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BACKGROUND: The impact of rurality on outcome for patients who had resected pancreatic ductal adenocarcinoma (PDAC) is unclear. We hypothesize that poor outcomes for rural patients are associated with adverse social determinants of health (SDoH). The objective of this study is to assess the difference in overall survival (OS) of PDAC patients between rural, urban, and contributing factors. METHODS: A cohort of 25,536 patients diagnosed with stage I–III pancreatic adenocarcinoma from 2003 to 2011 and underwent resection were evaluated from the National Cancer Database. Socioeconomic/demographic, clinicopathological, and treatment variables were compared between rural and urban residences. The 5-year OS was calculated using the Kaplan-Meier method. The Cox regression model was used to assess factors associated with OS. P value

Background The coronavirus disease 2019 pandemic has disrupted the delivery of safe surgical care worldwide. One specific aspect of global surgical care that has been severely limited is the ability for physicians and trainees to participate in global surgical outreach programs in low- and middle-income countries. Methods A narrative review of the literature regarding global surgical outreach programs during the coronavirus disease 2019 pandemic was performed. Factors that must be considered in the reinstatement of global surgical outreach programs were identified, and suggestions to address them were provided based on the available literature and the experiences of the senior authors. Results As global surgical outreach programs were canceled at the start of the pandemic, many academic surgeons turned to digital solutions to continue to engage with low- and middle-income country partners. With the advent of coronavirus disease 2019 vaccines and improved access to testing and treatment worldwide, the recommencement of global surgical outreach programs may begin to be considered. Important considerations before initiation include vaccine and testing availability for visiting providers, local staff, and patients, local hospital capacity, staff and equipment shortages, and the characteristics of the patient population and visiting providers. Region- and country-specific factors, including local infection rates and concomitant health crises, must also be taken into account. Expansion of digital collaborative efforts may further deepen international connections and promote sustainable models of care. Conclusion With careful consideration, global surgical outreach programs may begin to be safely restarted in the near future. The current article evaluates individual factors that must be considered to safely restart global surgical outreach programs as the coronavirus disease 2019 pandemic is better controlled.

“Old age, itself, is not a disease” (Suborne 2007). The rising rate of the global aging population is predicted to create a health care crisis within the next three decades. Vulnerable older adults suffer from multiple chronic conditions (MCCs) in addition to cognitive and physical decline during the process of aging resulting in an inability to optimally achieve self-management. In terms of resource utilization, complex inpatient, and outpatient care results in higher physician visits, polypharmacy, and higher prescription costs. Health literacy has become known as an important social determinant of health affecting the older population. Both reductions in health literacy and self-management are associated with poorer health outcomes. The patient activation measure (PAM) has been coined “a vital sign” to ascertain a patient activation level throughout the continuum of care with the introduction of an intervention’s progress. In this review, we conceptualize a systematic approach of the development of a “tailored” integrated community and care team to develop a partnership in assisting senior adults with MCCs. Through this intervention the value-based chronic care model (CCM) and PAM allows for an adaptable integration between the activated patient, their caregivers, and the community. The Model for Improvement (MFI) serves as a well-recognized technique for developing and executing quality improvement strategies in this “tailored” engaged and activated individual and community care team approach in achieving health outcomes and quality of life among the vulnerable older adult population worldwide.

