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Background Despite unprecedented changes to undergraduate medical education and the residency selection process during the COVID-19 pandemic, there is little objective evidence on how the pandemic impacted match outcomes such as matched applicant characteristics, interview distribution, geographic clustering, and associated costs. We investigated COVID-19’s impact on the residency match by comparing surgery applicants’ characteristics, interview distribution, and related costs from 2018-2020 to 2021. Methods Data from the Texas Seeking Transparency in Applications to Residency (STAR) initiative were analyzed. Descriptive statistics, bivariate testing, and sensitivity analysis were performed to compare matched applicants in surgical specialties from 2018-2020 to 2021. Results This study included 5,258 applicants who matched into ten surgical specialties from 2018-2021. In 2021, there was a decrease in proportion of students who reported a geographic connection to their matched program (38.4% vs. 42.1%; p=0.021) and no significant difference in number of interviews attended (mean (SD), 13.1 (6.2) vs. 13.3 (4.7); p=0.136) compared to prior years. Applicants in 2021 had more research experiences and fewer honored clerkships (both p, Graphical abstract, We investigate COVID-19’s impact on residency applicants by comparing matched surgery applicants’ characteristics, interview invitation and attendance patterns, and interview-associated costs from match years 2018-2020 to match year 2021. The importance of this report is providing a better understanding of the adoption of virtual interviews and virtual away rotations in preparation for future match cycles.

INTRODUCTION: Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. METHODS: The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. RESULTS: Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90–0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31–1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12–1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72–0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83–0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. CONCLUSIONS: Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.

Background Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. Methods This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan–Jun 2018) versus postintervention (Jan–Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. Results A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5–36.5). There was no significant difference in 2019 (–8 morphine milligram equivalents, 95% confidence interval –20.5 to 4.6). Conclusion Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

The utility of sentinel lymph node biopsy (SLNB) for non-ulcerated T1b melanoma is debated and associated costs are poorly characterized. Prior work using institutional registries may overestimate the incidence of nodal positivity in this population. The aim of this study was to estimate the use of SLNB, positivity prevalence, and procedural costs in patients with non-ulcerated T1b melanoma using a population-based registry. We identified patients with clinically node-negative, non-ulcerated melanoma 0.8–1.0 mm thick (T1b according to the 8th edition standard of the American Joint Committee on Cancer) in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. The prevalence of SLNB procedures and positive sentinel nodes were calculated. Factors associated with SLNB and sentinel node positivity were assessed using logistic regression. Medicare reimbursement costs and patient out-of-pocket expenses for SLNB and wide local excision (WLE) versus WLE alone were estimated. Among 7245 included patients, 3835(53%) underwent SLNB, 156 (4.1%, 95% confidence interval 3.5–4.7) of whom had a positive SLNB. Younger age, >1 mitosis per mm2, female sex, and truncal tumor location were associated with higher odds of positivity. The estimated SLNB cost to identify one patient with stage III disease was $71,700 (range $54,648–$83,172). Out-of-pocket expenses for a Medicare patient were estimated to be $652 for a WLE and SLNB and $79 for a WLE alone. In this population-based study, only 4% of selected non-ulcerated T1b patients had a positive SLNB, which is lower than prior reports. At the population level, SLNB is associated with high costs per prognostic information gained.

Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.

Background Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes Methods The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression. Results 251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders Conclusions Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.

Background: Early treatment of hepatocellular carcinoma (HCC) is associated with improved survival, but many patients with HCC do not receive therapy. We aimed to examine factors associated with HCC treatment and survival among incident patients with HCC in a statewide cancer registry. Materials and Methods: All patients with HCC from 2003 through 2013 were identified in the North Carolina cancer registry. These patients were linked to insurance claims from Medicare, Medicaid, and large private insurers in North Carolina. Associations between prespecified covariates and more advanced HCC stage at diagnosis (ie, multifocal cancer), care at a liver transplant center, and provision of HCC treatment were examined using multivariate logistic regression. A Cox proportional hazards model was developed to assess the association between these factors and survival. Results: Of 1,809 patients with HCC, 53% were seen at a transplant center Conclusions: In this population-based cohort of patients with HCC, Medicare/Medicaid insurance, rural residence, and Black race were associated with lower provision of HCC treatment and poorer survival. Efforts should be made to improve access to care for these vulnerable populations.

