Search

Introduction: A suspected diagnosis of cancer through an emergency department (ED) visit is associated with poor clinical outcomes. The purpose of this study was to explore the rate at which ED patients attend cancer screenings for lung, colorectal (CRC), and breast cancers based on national guidelines set forth by the United States Preventive Services Task Force (USPSTF). Methods: This was a prospective cohort study. Patients were randomly approached in the Eskenazi Hospital ED between August 2019–February 2020 and were surveyed to determine whether they would be eligible and had attended lung, CRC, and breast cancer screenings, as well as their awareness of lung cancer screening with low-dose computed tomography (LDCT). Patients who were English-speaking and ≥18 years old, and who were not critically ill or intoxicated or being seen for acute decompensated psychiatric illness were offered enrollment. Enrolled subjects were surveyed to determine eligibility for lung, colorectal, and breast cancer screenings based on guidelines set by the USPSTF. No cancer screenings were actually done during the ED visit. Results: A total of 500 patients were enrolled in this study. More participants were female (54.4%), and a majority were Black (53.0%). Most participants had both insurance (80.2%) and access to primary care (62.8%). Among the entire cohort, 63.0% identified as smokers, and 62.2% (140/225) of the 50- to 80-year-old participants qualified for lung cancer screening. No patients were screened for lung cancer in this cohort (0/225). Only 0.6% (3/500) were aware that LDCT was the preferred method for screening. Based on pack years, 35.5% (32/90) of the patients who were 40-49 years old and 6.7% (6/90) of those 30–39 years old would eventually qualify for screening. Regarding CRC screening, 43.6% (218/500) of the entire cohort was eligible. However, of those patients only 54% (118/218) had been screened. Comparatively, 77.7% (87/112) of the eligible females had been screened for breast cancer, but only 54.5% (61/112) had been screened in the prior two years. Conclusion: Many ED patients are not screened for lung/colorectal/breast cancers even though many are eligible and have reported access to primary care. This study demonstrates an opportunity and a need to address cancer screening in the ED.

Background Social Determinants of Health (SDOH) can be important contributors in health care outcomes. We hypothesized that certain SDOH independently impact the management and outcomes of stage I Non-Small Cell Lung Cancer (NSCLC). Study design Patients with clinical stage I NSCLC were identified from the National Cancer Database. The impact of SDOH factors on utilization of surgery, perioperative outcomes and overall survival were examined, both in bivariate and multivariable analyses. Results A total of 236,140 patients were identified. In multivariate analysis, SDOH marginalization were associated with less frequent use of surgery, lower 5-year survival and, in surgical patients, more frequent use of open surgery and lower 90-day postoperative survival. Conclusion SDOH disparities have a significant impact in the management and outcomes of stage I NSCLC. We identified SDOH patient groups particularly impacted by such disparities, in which higher utilization of surgery and minimally invasive approaches may lead to improved outcomes.

TPS8583 Background: There are approximately 35,000 cases of stage I lung cancer in the United States each year. While these patients have better 5-year overall survival (OS) rates than their counterparts with locally advanced and metastatic disease, there is still considerable room for improvement. Based on a recent publication validating the 8th edition of the TNM classification, the 5-year OS for node-negative pathologically-staged NSCLC between 1-4cm ranges from 73-86%, and recurrence rates for resected stage I NSCLC can range from 18-38%. Previous studies looking at adjuvant chemotherapy in this setting have shown no benefit for stage IA tumors, and the current standard of care is observation alone. Checkpoint blockade with PD-1/PD-L1 inhibitors has shown considerable activity in NSCLC including in metastatic disease, as consolidation in stage III disease after chemoradiation, and in studies evaluating neoadjuvant immunotherapy. Given this activity and their favorable safety profile, we designed a study of adjuvant PD-1 inhibition following resection in stage I NSCLC. Methods: This study is a randomized phase II multicenter trial of adjuvant Pembrolizumab versus observation alone following complete resection of stage I NSCLC with tumors between 1-4cm. The trial will enroll 368 patients randomized 1:1 to either Pembrolizumab 400mg IV every 6 weeks for up to 9 cycles or observation alone with scheduled CT scans and routine clinical follow-up. Stratification factors include PD-L1 ≥50% vs. < 50% and tumor size of 1-2cm vs. > 2-4cm. The lead site is Indiana University, and the trial will be conducted through the Big Ten Cancer Research Consortium. The primary endpoint is disease free survival (DFS), and secondary endpoints include OS, DFS at 1-, 2-, and 3-year time points, and toxicity. The trial opened to accrual at the lead site in May 2020, and there are currently 6 patients enrolled. Clinical trial information: NCT04317534.

Background When the stomach is not available, long-segment esophageal reconstruction remains a surgical challenge. Since 2005, we have used a "supercharged" isoperistaltic colon interposition conduit for long-segment esophageal reconstruction that reestablishes a dual blood supply. Methods An institutional database search of 449 patients who underwent esophagectomy from 2005 to 2012 identified 11 consecutive patients who underwent long-segment esophageal reconstruction using an isoperistaltic supercharged right (n = 9) or left (n = 2) colon conduit. All conduits were routed through the anterior mediastinum, maintaining the middle colic (right) or ascending left colic vessels (left) in situ, with reimplantation of the ileocolic vessels (right) or middle colic vessels (left) into the left internal thoracic artery and brachiocephalic vein to improve distal conduit blood flow. Results Patients were a mean age of 64 years (range, 47 to 76 years). Seven patients had a history of malignancy and 4 had a benign process. The stomach was unavailable for reconstruction due to prior gastric operations (n = 9) or neoplastic involvement (n = 2). All reimplanted vessels demonstrated excellent flow by Doppler evaluation. Esophagocolonic healing was successful in all patients; however, 1 patient required a temporary stent. Conclusions Supercharged isoperistaltic colon interposition appears to be an excellent option for the challenging situation where long-segment esophageal reconstruction is needed and the stomach is not available. The additional effort required to reestablish a dual blood supply appears justified to minimize ischemic-related morbidity. Unlike long-segment small bowel "supercharged" techniques, adequate blood supply to the distal conduit may still be present in case thrombosis of the reimplanted vessels occurs.

Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990–2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population. Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan–Meier plots were used for statistical survival analysis. A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival. EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.