Louisiana has the third highest breast cancer mortality in the US, despite ranking 30th in incidence. Whether surgical approach contributes to such a poor outcome is unknown. We compared outcomes of breast-conserving surgery plus radiation (BCT) vs mastectomy (MST) for Louisiana women with early-stage breast cancer.Data on women diagnosed with Stage I-II breast cancer from 2004 to 2016 were analyzed from the Louisiana Tumor Registry. Overall survival (OS) and breast cancer-specific survival (CSS) were compared between BCT and MST. Kaplan-Meier method and log-rank test were used to compare survival curves, and logistic regression was used to examine the association of sociodemographic and clinical factors with the type of breast cancer surgery. Values of p 0.05 were considered significant.Of the 18,260 patients, 9,968 patients (54.6%) had BCT and 8,292 patients (45.4%) had MST. Compared with BCT, the MST group tended to be underinsured/Medicare/Medicaid, more impoverished, had higher stage 2 disease, were more likely to reside in rural regions, travel ≥25 miles to radiation treatment facility, be treated at low volume centers, and have T3, node positive, and poorly differentiated tumors. Ten-year OS and CSS were significantly better among those who had BCT (OS: 80.0%; 95% CI: 79.0%-81.1%; CSS: 92.7%; 95% CI: 92.1%-93.4%) than those having MST (OS: 69.3%; 95% CI: 68.0%-70.5%; CSS: 88.8%:95% CI: 87.9%-89.7%) (p0.05). Even after controlling for sociodemographic and clinical variables, MST was associated with a 28.6% increased risk of death from all causes (hazard ratio [HR]:1.286; 95% CI:1.197-1.380) and a 29.8% increased risk of breast-cancer specific death (HR:1.298; 95% CI: 1.150-1.465).Surgical approach, a factor that is within the control of the surgeon, has an impact on mortality for Louisiana women with early-stage breast cancer.

In recognition of the rising incidence and mortality of cancer in low- and middle-resource settings, as well as the increasingly international profile of its membership, ASCO has prioritized efforts to enhance its engagement at a global level. Among the recommendations included in the 2016 Global Oncology Leadership Task Force report to the ASCO Board of Directors was that ASCO should promote the recognition of global oncology as an academic field. The report suggested that ASCO could serve a role in transitioning global oncology from an informal field of largely voluntary activities to a more formal discipline with strong research and well-defined training components. As a result of this recommendation, in 2017, ASCO formed the Academic Global Oncology Task Force (AGOTF) to guide ASCO’s contributions toward formalizing the field of global oncology. The AGOTF was asked to collect and analyze key issues and barriers toward the recognition of global oncology as an academic discipline, with an emphasis on training, research, and career pathways, and produce a set of recommendations for ASCO action. The outcome of the AGOTF was the development of recommendations designed to advance the status of global oncology as an academic discipline.

Hepatocellular carcinoma (HCC) is a male-dominated disease. Currently, gender differences remain incompletely defined. Data from the state tumor registry were used to investigate differences in demographics, comorbidities, treatment patterns, and cancer-specific survival (HSS) among HCC patients according to gender. Additional analyses were performed to evaluate racial differences among women with HCC. 2627 patients with HCC were included; 498 (19%) were women. Women were mostly white (58%) or African American (39%)—only 3.8% were of another or unknown race. Women were older (65.1 vs. 61.3 years), more obese (33.7% vs. 24.2%), and diagnosed at an earlier stage (31.7% vs. 28.4%) than men. Women had a lower incidence of liver associated comorbidities (36.1% vs. 43%), and more often underwent liver-directed surgery (LDS; 27.5% vs. 22%). When controlling for LDS, no survival differences were observed between genders. African American women had similar HSS rates compared to white women (HR 1.14 (0.91,1.41), p = 0.239) despite having different residential and treatment geographical distributions. African American race and age >65 were predictive for worse HSS in men, but not in women. Overall, women with HCC undergo more treatment options—likely because of the earlier stage of the cancer and/or less severe underlying liver disease. However, when controlling for similar stages and treatments, HCC treatment outcomes were similar between men and women. African American race did not appear to influence outcomes among women with HCC as it did in men.

Intraoperative management of refractory small bowel gastrointestinal bleeding continues to present challenges to surgeons, specifically, in localizing the source of bleeding. The need for operative intervention has decreased significantly with improved percutaneous radiologic techniques for embolization with good success rates. When percutaneous treatment methods fail, the surgeon is left with a variety of suboptimal options for localization if the pathologic source is not obvious on external inspection of the small bowel. This report describes a novel method for localizing small bowel gastrointestinal bleeding in those patients who have had previous coil embolization attempts at controlling small bowel gastrointestinal bleeding.