Radiation therapy often requires weeks of daily treatment making travel distance a known barrier to care. However, the full extent and variability of travel burden, defined by travel time, across the nation is poorly understood. Additionally, some states restrict radiation oncology (RO) services through Certificate of Need (CON) policies, but it is unknown how this affects travel times to care. Therefore, we aim to evaluate travel times to US RO facilities and assess the association with CON policies.RO facilities were identified from the 2018 National Plan and Provider Enumeration System (n = 2302). Travel times from populated US census tracts to nearest facility were calculated; differences by rurality, area deprivation, and region were computed. Multivariable linear regression was used to estimate adjusted differences in travel time by area characteristics. Logistic regression was used to assess the association of state CON laws with travel time1 hour.Among 72,471 census tracts, 92.4% were within 1 hour of the nearest radiation facility. Among the 12,453 rural tracts, 34.4% were1 hour. On adjusted analysis, the 3054 isolated rural tracts had an estimated 58-minute (95% confidence interval [CI] 57, 59; P.001) longer travel time than urban tracts. CON laws decreased rural travel time overall, but the association varied by region with decreased odds of prolonged travel in the South (P.001), increased odds in the Northeast and Midwest (P.001), and no association in the West (P = NS).Isolated rural US census tracts, accounting for 9.4 million Americans, have nearly 1-hour longer adjusted travel time to the nearest RO facility, compared with urban tracts. CON laws had region-dependent associations with prolonged travel.

SEER data are widely used to study rural–urban disparities in cancer. However, no studies have directly assessed how well the rural areas covered by SEER represent the broader rural United States. Public data sources were used to calculate county level measures of sociodemographics, health behaviors, health access and all cause cancer incidence. Driving time from each census tract to nearest Commission on Cancer certified facility was calculated and analyzed in rural SEER and non-SEER areas. Rural SEER and non-SEER counties were similar with respect to the distribution of age, race, sex, poverty, health behaviors, provider density, and cancer screening. Overall cancer incidence was similar in rural SEER vs non-SEER counties. However, incidence for White, Hispanic, and Asian patients was higher in rural SEER vs non-SEER counties. Unadjusted median travel time was 53 min (IQR 34–82) in rural SEER tracts and 54 min (IQR 35–82) in rural non-SEER census tracts. Linear modeling showed shorter travel times across all levels of rurality in SEER vs non-SEER census tracts when controlling for region (Large Rural: 13.4 min shorter in SEER areas 95% CI 9.1;17.6; Small Rural: 16.3 min shorter 95% CI 9.1;23.6; Isolated Rural: 15.7 min shorter 95% CI 9.9;21.6). The rural population covered by SEER data is comparable to the rural population in non-SEER areas. However, patients in rural SEER regions have shorter travel times to care than rural patients in non-SEER regions. This needs to be considered when using SEER-Medicare to study access to cancer care.

Background Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors. Study design We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews. Results We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02–3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p Conclusion Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon’s clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.

Few studies examine outcomes by surgical approach in non-small-cell lung cancer (NSCLC) with N2 disease. We examined time trends in surgical approach and outcomes among patients undergoing minimally invasive (MIS, robotic and video-assisted thoracoscopic surgery [VATS]) vs open lobectomy in this patient population. We performed a retrospective analysis of patients from the National Cancer Database diagnosed with clinical Stage IIIA-N2 NSCLC from 2010 to 2016. We examined the yearly proportion of MIS vs open resections. Multivariable regression was used to assess the association of surgical approach with length of stay, unplanned readmissions, 30-day and 90-day mortality. Multivariable Cox proportional hazards modeling was used to assess the association of surgical approach with 5-year overall mortality. We identified 5741 patients who underwent lobectomy for Stage IIIA-N2 NSCLC (459 robotic, 1403 VATS, 3879 open). From 2010 to 2016, the proportion of minimally invasive procedures increased from 20% to 45%. MIS patients, on average, stayed 1 day less in the hospital (95% confidence interval [CI] 0.7, 1.5) and had lower odds of 90-day (odds ratio [OR] 0.74; 95% CI 0.54, 0.99) and 5-year mortality (OR 0.82; 95% CI 0.75, 0.91), compared to open resections. There was no difference in odds of readmission by surgical approach (OR 0.97; 95% CI 0.71, 1.33). Among MIS procedures, robotic resections had lower odds of 90-day mortality (OR 0.42; 95% CI 0.18, 0.97) than VATS. Among patients undergoing lobectomy for locally advanced N2 NSCLC robotic and VATS techniques appear safe and effective compared to open surgery and may offer short- and long-term advantages.

Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits.This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits.This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018.This study was conducted in a large statewide health care system (10 affiliated hospitals,300 practices).All adult patients undergoing colorectal surgery were included unless they had a length of stay1 day or died during the index hospitalization.Early (10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed.The primary outcome measured was the time to 30-day postdischarge emergency department visit.Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually.We used retrospective data and were unable to assess for health care utilization outside our health system.Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía1 día o murieran durante el índice de hospitalización.Temprano (10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).

To determine predictive factors for a successful residency match among general surgery applicants from 2018 to 2021.A retrospective cross-sectional study of general surgery applicants who matched and went unmatched in match years 2018 to 2021. Applicant characteristics, geographic connections to a program, and away rotations were compared among matched and unmatched applicants.Data were sourced from the Texas Seeking Transparency in Applications to Residency initiative for general surgery applicants.All fourth-year medical students applying in the 2018 to 2021 cycles at participating U.S. medical schools were eligible to respond to the Texas Seeking Transparency in Applications to Residency survey. This study included a total of 1,425 general surgery applicants.Of 1,425 general surgery applicants, 88% matched and 12% went unmatched. Significant predictors for a successful match included Step 1 Score ≥237 (odds ratio (OR) 1.59 [95% CI 1.15-2.19]; p = 0.005); Step 2 CK Score ≥252 (OR 1.88 [95% CI 1.36-2.60]; p0.001); ≥3 Honored Clerkships (OR 1.84 [95% CI 1.33-2.53]; p0.001); Honors in General Surgery Clerkship (OR 1.73 [95% CI 1.33-2.53]; p = 0.001); AOA membership (OR 2.14 [95% CI 1.34-3.42]; p = 0.001); ≥4 abstracts, posters, or publications (OR 1.66 [95% CI 1.20-2.30]; p=0.002); and ≥1 peer-reviewed publications (OR 1.52 [95% CI 1.09-2.12]; p = 0.014). On average, matched applicants completed more away rotations than unmatched applicants (p = 0.004). Overall, 36% of matched applicants reported a geographic connection to the program where they matched.We found that Step 2 CK score, research productivity, honored clerkships, AOA status, and away rotations are significant predictors for successfully matching into general surgery residency. Medical schools can encourage students to prepare a holistic application incorporating variables quantified in this study in preparation for the Step 1 reporting change.

Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities.

OBJECTIVE Expand Operative Stress Score (OSS) increasing procedural coverage and assessing OSS and frailty association with Preoperative Acute Serious Conditions (PASC), complications and mortality in females versus males. SUMMARY BACKGROUND DATA Veterans Affairs male-dominated study showed high mortality in frail veterans even after very low stress surgeries (OSS1). METHODS Retrospective cohort using NSQIP data (2013-2019) merged with 180-day postoperative mortality from multiple hospitals to evaluate PASC, 30-day complications and 30-, 90- and 180-day mortality. RESULTS OSS expansion resulted in 98.2% case coverage versus 87.0% using the original. Of 82,269 patients (43.8% male), 7.9% were frail/very frail. Males had higher odds of PASC (aOR = 1.31, 95%CI = 1.21-1.41, P

