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Pancreatic cancer (PC) is highly fatal, and its incidence is increasing in the United States. Population-based registry studies suggest associations between a few autoimmune conditions and PC risk, albeit based on a relatively small number of cases. We conducted a population-based, nested case-control study to examine the associations between autoimmune conditions and PC risk within the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare population. Incident primary malignant PC cases (n = 80 074) were adults ≥66 years and diagnosed between 1992 and 2015. Controls (n = 320 296) were alive at the time cases were diagnosed and frequency-matched to cases (4:1 ratio) by age, sex, and year of diagnosis. We used multivariable-adjusted, unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for 45 autoimmune conditions identified from Medicare claims. Eight autoimmune conditions including ankylosing spondylitis (OR = 1.45; 95% CI: 1.14-1.84), Graves' disease (OR = 1.18; 95% CI: 1.03-1.34), localized scleroderma (OR = 1.27; 95% CI: 1.06-1.52), pernicious anemia (OR = 1.08; 95% CI: 1.02-1.14), primary sclerosing cholangitis (OR = 1.37; 95% CI: 1.18-1.59), pure red cell aplasia (OR = 1.31; 95% CI: 1.16-1.47), type 1 diabetes (OR = 1.11; 95% CI: 1.07-1.15), and ulcerative colitis (OR = 1.18; 95% CI: 1.07-1.31) were associated with increased PC risk (false discovery rate-adjusted P values.10). In subtype analyses, these conditions were associated with pancreatic ductal adenocarcinoma, whereas only ulcerative colitis was associated with pancreatic neuroendocrine tumors. Our results support the hypothesis that autoimmune conditions may play a role in PC development.

Background and aims Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. Methods A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access . Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. Results Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. Conclusions In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

PURPOSE: Pancreatic cancer (PC) has an overall 5-year survival rate of 10%. The use of neoadjuvant chemoradiation is debated in resectable disease. The purpose of this study is to evaluate the cost-effectiveness of neoadjuvant chemoradiation followed by pancreaticoduodenectomy (NACRT) versus upfront pancreaticoduodenectomy and adjuvant chemotherapy (USR) in resectable PC. METHODS: A decision tree model was used to estimate the cost-effectiveness of NACRT versus USR. Values from the published literature populate the tree: costs from Medicare (FY2021) reimbursements, and morbidity and survival data for quality-adjusted life-years (QALYs). Patients with resectable pancreatic adenocarcinoma who qualified for resection were included. The ICER was the primary outcome. The model was validated using one-way and two‐way deterministic, as well as probabilistic sensitivity analyses. RESULTS: The base case was modeled using a 65-year-old male. NACRT yielded 1.61 QALYs at $45,483.52 USD. USR yielded 1.47 QALYs at a discount of $6,840.96 USD. The ICER was $48,130 USD, which favors NACRT. One-way sensitivity analyses upheld these results except when ≤ 21.0% of NACRT patients proceeded to surgery and when ≤ 85.4% of NACRT patients were resectable at surgery. Two-way sensitivity analyses also favored NACRT except in cases when the proportion of resected disease after NACRT decreased. NACRT was favored in 94.3% of 100,000 random-sampling simulations. CONCLUSION: It is more cost-effective to administer NACRT before surgery for patients with resectable PC. On the basis of sensitivity analyses, USR with adjuvant therapy is only favored if rates of resection and eligibility for resection after NACRT decrease. NACRT should be considered in all patients unless there is an absolute contraindication.