BACKGROUND: Racial disparities have long been a subject of concern between patients afflicted with pancreatic cancer in the United States. We believe that, in addition to a high-volume center, treatment at an academic research program (ARP) will mitigate racial outcome disparities. METHODS: A total of 12,950 patients diagnosed with stage I–III pancreatic adenocarcinoma from 2003–2011 and at ACS Commission on Cancer (COC) accredited facilities [e.g., high-volume (≥12 cases/year) ARPs] were evaluated from the National Cancer Data Base (NCDB). Sociodemographic, clinicopathological, and treatment variables were compared between Black (N=1,127) and White (N=11,823) patients. The Kaplan-Meier Estimator and Cox Proportional Hazards Model were used for survival analysis. P value ≤0.05 was considered significant. RESULTS: Black patients had a significantly higher overall survival (OS) than White patients, despite having a significantly lower household income, lower education level, more stage III disease, more Medicaid recipients, and higher comorbidity index (P

Background Portal vein injury is uncommon, and the optimal treatment is controversial. We compared the outcomes of ligation vs repair of portal injury using the National Trauma Data Bank. Methods Adult patients who suffered portal injury were identified from the National Trauma Data Bank (2002-2014) by International Classification of Diseases, Ninth Revision diagnosis codes. Patients were stratified by treatment modality into no surgery, ligation, and surgical repair using International Classification of Diseases procedure codes. Outcomes including hospital mortality, bowel resection, and length of stay between ligation and surgical repair were compared by Kruskal-Wallis or Fisher exact test as appropriate. Multivariable analyses were performed with logistic regression. Results Among 752 patients with portal vein injury, 345 patients (45.9%) underwent no surgery, 103 patients (13.7%) had ligation, and 304 (40.4%) underwent surgical repair. Overall mortality was 49%. Age, sex, Injury Severity Score, Glasgow Coma Scale score, presenting blood pressure, and heart rate were similar between groups that underwent ligation and surgical repair. The hospital mortality (59.2% vs 47.7%; P = .08), bowel resection (1.9% vs 1.0%; P = .55), and length of stay (12.5 vs 15.0 days; P = .08) were also comparable between ligation and repair in univariate analysis. In multivariable analysis, hospital mortality for surgical repair was similar to ligation (risk ratio, 0.69; 95% confidence interval, 0.41-1.16; P = .16). Conclusions Portal vein injury is associated with significant mortality and morbidity. Surgical repair showed a trend for lower postoperative mortality than ligation, but this was not statistically significant on multivariate analysis. Repair of a traumatic portal vein injury should be attempted, but ligation is an acceptable alternative without an increase in bowel resection rates or a statistically significant increase in mortality.

BACKGROUND Louisiana is one of the few Southern states that enacted the Medicaid expansion of the Patient Protection and Affordable Care Act (ACA). To the authors' knowledge, the issue of how this has affected the breast cancer landscape in Louisiana is unknown. The authors have postulated that ACA expansion had a positive impact for Louisiana women diagnosed with breast cancer. METHODS Data from the Louisiana Tumor Registry regarding 14,640 women aged 20 to 64 years who resided in Louisiana and were diagnosed with American Joint Committee on Cancer stage 0 to stage IV breast cancer between 2012 and 2018 were analyzed. The study period was divided into 2 groups: 1) before ACA expansion (January 1, 2012-May 31, 2016); and 2) after ACA expansion (June 1, 2016-December 31, 2018). The chi-square test and multivariable logistic regression models were used to assess the impact of ACA expansion. A P value