Background There are multiple different systems that define a rural area in health services research, but few studies compare their ability to measure access to health resources. Our objective was to compare various definitions of rurality to determine which system best measures local surgeon supply. Materials and methods In this retrospective observational study, we used the 2019 Area Health Resource File to obtain the 2017 county-level supply of general surgeons, surgical subspecialists, and total physicians for all counties in the United States. Physicians per 100,000 population were calculated for each physician measure and were the primary outcomes. The rural-urban measurements included were the Office of Management and Budget 2017 definition, Urban Influence Codes (UIC), Rural-Urban Commuting Codes (RUCCs), and Census urban population within the county. We also developed and tested a measure combining the RUCCs and Census urban population. Linear regression was used to compare performance of these definitions for each outcome using adjusted R2 values. Results In 3138 counties included in the study, dichotomous measures of rural-urban using the UIC/RUCC had the lowest adjusted R2 values across all outcomes. Quartiles using the Census urban population and the RUCC/Census urban population combined measure had the highest adjusted R2 values for all outcomes. Conclusions The Census urban population had the best performance in measuring geographic access to surgical care. This study can inform surgical health services researchers who want to include measures of rurality in their analysis.

The utility of sentinel lymph node biopsy (SLNB) for non-ulcerated T1b melanoma is debated and associated costs are poorly characterized. Prior work using institutional registries may overestimate the incidence of nodal positivity in this population.The aim of this study was to estimate the use of SLNB, positivity prevalence, and procedural costs in patients with non-ulcerated T1b melanoma using a population-based registry.We identified patients with clinically node-negative, non-ulcerated melanoma 0.8-1.0 mm thick (T1b according to the 8th edition standard of the American Joint Committee on Cancer) in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. The prevalence of SLNB procedures and positive sentinel nodes were calculated. Factors associated with SLNB and sentinel node positivity were assessed using logistic regression. Medicare reimbursement costs and patient out-of-pocket expenses for SLNB and wide local excision (WLE) versus WLE alone were estimated.Among 7245 included patients, 3835(53%) underwent SLNB, 156 (4.1%, 95% confidence interval 3.5-4.7) of whom had a positive SLNB. Younger age,1 mitosis per mmIn this population-based study, only 4% of selected non-ulcerated T1b patients had a positive SLNB, which is lower than prior reports. At the population level, SLNB is associated with high costs per prognostic information gained.

Background Travel distance to surgical cancer care is increasing. The relationship between increased travel distance and receipt of surgical cancer care in the United States is not well characterized. Methods A systematic review of studies examining travel distance and receipt of surgery for adult patients in the United States was performed. Literature searches were conducted using PubMed and EMBASE. Results Seven studies were included. Only one found lower likelihood of surgery with increasing travel distance. Three studies, all based on hospital-based data, found that increased travel distance was associated with a higher likelihood of receiving surgery. Two studies found no association and one study had mixed findings. Conclusion We were unable to identify a consistent relationship between travel distance and receipt of surgery. Our results highlight the need for additional research examining how increasing travel distance impacts receipt of surgical cancer care.

PURPOSE Major cancer surgeries have regionalized to fewer and higher-volume hospitals, with the goal of improving the quality of surgical care. However, regionalization may have negative effects on geographic access to care. We hypothesize that lung cancer patients have been traveling further for surgery over time as regionalization has occurred, and this increased travel has primarily impacted rural patients. METHODS A North Carolina all-payer state discharge database was used to capture discharges from 2005 to 2015 for patients undergoing lung cancer resection. Changes in patterns of care over time in high-volume centers (HVC) were examined. Adjusted patient straight-line travel distance was estimated over time and stratified by rural-urban location. FINDINGS The number of hospitals performing lung cancer resections decreased from 49 to 31 over the study period (P = .0006), and the proportion of patients receiving care at HVC increased from 23% to 44% (P < .0001). Rural patient travel distance increased over time by 8.5 miles (95% CI: 0.56-17.10, P = .048), from 45.1 to 53.6 miles. There was no change in urban patient travel distance. The difference in adjusted travel distance between rural and urban patients nearly doubled from 2005 to 2015 (9.6 to 17.9 miles,P < .0001). CONCLUSION In North Carolina, lung cancer surgical regionalization occurred over the study period and was accompanied by increases in travel distance for rural patients only. Further work is needed to determine the effects of greater travel distance on patterns of cancer care for rural patients.

