for kidney transplant patients, accounting for 30% of all post-transplant hospitalizations. Variation exists in the inpatient care, outcomes, and costs between by hospital type. Further studies are needed to better understand the mechanisms behind these phenomena.

Objectives: Radiotherapy for soft-tissue sarcoma (STS) has been shown to reduce local recurrence, but without clear improvement in survival. We conducted a meta-analysis to study the association between radiotherapy and survival in patients undergoing surgery for STS. Methods: A systematic review was conducted from PubMed, EMBASE, Web of Science, and Cochrane databases. Our population of interest consisted of adults with primary extremity, chest wall, trunk, or back STS. Our metameters were either an odds or hazard ratio for mortality. A bias score was generated for each study based on margin status and grade. Results: Of 1044 studies, 30 met inclusion criteria for final analysis. The pooled odds ratio in patients receiving radiation was 0.94 (95% confidence interval [CI], 0.78-1.14). The pooled estimate of the hazards ratio in patients receiving radiation was 0.87 (95% CI, 0.73-1.03) overall and 0.65 (95% CI, 0.52-0.82) for studies judged to be at low risk of bias. Significant publication bias was not seen. Conclusions: High-quality studies reporting adjusted hazard ratios are associated with improved survival in patients receiving radiotherapy for STS. Studies in which odds ratios are calculated from event data and those that do not report adjusted outcomes do not show the same association, likely due to confounding by indication.

BackgroundA Memorial Sloan Kettering (MSKCC) nomogram predicts disease specific survival (DSS) for gastric adenocarcinoma. The goal of this study is to use a cancer registry to compare nomogram predicted survival with actual survival in the general population.MethodsAll patients undergoing surgery for gastric adenocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) database (1988–2012) were studied.Results6954 patients were identified. Majority of cancers were in the antrum (30.2%), and had intestinal histology (73.7%). Median follow‐up was 8.2 years. Five year DSS for nomogram risk groups (0–25%, 26–50%, 51–75%, and 76–100%) was 23%, 48%, 57%, and 81% respectively. Actual DSS was 7–15% lower than nomogram predicted DSS. Relative to patients in the 76–100% 5‐year DSS risk group, patients in the 0–25%, 26–50%, and 51–75% groups had significantly higher risks of death with hazard ratios of 6.84 (95%CI 6.12–7.65), 3.30 (95%CI 2.83–3.86), and 2.64 (95%CI 2.30–3.03), respectively (all P < 0.001). The concordance index for 5‐year nomogram predicted DSS was 0.68 (95%CI 0.67–0.69).ConclusionsThe MSKCC gastric cancer nomogram over‐estimates DSS from gastric cancer in the general population and has a moderate concordance index. Predictive tools generated at specialized institutions may not perform as well in the general population. J. Surg. Oncol. 2015; 112:377–380. © 2015 Wiley Periodicals, Inc.

BACKGROUNDBiomarkers are routinely used to predict responses to systemic therapies, but their utility for predicting responses to local therapy for breast cancer is not known. This study determined whether biomarkers could predict responses to breast‐conserving therapy (BCT) and mastectomy.METHODSA review of the Surveillance, Epidemiology, and End Results database identified women diagnosed with early‐stage invasive ductal breast cancer and treated with BCT or mastectomy from 1998 to 2008. The estrogen receptor (ER) status and the histologic grade were used to construct 3 biomarker profiles: low risk (ER‐positive, low/intermediate grade), intermediate risk (ER‐positive, high grade), and high risk (ER‐negative, any grade). The primary measured outcome was disease‐specific survival (DSS).RESULTSBCT and mastectomy were performed in 114,486 patients (59.2%) and 79,035 patients (40.8%), respectively. There were 122,420 low‐risk patients (63.3%), 34,341 intermediate‐risk patients (17.7%), and 36,760 high‐risk patients (19.0%). Multivariate analyses were performed separately for patients with low‐, intermediate‐, and high‐risk tumors. The adjusted hazard ratios for DSS for patients who underwent mastectomy versus BCT for low‐, intermediate‐, and high‐risk tumors were 1.66 (95% confidence interval [CI], 1.54‐1.79; P < .001), 1.40 (95% CI, 1.29‐1.53; P < .001), and 1.27 (95% CI, 1.19‐1.35; P < .001), respectively.CONCLUSIONSPatients with ER‐positive, low‐grade breast cancers who underwent mastectomy had a 66% increase in disease‐specific mortality versus those who underwent BCT. Biomarker profiles defined by the ER status and grade may improve the selection of local therapy for breast cancer. Cancer 2015;121:2705‐2712. © 2015 American Cancer Society