BACKGROUND/AIM Radiotherapy for carcinoma invasion of the sacrum (CIS) is an alternative treatment to surgery in patients with advanced, inoperable tumors or those not medically eligible for resection of the neoplasm. Herein we present an observational study of patients with imaging-confirmed CIS who were treated non-operatively with radiation. PATIENTS AND METHODS A retrospective chart review of CIS patients treated with palliative radiotherapy (PR) during a 9-year period (2004-2013) was performed. RESULTS Six women and 13 men with an average age of 60 years took part in this study. Most patients (84%) exhibited extrasacral metastases. Primary tumors included lung (n=6), colorectal (n=6), breast (n=3), bladder or kidney (n=2), and liver carcinoma or a tumor in an unknown primary site (n=2). The mean follow-up time was 10 months with a 2-year survival rate of 9%. The majority (71%) of symptomatic patients obtained relief from pain following PR. Half of those individuals who were non-ambulatory prior to therapy regained mobility. There were no acute ill-effects or later complications after irradiation. CONCLUSION Despite the small cohort and poor overall survival rate, non-operative radiation treatment is a beneficial method of palliative care in patients with CIS.

BACKGROUND/AIM A re-excision for positive margin(s) following a lumpectomy for invasive breast cancer is a standard recommendation. However, for elderly women with stage I estrogen receptor-positive (ER+) tumors, who may be at higher surgical risk, whether radiation therapy without re-excision will be adequate is not known. PATIENTS AND METHODS We evaluated a cohort of 53,950 women aged ≥70 years with Stage I, ER+ breast cancer who had lumpectomy and anti-hormone therapy diagnosed between 2004 and 2011 in the National Cancer Data Base. Patients were divided into four groups: 1) negative margins without radiation (XRT), 2) negative margins with XRT, 3) positive margins without XRT, and 4) positive margins with XRT. Clinicopathological and sociodemographic variables were compared among these groups. Univariable and multivariable analysis were employed. RESULTS The 5-year overall survival (OS) rates for the groups were as follows: 1) negative margins without radiation (XRT); 77.1%, 2) negative margins with XRT; 90.0%, 3) positive margins without XRT; 62.9%, and 4) positive margins with XRT; 86.8% (p

Uterine leiomyomas are one of the most common tumors affecting reproductive-age women. Leiomyomas can present as an intrauterine mass or rarely as an extrauterine tumor. Depending on its location, the diagnosis of extrauterine leiomyoma can be challenging, and multiple imaging modalities may be needed for correct identification and differentiation from malignant entities. We report the case of a 48-year-old-postmenopausal female who presented with a painful left inguinal mass, which was clinically diagnosed as inguinal hernia. Ultrasound, computed tomography, magnetic resonance imaging, and percutaneous biopsy were used to characterize the mass. Surgical resection and histopathological analysis revealed the mass to be a parasitic leiomyoma, a very rare cause of inguinal hernia, especially in a postmenopausal woman. Keywords: Parasitic leiomyoma, Intra-abdominal mass, Inguinal hernia

The Cancer and Leukemia Group B 9,343 demonstrated that postoperative radiation can be safely omitted in women ≥70 years who underwent breast-conserving therapy for clinical stage I (T1N0M0) estrogen receptor positive breast cancer treated with antihormonal therapy. Whether such results are observed in real-world population is unknown. In this hospital-based data, we report the survival outcomes of patients who received adjuvant radiation therapy versus those who did not.Using the National Cancer Data Base, we evaluated a cohort of 47,358 women with newly diagnosed breast cancer between 2004 and 2011 who underwent a lumpectomy and antihormonal therapy with the following criteria: age ≥70 years, clinical stage I, estrogen receptor positive, and negative margins. Patients were stratified into 2 groups: (1) radiation therapy and (2) no radiation therapy. Propensity score matching was used to compensate for differences in demographic and clinical characteristics of the patients. Univariate and multivariable survival analysis were employed to determine factors associated with overall survival.The 5-year overall survival after propensity score matching was 87.2% for radiation therapy and 79.4% for no radiation therapy (P .0001). The median survival time was 113.7 months for radiation therapy and 105.2 months for no radiation therapy. After adjusting for sociodemographic and clinical factors, the risk of overall deaths was significantly higher for those not receiving radiation therapy (hazard ratio = 1.66; 95% confidence interval, 1.54-1.79). Other significant adjusted predictors (P .05) of poor overall survival were, advanced age, comprehensive community cancer program, facility location, poorly differentiated tumor, and high comorbidity index.Patients who received radiation therapy had better survival outcomes than those who did not, revealing discordance between results of randomized trials and real-world setting.