Background: Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the patient perspective frames and modifies the impact of these risk factors. This study aimed to explain why individual risk-factors led a patient to seek non-routine postdischarge care. Methods: This single institution prospective cohort study identified consecutive adult inpatient colorectal surgery patients from 2017-2018. We used a convergent parallel design to integrate electronic health record data with brief phone surveys and in-depth interviews to generate a “what, why, and so what” summary of findings. Findings: We enrolled 258 participants, surveyed 167, and interviewed 18. Overall, 20% were readmitted, 3% had an ED visit, 2% had an observation stay, and 75% had routine postdischarge care. Undergoing open surgery (RR 2.25, 95% CI 1.31-3.87) and reporting depressive symptoms (RR 1.85, 95% CI 1.02-3.37) were associated with an increased non-routine healthcare utilization. Whereas, each 10 miles increasing travel distance (RR 0.94, 95% CI 0.90-0.98), private insurance (RR 0.61 , 95% CI 0.40-0.93), and proactively scheduled follow-up appointments (RR 0.43, 95% CI 0.27-0.69) were protective factors. Patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p

For patients with sentinel node-positive melanoma (SNPM), randomized trials, first reported in 2015, found no benefit for routine completion lymph node dissection (CLND) in selected patients. This study examines time trends in CLND and explores institutional and clinical factors associated with CLND.The National Cancer Database was queried for patients older than 18 years from 2012 to 2016 with SNPM. A high-volume center was defined as80th percentile for number of sentinel node procedures. Poisson regression assessed temporal trends and identified patient, pathologic, and institutional characteristics associated with CLND.From 2012 to 2016, we identified 7,146 patients with SNPM. The proportion of patients undergoing CLND was steady in 2012 to 2014 (61% to 63%), but decreased to 57% in 2015 and 50% in 2016 (p0.0001). The proportion of patients with SNPM who underwent CLND decreased over time for both high- (66% to 52%; p0.0001) and lower-volume centers (55% to 45%; p = 0.06). Female sex (relative risk [RR] 0.97; p0.001) and increasing age (RR 0.98; p0.0001) were associated with lower likelihood of CLND. Increased Breslow depth (RR 1.015; p = 0.006), ulceration (RR 1.067; p = 0.02), and high-volume centers (RR 1.180; p0.0001) were associated with higher likelihood of CLND. Regional differences in likelihood of CLND were also present (p0.0001).Completion lymph node dissection in SNPM decreased over time, with the greatest change in 2016. Several patient, pathologic, and institutional characteristics were associated with likelihood of CLND. As evidence supports close observation for selected patients, efforts should be undertaken to improve and standardize patient selection for CLND across institutions caring for patients with melanoma.

Tumor mitotic rate (TMR) is a known prognostic variable in thin melanoma patients. Its significance in stage II melanoma patients is yet to be demonstrated. Retrospective analysis of a prospective melanoma database from 9/1997 to 7/2015 was performed. All stage II melanoma, with documented TMR, and six months of follow-up were included. We evaluated the association of clinicopathologic variables, TMR, as a continuous and categorical variable with recurrence-free survival (RFS) and overall survival (OS) using Cox proportional hazards modeling. We used a statistical model, X-tile, to develop optimal categorizations of TMR. A total of 265 patient characteristics are included in this study. Recurrences occurred in 82 (30.9%) patients, including 5 local, 41 regional, and 36 distant patients. In multivariate model, ulceration, Breslow, and continuous TMR were associated with worse RFS\OS. Continuous TMR demonstrated worse RFS (hazards ratio [HR] 1.02 (1.00–1.05)) and OS (HR 1.02 (1.00–1.04)), whereas dichotomized TMR (≥1 vs 10.4 mitoses/mm2 has a 5-year RFS\OS of 27.2 and 44.3 per cent, respectively, compared with 57.4 and 71.4 per cent, respectively, for TMR

Objective To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. Methods We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (> 20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. Results We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n = 2494) of patients and use varied widely by hospital, from 5%–55%. High utilization hospitals (n = 1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23–55%), while low utilization hospitals (n = 2671, 14 hospitals) had a median rate of 10% (range 5–17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83–0.97 and HR 0.85 95% CI 0.75–0.95). Conclusions Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.