Initial staging of pancreatic ductal adenocarcinoma (PDAC) is performed with computed tomography (CT). Laparoscopy with peritoneal cytology at staging can uncover occult disease undetected by CT. This case series assessed clinical course following staging laparoscopy with cytology in patients with PDAC.This single-center study examined patients with non-metastatic PDAC diagnosed from 2017 to 2020. Patients underwent CT and subsequent laparoscopy with cytology prior to treatment. Demographics, clinicopathologic status, treatment course, and survival were compared.Eight patients were identified. All had negative laparoscopies. Five cytologies were negative, two were atypical, and one was positive. Two patients with negative cytology received neoadjuvant chemotherapy and underwent resection, with an average follow-up time of 32.9 months since diagnosis. Of the three remaining patients with negative cytology, none underwent resection. One received delayed chemotherapy, while the others could not due to medical contraindications. The average survival was 3.5 months (n=2). Of two patients with atypical cytology, neither underwent resection. One could not receive chemotherapy due to medical contraindication, while the other was lost to follow-up shortly after diagnosis. The average survival was 1.3 months (n=1). The patient with positive cytology received definitive chemotherapy without resection and survived for 21.6 months.The patient with positive cytology may have been spared non-therapeutic surgery. Remaining unresected patients showed poor survival, though the lack of immediate chemotherapy may contribute to this finding. Further research is needed to determine optimal candidates for invasive staging and implications of atypical cytology.

Background Body mass index (BMI) during adulthood has been associated with pancreatic ductal adenocarcinoma (PDAC), however, patterns of body size across the adult life course have not been studied extensively. We comprehensively evaluated the association between adiposity across adulthood and PDAC. Methods We conducted a prospective analysis of 269 480 (162 735 males, 106 745 females) National Institutes of Health–AARP Diet and Health Study participants, aged 50-71 years (1995-1996) who self-reported height and weight history. Participants were followed through December 31, 2011. We examined associations between BMI (kg/m2) at ages 18, 35, 50, and 50-71 (baseline) years, their trajectories determined from latent-class trajectory modeling, and incident PDAC. Cox proportional hazard models were used to calculate multivariable adjusted hazards ratios (HRs) and 95% confidence intervals (CIs). Results During up to 15.2 years of follow-up, 3092 (2020 males, 1072 females) patients with incident PDAC were identified. BMI at all 4 ages were statistically significantly associated with increased PDAC (per 5-unit increase, HR = 1.09-1.13) with higher magnitude associations in males than females at ages 35 years and older (Pinteraction Conclusions High BMI and BMI trajectories that result in overweight or obesity during adulthood were positively associated with PDAC, with stronger associations among those with early onset adiposity and those with male sex. Avoidance of excess body weight throughout the adult life course may prevent PDAC.

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of − $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Pancreatic cancer (PC) is highly fatal, and its incidence is increasing in the United States. Population-based registry studies suggest associations between a few autoimmune conditions and PC risk, albeit based on a relatively small number of cases. We hypothesize that autoimmune conditions are associated with risk of PC. We conducted a population-based, nested case-control study to examine the association between autoimmune conditions and PC risk within the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare population. Incident primary malignant PC cases (n=80,074) were adults > 66 years and diagnosed between 1992 and 2015. Controls (n=320,296) were alive at the time cases were diagnosed and frequency-matched to cases (4:1 ratio) by age, sex, and year of diagnosis. We used multivariable-adjusted, unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for 45 autoimmune conditions identified from Medicare claims. Eight autoimmune conditions including ankylosing spondylitis (OR = 1.45; 95% CI: 1.14-1.84), Graves’ disease (OR = 1.18; 95% CI: 1.03-1.34), localized scleroderma (OR = 1.27; 95% CI: 1.06-1.52), pernicious anemia (OR = 1.08; 95% CI: 1.02-1.14), primary sclerosing cholangitis (OR = 1.37; 95% CI: 1.18-1.59), pure red cell aplasia (OR = 1.31; 95% CI: 1.16-1.47), type 1 diabetes (OR = 1.11; 95% CI: 1.07-1.15), and ulcerative colitis (OR = 1.18; 95% CI: 1.07-1.31) were associated with increased PC risk (false discovery rate-adjusted P values < 0.10). In subtype analyses, these conditions were associated with pancreatic ductal adenocarcinoma, whereas only ulcerative colitis was associated with pancreatic neuroendocrine tumors. Our results support the hypothesis that autoimmune conditions may play a role in PC development. Citation Format: Fancheng Yuan, Ruth M. Pfeiffer, Sachelly Julian-Serrano, Simran Arjani, Michael J. Barrett, Jill Koshiol, Rachael Z. Stolzenberg-Solomon. Autoimmune conditions and pancreatic cancer risk in older American adults [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B082.

