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Background: Healthcare policies have focused on centralizing care to high-volume centers in an effort to optimize patient outcomes; however, little is known about patients' and caregivers' considerations and selection process when selecting hospitals for care. We aim to explore how patients and caregivers select hospitals for complex cancer care and to develop a taxonomy for their selection considerations., Methods: This was a qualitative study in which data were gathered from in-depth interviews conducted from March to November 2019 among patients with hepatopancreatobiliary cancers who were scheduled to undergo a pancreatectomy (n = 20) at a metropolitan, urban regional, or suburban medical center and their caregivers (n = 10)., Results: The interviews revealed six broad domains that characterized hospital selection considerations: hospital factors, team characteristics, travel distance to hospital, referral or recommendation, continuity of care, and insurance considerations. The identified domains were similar between participants seen at the metropolitan center and urban/suburban medical centers, with the following exceptions: participants receiving care specifically at the metropolitan center noted operative volume and access to specific services such as clinical trials in their hospital selection; participants receiving care at urban/suburban centers noted health insurance considerations and having access to existing medical records in their hospital selection., Conclusions: This study delineates the many considerations of patients and caregivers when selecting hospitals for complex cancer care. These identified domains should be incorporated into the development and implementation of centralization policies to help increase patient access to high-quality cancer care that is consistent with their priorities and needs.

Background: Pancreatectomy for cancer continues to have substantial perioperative risk, and the factors affecting mortality are ill defined. An integer-based risk score based on national data might help clarify the risk of in-hospital mortality in patients undergoing pancreatic resection., Methods: Records with the diagnosis of pancreatic cancer were queried from the Nationwide Inpatient Sample for 1998-2006. Procedures were categorized as proximal, distal, or nonspecified pancreatectomies on the basis of ICD-9 codes. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of in-hospital mortality using patient demographics, comorbidities (Charlson comorbidity score), procedure, and hospital type. A random sample of 80% of the cohort was used to create the risk score with a 20% internal validation set., Results: A total of 5715 patient discharges were identified. Composite in-hospital mortality was 5.8%. Predictors used for the final model were age group, Charlson score, sex, type of pancreatectomy, and hospital volume status (low-, medium-, or high-volume center). Integer values were assigned to these characteristics and then used for calculating an additive score. Three clinically useful score groups were defined to stratify the risk of in-hospital mortality (mortality was 2.0, 6.2, and 13.9%, respectively; P < 0.0001), with a 6.95-fold difference between the low- and high-risk groups. There was sufficient discrimination of both the derivation set and the validation set, with c statistics of 0.71 and 0.72, respectively., Conclusions: An integer-based risk score can be used to accurately predict in-hospital mortality after pancreatectomy and may be useful for preoperative risk stratification and patient counseling.

Background: The maximum size of adrenal tumors that should be removed with a laparoscopic approach is controversial. It has been suggested that laparoscopic adrenalectomy is appropriate only for adrenal tumors < 6 cm in size. We report our experience with laparoscopic adrenalectomy in patients with adrenal tumors of > or =6 cm compared with patients with smaller tumors., Methods: We retrospectively reviewed a consecutive series of patients who had a laparoscopic adrenalectomy. Patients were considered candidates for laparoscopic adrenalectomy if their computed tomography (CT) scan showed a well-encapsulated tumor confined to the adrenal gland., Results: Sixty laparoscopic adrenalectomies were performed in 53 patients. Twelve of the adrenalectomies (20%) were for tumors that were > or =6 cm (median, 8 cm; range, 6 to 12 cm). There have been no local or regional recurrences, but one patient with adrenocortical carcinoma developed pulmonary metastases. When the 12 patients with large tumors were compared with the 36 patients with tumors < 6 cm, the median operative time (190 vs. 180 minutes; P =.32), operative blood loss (100 vs. 50 mL; P =.53), and postoperative hospital stay (2 vs. 2 days; P = 1.0) were similar., Conclusions: The size of an adrenal tumor should not be the primary factor in determining whether a laparoscopic adrenalectomy should be performed. Large adrenal tumors that are confined to the adrenal gland on CT can be removed with a laparoscopic approach.

Background: Local recurrence after transurethral resection of bladder tumors (TURB) is common and might be diminished if free tumor cells within the bladder are prevented from reattaching., Methods: In vitro inhibition of murine bladder tumor cells to an approximation of urothelial matrix with agents that might block attachment to components of the extracellular matrix, and in vivo inhibition of attachment in cautery-injured murine bladder., Results: GRGDS, (0.1-2.5 mg/ml), a fibronectin-related peptide, mannose-6-phosphate, (0.1-20 mg/ml), a carbohydrate, and heparin (1-625 units/ml) all inhibited attachment in vitro in a dose-dependent fashion. YIGSR (0.1-2 mg/ml), a laminin-related peptide, did not. Mannose (10 mg/ml) did not significantly inhibit attachment of tumor cells to cauterized urothelium in vivo, whereas there was a 77% reduction of attachment in bladders irrigated with GRGDS (6.25 mg/ml) (p < 0.05), and the appearance of subsequent tumors in the bladder was inhibited. Finally, GRGDS (6.25 mg/ml) did not inhibit healing of the cautery ulcer., Conclusions: RGD-containing peptides may be useful as adjuvant therapy to decrease local recurrence after TURB and perhaps in other circumstances in which tumor cells spilled into a wound or body cavity threaten surgical success.