Patients with stage II melanoma have a considerable risk for recurrence. Current guidelines are imprecise as to optimal follow-up. We hypothesized that by examining recurrence patterns, we could help to better inform guidelines.We queried IRB-approved melanoma databases of Thomas Jefferson University and University of North Carolina, identifying 581 patients with stage II melanoma between 1996 and 2015 with at least 1 year of follow-up. Data included location of first recurrence and how recurrence was detected (ie patient symptom, physician examination, or routine surveillance imaging). Cox regression with backward elimination was used for multivariable analysis.One hundred and seventy-one patients had a recurrence (29.4%), the incidence increased considerably by stage sub-group. Significant predictors of recurrence included male sex (p = 0.003), ulceration (p = 0.03), and stage (p0.001). On multivariable analysis, male sex and stage continued to be significant (p0.01). For overall survival, regression, ulceration, stage, and age were significant predictors of survival. Stage, regression, and age remained significant by multivariable analysis. Patient symptoms were the most frequent mode of detection (40%), followed by physician examination (30%) and surveillance imaging (26%)-this did not differ significantly by stage. Regional nodes were the most common site of recurrence (30%), followed by lung (27%) and in-transit (18%).The majority of recurrences in stage II melanoma are detected by patients and their physicians and rarely by routine imaging. As such, clinical follow-up and patient education are critical factors in detection of recurrence. With the prevalence of regional nodal recurrences, ultrasound might prove to be an important strategy in early recurrence detection.

Background The costs of cancer care in the US continue to increase and may have serious consequences for patients. We hypothesize that even cancer patients treated with curative-intent surgery alone experience substantial financial burden. Methods A questionnaire was administered to adult cancer patients who were treated with curative-intent surgery. Survey items included a validated instrument for measuring financial toxicity, the COST score. Demographic variables and survey responses were examined using Chi-square and Fisher exact tests. A multivariate general linear model was performed to examine the relationship between age and COST score. Results COST scores varied widely. 30% of respondents had a COST score of ≤24 (high burden). Younger participants reported more financial burden (p = 0.008). Respondents reported that financial factors influenced their decisions regarding surgery (14%) and caused them to skip recommended care (4.7%). Cancer care influenced overall financial health (38%) and contributed to medical debt (26%). Conclusion Curative-intent cancer care places a substantial portion of patients at risk for financial toxicity even when they don't require chemotherapy. Interventions should not be limited to patients receiving chemotherapy.

Upfront chemoradiation with omission of surgery (CR-only) is increasingly being used to treat rectal cancer. When CR-only is used with curative intent, intense surveillance is recommended. We hypothesized that in practice, few patients treated with CR-only receive intensive post-treatment surveillance.Using Surveillance, Epidemiology, and End Results (SEER)-Medicare, all nonmetastatic rectal cancer patients (≥66 years old) diagnosed from 2004 to 2012, who received upfront chemoradiation, were included. Patients who received CR-only were compared with patients receiving neoadjuvant therapy plus proctectomy. In the 24 months after treatment, markers of surveillance, including carcinoembryonic antigen testing (CEA), endoscopy, and imaging, were compared between groups.A total of 2,482 individuals met the inclusion criteria: 21% (n = 514) had CR-only and 79% had conventional treatment (ie chemoradiation plus proctectomy). Only 2.5% and 3.4% of those in the CR-only and conventional treatment groups, respectively, were in complete compliance with National Comprehensive Cancer Network surveillance guidelines during the first 2 years post-treatment (p0.01). The CR-only group was less likely than the conventional treatment group to receive: CEA (adjusted risk ratio [aRR] 0.57; 95% CI 0.50 to 0.65), endoscopy (aRR 0.76; 95% CI 0.66 to 0.87), and office visits (aRR 0.88; 95% CI 0.84 to 0.92), respectively. However, there were similar rates of cross-sectional imaging between groups (aRR 1.31; 95% CI 0.93 to 1.85).Adherence to guideline-recommended surveillance was poor for all Medicare patients with rectal cancer. Despite recommendations for closer follow-up, patients treated with CR-only were less likely to receive surveillance than those treated with conventional treatment. Efforts should be made to increase adherence to surveillance guidelines for all rectal cancer patients treated with curative intent, but particularly for those with higher risk of recurrence, such as those treated with CR-only.

