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Introduction: Centralization of ovarian cancer treatment is associated with higher rates of optimal surgery and longer survival. However, preoperative diagnosis of ovarian cancer is challenging and some diagnoses are made incidentally after surgery. This study investigated the surgical and oncological outcomes of patients with incidental findings of borderline ovarian tumors or ovarian cancer who were centralized postoperatively and treated with a two-stage surgical procedure, and compared these with those of patients with adnexal masses of suspected malignancy who were offered a single-stage surgical procedure with intraoperative frozen section in a tertiary hospital., Methods: A database of 390 patients with adnexal masses and surgical treatment at the Bern University Hospital, Switzerland was retrospectively reviewed to identify patients with borderline ovarian tumors or ovarian cancer between 2010 and 2020., Results: Among 390 patients with adnexal masses, 223 were diagnosed with a borderline ovarian tumor or ovarian cancer. Compared with patients with suspected malignancy and a centralized single-stage surgical procedure, patients with an incidental postoperative malignancy diagnosis and a two-stage surgical procedure underwent more surgical interventions (1.3 vs. 2.1 p<.001) and had a longer time interval from diagnosis to initiation of chemotherapy (33.3 vs. 45.1 p=.005) and to completion of surgical cytoreduction (31.9 vs. 73.7 days, p<.001). However, there were no differences in the rates of complete cytoreduction (90.0% vs. 93.2%, p=.719), intraoperative (11.3% vs. 13.7%, p=.664) or postoperative (38.7% vs. 37.0%, p=.884) complication rates, and number of hospitalization days (11.1 vs. 12.0 days, p=.369). An incidental diagnosis of malignancy with postoperative referral was neither associated with an increased risk of recurrence (hazard ratio (HR) 0.8, 95% confidence interval (CI) 0.6-1.8, p=.839) nor death (HR 0.7, 95% CI 0.4-1.1, p=.113), and there was no difference in mean recurrence-free survival between the study subgroups., Discussion: Although patients with incidental findings of borderline ovarian tumors or ovarian cancer treated with a two-stage surgical procedure had a longer time to completion of surgical staging and initiation of chemotherapy, our results showed no negative impact on oncological outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Joder, Smaadahl-Wey, Zumwald, Saner, Rauh, Hofer, Wampfler, Schlootz, Rau, Christe, Solass, Imboden, Mueller and Siegenthaler.)

Background: The demographics and geography of Australia and New Zealand (ANZ), with few metropolitan centres and vast, sparsely populated rural areas, represent a challenge to providing equal care to all patients. This study aimed to compare rectal cancer care at rural and urban hospitals in ANZ., Methods: From the Bowel Cancer Outcomes Registry (BCOR, formerly known as the Bi-National Colorectal Cancer Audit; BCCA), rectal cancer patients treated between 2007 and 2020 were compared based on hospital location (urban versus rural). Propensity-score matching was performed to correct for differences in baseline characteristics between groups., Results: A total of 9385 rectal cancer patients were identified from the BCOR: 1329 (14.2%) were treated at rural hospitals and 8056 (85.8%) at urban hospitals. Propensity-score matching resulted in 889 patients in each group, matched for age, ASA score, hospital type (public/private), tumour height from the anal verge, and pre-treatment cT- and cAJCC-stage. Rural patients had fewer pre-treatment MRIs (67.9% versus 74.7%; P = 0.002), and underwent less neoadjuvant therapy (44.7% versus 50.9%; P = 0.01). Rural patients underwent fewer ULARs (39.4% versus 45.6%; P = 0.03), and fewer anastomoses were formed (67.9% versus 74.4%; P = 0.05). CRM rates and postoperative AJCC stages (P = 0.19) were similar between groups (P = 0.87). Fewer rural patients received adjuvant chemotherapy (37.8% versus 43.3%; P = 0.02)., Conclusion: There are significant differences in pre-treatment MRI rates, (neo)adjuvant treatment rates and surgical procedures performed between rectal cancer patients treated at rural and urban hospitals in ANZ, while CRM rates and postoperative AJCC stages are similar., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Stanford Type A Aortic Dissection (TAAD) is associated with high in-hospital mortality and the need for immediate surgical intervention. Larger hospital size may be associated with better patient care and surgical outcomes. This study aimed to examine the effect of hospital size on TAAD outcomes., Method: Patients who underwent TAAD repair were identified in National Inpatient Sample (NIS) from Q4 2015-2020. NIS stratifies hospital size into small, medium, and large based on the number of hospital beds, geographical location, and the teaching status of the hospitals. Patients admitted to small/medium and large hospitals were stratified into two cohorts. Multivariable logistic regressions were performed to compare in-hospital outcomes, adjusted for demographics, comorbidity, primary payer status, and hospital characteristics including procedural volume., Results: There were 1106 and 3752 TAAD admitted to small/medium and large hospitals, respectively. Among patients admitted to small/medium hospitals, there was higher mortality (17.27% vs 14.37%, aOR = 1.32, P < 0.01), but shorter length of stay ( P < 0.01) and lower cost ( P = 0.03) compared to larger hospitals. There was no difference in morbidities., Conclusions: Marked higher mortality is associated with admission to smaller hospitals among patients with TAAD, which may in turn decrease the average hospital stay and cost. Given that a significant percentage of patients are already being transferred out of the initial hospital and small/medium hospital is associated with higher mortality, centralization of care in centers of excellence may decrease the high mortality associated with TAAD., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Backgrounds: Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi-visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ)., Methods: Data were collected from the Bi-National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+)., Results: A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4-26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1-29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi-visceral resections: range 24.3-26.8%, versus 32.6-37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001)., Conclusion: Positive resection margins and rates of multi-visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi-visceral resection., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Centralized care for patients with pancreatic cancer is associated with longer survival. We hypothesized that increased travel distance from home is associated with increased survival for pancreatic cancer patients., Methods: The National Cancer Database user file for all pancreatic cancer patients was investigated from 2004 through 2015. Distance from the patients' zip code to the treating facility was determined. Survival was investigated using the Kaplan-Meier method. Cox hazard ratios (CoxHRs) were determined based on stage of disease, distance traveled for care, and clinical factors., Results: 340 780 patients were identified. In the average age of 68 ± 12 years, 51% were male and 83% were Caucasian. For all stages of cancer, longer survival was associated with traveling farther ( P < .001). The survival advantage was longer for Caucasians than African Americans (3.7 months vs. 2.6 months, P < .001) Travel was associated with a 13% decrease in risk of death ( P < .001). Even controlling for the pathologic stage, traveling farther was associated with decreased risk of death (CoxHR = .91, P < .001)., Discussion: Traveling for care is associated with improved survival for pancreatic cancer patients. While a selection bias may exist, the fact that all stages of patients investigated benefited suggests that this is a real phenomenon.