Introduction Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes). Methods Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake. Results Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet. Conclusions The “ASSIST” method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities.

An estimated 100,000 individuals within the United States experience operations that result in a colostomy or ileostomy each year. Ostomy formation is used in surgery for operations involving several pathologies involving the small intestine or colon. Evidence shows that loop ileostomy or loop colostomy for fecal diversion effectively reduce the complications of anastomotic dehiscence. Anastomotic leak can cause significant morbidity and mortality. The role of temporary fecal diversion though a loop ileostomy or colostomy is vital in protecting tenuous anastomoses in the pelvis, immunocompromised patients, or those who are septic. 4 We present a case of a patient with a perforated colon cancer who required an innovative technique for fecal diversion.

Although a volume-outcome relationship has been well established for pancreatectomy, little is known about differences in mortality by facility type. The objective of this study is to evaluate the impact of facility type on short-term and long-term survival outcomes for patients with pancreatic adenocarcinoma who underwent pancreatectomy and identify determinants of overall survival (OS).A cohort of 33,382 patients with Stage I-III pancreatic adenocarcinoma diagnosed between 1998 and 2011 were evaluated from the National Cancer Data Base. Clinicopathological, sociodemographic and treatment variables were compared among three facility types where patients received resection: (i) community cancer program (CCP), (ii) comprehensive community cancer program (CCCP), and (iii) academic research program (ARP). 5-year OS was calculated using the Kaplan-Meier method.Despite ARP having significantly higher percentage of poorly differentiated tumors, higher T-stage tumors, more positive lymph nodes, and greater circle distance compared to the other facilities, it had the highest 5-yr OS. The 5-yr OS for CCP, CCCP, and ARP was 11.2%, 13.2%, and 16.6%, respectively (P 0.0001) and the median survival time (months) was 12.4, 15.6 and 19.1, respectively.Patients receiving pancreatic resection at an ARP yielded a higher 5-year OS compared to CCP or CCCP.

It is unknown whether rural patients with operable breast cancer do worse than urban patients in Louisiana. We performed an analysis of breast cancer based on rural versus urban residencies and evaluate factors associated with worse survival.Data on women diagnosed with stages I to III breast cancer from 2004 to 2016 were obtained from the Louisiana Tumor Registry. Overall survival and cancer-specific survival were compared between rural and urban residencies by sociodemographic, clinical-pathologic, and treatment variables. Kaplan-Meier method and the log-rank test were used to compare the survival curves. Cox regression model was used to assess independent factors associated with overall survival and cancer-specific survival.Of the 27,780 patients, 2,441 patients (8.7%) resided in rural areas. Compared with urban patients, rural patients tended to be older, underinsured, more impoverished, less likely to be treated at an American College of Surgeons accredited institution, and more likely to be treated at a low-volume center (P.005 each). For stages I and II diseases, there was a statistically significant difference in overall survival favoring urban regions, but no difference in cancer-specific survival. For stage III disease, there was no difference in either overall survival or cancer-specific survival between the 2 cohorts. Overall survival and cancer-specific survival curves for the entire cohort were not different at the 5-year mark, but become statistically significant with greater time; although rural patients had a lower long-term overall survival (P = .0001) and cancer-specific survival (P = .049) compared with urban patients, the rural-urban differences in overall survival and cancer-specific survival were no longer different after adjusting for other covariates, indicating the observed differences in univariate analysis were attributable to sociodemographic, clinicpathologic, and treatment factors.Despite rural patients with operable breast cancer having an overall lesser overall survival and cancer-specific survival than their urban counterpart, rural residence itself was not an independent predictor of outcome. In fact, particular socioeconomic factors increased the risk of death among patients residing in rural areas. Additional analysis at the patient-level is needed to understand the interactions between rurality and breast cancer outcomes in Louisiana.