Purpose Neoadjuvant chemoradiation for stage II/III rectal cancer results in up to 49% of patients with a clinical complete response. As a result, many have questioned whether surgery can be omitted for this group of patients. Currently, there is insufficient evidence for chemoradiation only, or nonoperative management (NOM), to support its adoption. Despite this, anecdotal evidence suggests there is a trend toward increased use of NOM. Our objective was to examine the use of NOM for rectal cancer over time, as well as the patient- and facility-level factors associated with its use. Methods We included all incident cases of invasive, nonmetastatic rectal adenocarcinoma reported to the National Cancer Database from 1998 to 2010. We performed univariate and multivariate analyses to assess for NOM use over time, as well as associated patient- and facility-level factors. Results A total of 146,135 patients met the inclusion criteria: 5,741 had NOM and 140,394 had surgery with or without additional therapy. From 1998 to 2010, NOM doubled, from 2.4% to 5% of all cases annually. Patients who were black (adjusted odds ratio [AOR], 1.71; 95% CI, 1.57 to 1.86), uninsured (AOR, 2.35; 95% CI, 2.08 to 2.65) or enrolled in Medicaid (AOR, 2.10; 95% CI, 1.90 to 2.33), or treated at low-volume facilities (AOR, 1.53; 95% CI, 1.42 to 1.64) were more likely to receive NOM than were patients who were white, privately insured, and treated at a high-volume facility, respectively. Conclusion NOM demonstrates promise for the treatment of rectal cancer; currently, however, the most appropriate strategy is to pursue this approach with well-informed patients in the context of a clinical trial. We observed evidence of increasing NOM use, with this increase occurring more frequently in black and uninsured/Medicaid patients, raising concern that increased NOM use may actually represent increasing disparities in rectal cancer care rather than innovation. Further studies are needed to assess survival differences by treatment strategy.

Evidence suggests that high-volume facilities achieve better rectal cancer outcomes. Logistic regression was used to evaluate association of facility type with treatment after adjusting for patient demographics, stage, and comorbidities. SEER-Medicare beneficiaries who were diagnosed with stage II/III rectal adenocarcinoma at age ≥66 years from 2005 to 2009 and had Parts A/B Medicare coverage for ≥1 year prediagnosis and postdiagnosis plus a claim for cancer-directed surgery were included. Institutions were classified according to National Cancer Institute (NCI) designation, presence of residency program, or medical school affiliation. Two thousand three hundred subjects (average age = 75) met the criteria. Greater proportions of those treated at NCI-designated facilities received transrectal ultrasound (TRUS) or magnetic resonance imaging (MRI)-pelvis (62.1 vs. 29.9 %), neoadjuvant chemotherapy (63.9 vs. 41.8 %), and neoadjuvant radiation (70.8 vs. 46.3 %), all p