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana., (© 2020 American Cancer Society.)

Objective: Little is known about the relationship between case volume and patient outcomes of those treated for ruptured abdominal aortic aneurysm (rAAA) after either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR). This study evaluated the impact of hospital case volume on outcomes after rAAA., Methods: Patients with rAAA were identified in the Society for Vascular Surgery Vascular Quality Initiative database from 2003 to 2017, excluding patients from years in which a limited number of hospitals were included (2003-2009, 2017). Patients were stratified according to type of aneurysm repair and further stratified according to aortic surgical volume of the treating facility. Univariate and multivariable analyses were performed., Results: Between 2010 and 2016, of 2895 patients who presented emergently with rAAA, 1246 underwent ruptured OAR (rOAR) and 1649 underwent ruptured EVAR (rEVAR). Before adjustment for demographics, comorbidities, and clinical characteristics, there were no differences in 1-year patient survival based on hospital OAR or EVAR volumes among patients undergoing rOAR or rEVAR. After adjustment for confounding variables, patients treated with rOAR at the highest volume OAR hospitals had a 33% lower hazard of mortality at 1 year relative to patients treated with rOAR at the lowest volume OAR hospitals. Preoperative interfacility transfer was associated with a 27% lower hazard of mortality after rOAR. There was no significant difference in hazard of mortality among patients undergoing rEVAR when they were stratified according to hospital EVAR volumes after adjustment for all other covariates., Conclusions: Outcomes after rAAA repair are associated with hospital volume among patients undergoing rOAR but not among patients undergoing rEVAR. Thus, centralization of care may have an important impact on outcomes when OAR is indicated, suggesting a benefit for preoperative interfacility transfer of care when it is feasible., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the US national trends and factors associated with cytoreductive surgical radicality in women with advanced ovarian cancer (OC)., Methods: An analysis of the National Inpatient Sample database was performed. All admissions from 1993 to 2011 for advanced OC cytoreductive surgery (CRS) were identified and categorized as simple pelvic (SP), extensive pelvic (EP), and extensive upper abdominal (EUA) surgery. Annual trends in CRS were analyzed. Associations between patient- and hospital-specific factors, with CRS radicality as well as perioperative complications were explored between 2007 and 2011., Results: In total, 28,677 un-weighted admissions were analyzed. The rate of EP and EUA resections increased over time (8% to 18.1% and 1.3% to 5.4%, P<0.01, respectively). On multivariate analysis, patients were more likely to undergo EUA resections in the Northeast (OR 1.44) or West Coast (OR 1.47) at urban (OR 2.3), or large hospitals (OR 1.4), or if they had private insurance (OR 1.45). EUA surgeries were performed more frequently at high-volume ovarian cancer centers (OR 2.65); additionally, fewer complications were observed after EUA at high compared with low and medium volume hospitals (10.2%, 21.2%, and 21.7%, respectively; P=0.01). Specifically, patients treated at high volume hospitals experienced lower rates of hemorrhage, vascular/nerve injury, prolonged hospitalization, and non-routine discharge than at lower (P<0.05)., Conclusions: The US rate of radical cytoreductive surgery for advanced ovarian cancer is increasing. At high-volume hospitals, patients receive more radical surgery with fewer complications, supporting further study of a centralized ovarian cancer care model., (Published by Elsevier Inc.)

Paediatric tertiary care is highly centralized in the Netherlands. The country is small (16 million inhabitants, overall unemployment rates were approximately 7 % in 2014, while young adult (< 25 years) unemployment rates were 12 %) with the majority of the population living in Amsterdam and Rotterdam and their neighbouring cities/villages. There are 90 hospitals taking care for children in the Netherlands. Specific types of highly specialized care, such as transplantation, are provided in a maximum of three centres (kidney transplants in 3, bone marrow tranplants in 2, liver transplants in only one center), while neonatal intensive care is offered in 10 hospitals. Recently, patients with solid tumours in the thorax and abdomen were concentrated in a single centre with five university centres who provide care during the less intensive part of the treatment (in shared care). Similar changes are planned for congenital surgery, aiming for two such centres in the Netherlands. The general view of the Dutch Paediatric Association underscores the need for centralisation, while high-level care should be guaranteed at those hospitals where no specialized centre is present.