The incidence of pancreatic cancer is rising. Understanding trends of pancreatic cancer is crucial prior to putting policies and interventions in place. Countries with a high human development index (HDI) have a higher incidence, prevalence and mortality due to pancreatic cancer. This global trend is replicated in the Asia-Pacific countries with high HDI having higher incidence, prevalence and mortality due to pancreatic cancer. The incidence of pancreatic cancer is rising in the Asia-Pacific population as life expectancy increases with a rising HDI. Lack of good cancer registries has resulted in under reporting of pancreatic cancer in developing countries in the Asia-Pacific region. The mortality still remains high as in the Western world as most pancreatic cancers are diagnosed in an advanced stage of the disease due to non-availability of cost-effective screening tools with few patients receiving definitive care. Smoking, alcohol consumption, poor diet and obesity are significant modifiable risk factors contributing to the development of pancreatic cancer. Population based screening for pancreatic cancer is not cost-effective. Identification of hereditary and genetic factors in the Asia-Pacific population can help in targeted screening of high-risk individuals. Policies and interventions aimed at primary prevention have the greatest potential to be cost-effective yet impactful and reduce the disease burden.

Background: The adoption of sorafenib into oncology practice as a first-line systemic treatment for advanced hepatocellular carcinoma (HCC) is not well understood. We examined sorafenib use since Food and Drug Administration (FDA) approval in 2007 and associated survival for individuals diagnosed with advanced HCC, conducting a population-based evaluation of treatment patterns and outcomes for this newly approved drug in the US over time. Methods: We identified individuals diagnosed with Barcelona Clinic Liver Cancer Stage C from the 2007 and 2012 National Cancer Institute Patterns of Care study. We examined trends in use as well as patient and clinical factors associated with receiving sorafenib using multivariate logistic regression analysis. We then evaluated the association between sorafenib use and overall hazard of death using multivariate Cox proportional hazards regression. Results: Among 550 individuals diagnosed with advanced HCC, we found no significant increase in the proportion of patients treated with sorafenib from 2007 to 2012 (26.3 vs. 30.4%). After adjusting for patient and clinical characteristics, non-Hispanic Blacks (compared to non-Hispanic Whites) and those with a lower Child-Pugh score remained more likely to receive sorafenib. Individuals receiving systemic chemotherapy only, radiation therapy only, or no treatment at all experienced a higher risk of death than those treated with sorafenib, while those receiving a transplant experienced a lower risk of death. Conclusions: Sorafenib has not been widely adopted into oncology practice since FDA approval for advanced HCC. Few factors apart from Child-Pugh score and race/ethnicity predict sorafenib use in clinical practice, although sorafenib treatment is associated with a lower risk of death.

BACKGROUND The Cancer and Leukemia Group B (CALGB) 9343 trial demonstrated that adjuvant radiation therapy (RT) can be omitted in women aged 70 years or older, with small, estrogen receptor (ER)+ breast cancer. We postulated that RT usage after CALGB's publication should have decreased over time. STUDY DESIGN We evaluated a cohort of 205,860 women aged 70 years or older, with stage I, ER+/progesterone receptor (PR)+ breast cancer with lumpectomy, diagnosed between 1998 and 2012, in the National Cancer Data Base. Clinicopathologic and sociodemographic variables were compared between pre-CALGB and post-CALGB publication (circa 2004). Univariate and multivariate analysis were used. RESULTS Radiation therapy usage decreased by only 2.95% after CALGB publication (68.71% vs 65.76%; p < 0.0001). Almost one-third of women with short life expectancy (≥85 years) received RT in the post-CALGB group. Significant predictors (p < 0.01) of lowest RT use include advanced age, increased great circle distance, academic research program, East South Central region, rural population < 2,500 not adjacent to a metropolitan area, low income level, high comorbidity index, small tumor, well-differentiated histology, residual tumor, and lack of receipt of anti-hormonal therapy. CONCLUSIONS The CALGB trial had a minimal impact on the rate of adjuvant RT use among elderly women with small, hormone positive breast cancers. Significant variation in RT usage exists across sociodemographic strata.