112 Background: Rural-urban disparities in the receipt of surgery for early-stage non-small cell lung cancer (NSCLC) have been noted, but few studies have considered access to other available treatments (i.e. radiation) or examined changes over time. Rural hospital closures, regionalization and workforce changes could lead to temporal changes in treatment access. Therefore, the primary objective was to evaluate geographic disparities in lung cancer treatment modalities in North Carolina and to characterize how practice patterns are changing over time. We hypothesized that rural patients would be less likely to undergo treatment compared to urban patients with widening disparities over time. Methods: North Carolina cancer registry data linked with Medicaid, Medicare, and private insurance claims were used to identify patients with Stage I or II NSCLC from 2006-2015. The primary outcome was first course treatment modality: surgery, radiation, or no treatment. Rural-urban status was defined based on Rural-Urban Commuting Codes. Calendar years were split into early (2006-10) and late (2011-15) periods. Multivariable logistic regression was used to assess the association of rural/urban status and time period with surgery and any treatment (surgery or radiation) while controlling for clinical, demographic, and area-level factors. Results: Among 7532 patients, 4144 (56%) patients underwent surgery, 1991 (27%) received radiation, and 1397 (19%) had no therapy. Rural patients were as likely to undergo treatment in either time period as urban patients. Among rural patients, the odds of surgery decreased over time (2011-15 vs. 2006-10 OR 0.79, 95%CI 0.66,0.94) and the odds of radiation increased (2011-15 vs. 2006-10 OR 1.46, 95%CI 1.40,1.78). Meanwhile urban patients had no significant change in surgery over time, but also had an increase in likelihood of undergoing radiation (2011-15 vs. 2006-10 OR 1.34 95%CI 1.18,1.52). Conclusions: Between 2006-2015, nearly 1 in 5 insured patients in North Carolina did not receive any treatment for potentially curable lung cancer. Over time, rural patients are less likely to undergo surgery, the standard of care, while radiation use is increasing everywhere. As rural patients are less likely to undergo surgery over time, this may have downstream effects on rural-urban disparities in survival. Further work aims to understand the patient and system level drivers behind these trends.

BACKGROUND Surgical resection provides the only potentially curative treatment of pancreatic cancer. Neoadjuvant chemotherapy and/or radiation (NAT) is used to downstage patients with borderline resectable tumors. The objective of this study was to examine the postoperative morbidity and mortality of NAT after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA). METHODS Using the American College of Surgeons-National Surgical Quality Improvement Project Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA from 2014 to 2015. Patients were grouped by receipt of NAT 90 days before PD. Bivariable and multivariable analyses was used to compare postoperative outcomes. RESULTS A total of 3748 patients with PDA underwent PD; 926 (24.7%) received NAT. Those in the NAT group had more major vein resections, and longer operating times (all P

Background and Objectives Tumor mitotic rate (TMR) is an important prognostic variable for patients with thin melanoma. However it remains unclear what the significance of TMR is for more deeply invasive melanoma pathologically staged with a sentinel lymph node biopsy. We sought to determine the prognostic value of TMR in clinically node-negative T2 melanoma patients staged with sentinel lymphadenectomy. Methods A prospective IRB-approved database of cutaneous melanoma patients treated from 09/01/1997–03/01/2011 was used to identify patients with T2 melanoma staged with a SLN. Associations were evaluated using Fisher's Exact test, and Kaplan–Meier analysis. Results Three hundred thirteen T2 patients were included. 19% had ulceration, 11% a positive sentinel node (SLN), and 10% recurred. 44% of patients had TMR ≥1/mm2. TMR ≥1/mm2 did not predict SLN status. TMR ≥1/mm2 was significantly associated with recurrence in SLN negative patients; only 3% of those with TMR

Tumor mitotic rate (TMR) is a known prognostic variable in thin melanoma patients. Its significance in stage II melanoma patients is yet to be demonstrated. Retrospective analysis of a prospective melanoma database from 9/1997 to 7/2015 was performed. All stage II melanoma, with documented TMR, and six months of follow-up were included. We evaluated the association of clinicopathologic variables, TMR, as a continuous and categorical variable with recurrence-free survival (RFS) and overall survival (OS) using Cox proportional hazards modeling. We used a statistical model, X-tile, to develop optimal categorizations of TMR. A total of 265 patient characteristics are included in this study. Recurrences occurred in 82 (30.9%) patients, including 5 local, 41 regional, and 36 distant patients. In multivariate model, ulceration, Breslow, and continuous TMR were associated with worse RFS\OS. Continuous TMR demonstrated worse RFS (hazards ratio [HR] 1.02 (1.00-1.05)) and OS (HR 1.02 (1.00-1.04)), whereas dichotomized TMR (≥1 vs1) was not significant. TMR10.4 mitoses/mm2 has a 5-year RFS\OS of 27.2 and 44.3 per cent, respectively, compared with 57.4 and 71.4 per cent, respectively, for TMR3.2 mitoses/mm2. Continuous TMR predicts incidence of recurrence in stage II melanoma. We propose a new categorization method developed by statistical modeling for optimal stratification that may guide surveillance for this disparate patient population.