To perform a comparative analysis of postthyroidectomy radioactive iodine ablation dosing with or without the implementation of a diagnostic whole-body scan in patients with well-differentiated thyroid cancer.Decision analysis model.Hospital or ambulatory center.A decision tree model was created to determine the cost-effectiveness of radioactive iodine ablation dosed with diagnostic whole-body scans versus empiric radioactive iodine ablation in patients with differentiated thyroid cancer undergoing postthyroidectomy ablation. The decision tree was populated with values from the published literature. Costs were represented by 2020 Medicare reimbursement rates (US dollars), and morbidity and survival data were used to calculate quality-adjusted life-years. The incremental cost-effectiveness ratio was the primary outcome.Empiric radioactive iodine dosing was the dominant economic strategy, producing 0.94 more quality-adjusted life-years while costing $1250.07 less than management with a diagnostic whole-body scan. Sensitivity analyses upheld these results except in cases involving a large discrepancy in successful ablation rates between the diagnostic and empiric treatment arms.For patients with differentiated thyroid cancer requiring postthyroidectomy ablation, it is more cost-effective to administer radioactive iodine empirically.

Lifestyle medicine has the power to reverse the growing burden of chronic disease that now plagues our health care system. The World Health Organization, the Centers for Disease Control and Prevention, and the American College of Lifestyle Medicine have all independently recognized the need for community-centered lifestyle medicine education as a means of empowering individuals to take charge of their own health. Students in undergraduate, medical, and allied health schools may serve as mediators for these conversations. With guidance from faculty lifestyle medicine mentors, these students can operate as peer educators in primary and secondary schools to supplement current health teaching with the core tenants of lifestyle medicine: nutrition, exercise, sleep, mental and social well-being, and substance avoidance as strategies to prevent and treat chronic disease. We present models of two such student-led programs working with middle and high school students in Massachusetts and New Jersey. Both programs have found success by engaging middle and high school students in interactive workshops and by responding to their individual interests and community needs. We share our currently available resources and, moving forward, hope to publish a tested curriculum that students around the country can implement in their communities to promote lifestyle medicine.

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness.A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses.Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time.In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Background: Adiposity is associated with pancreatic ductal adenocarcinoma (PDAC), but the effects of weight excess over an adult life course have not been studied extensively. We examined the association between trajectories of body mass index (BMI) from ages 18 up to 71 years and risk of subsequent PDAC. Methods: Our analysis included 270,722 (163,873 men, 106,849 women) NIH-AARP Diet and Health Study participants, 50-71y, who successfully completed questionnaires with self-reported height and weight at ages 18, 35, 50 and at baseline (50-71y, 1995-1996) and from which BMI (kg/m2) was calculated. We used latent class growth mixture modeling to identify BMI trajectories using adult BMI reported at each of the four timepoints. We identified BMI trajectories for all sample combined and separately for men and women. We then examined the association between BMI trajectories and incident PDAC using Cox proportional hazards models to calculate age, smoking, and sex adjusted hazard ratios (HR) and 95% confidence intervals (CI) overall and by sex. Participants that maintained normal weight status over their adulthood were set as the referent group. Results: Over an average follow-up time of 13.1 years (max: 15.17 years), 3105 incident PDAC cases (2033 men, 1072 women) were identified in the overall cohort. We identified four overall and sex specific BMI trajectory groups, each with one maintainer and three increasers. Participants either maintained normal weight (N-N, 37.1% of the cohort), or increased from normal-overweight (N-OW, 36.4%), normal-obese (N-O, 20.7%), or normal-severely obese (N-SO, 5.8%). The male cohort was divided into N-N (35.5%), N-OW (23.3%), normal-higher overweight (N-HOW, 34.8%), and N-SO (6.6%) while the female cohort was divided into N-N (51.6%), N-OW (34.5%), N-SO (11.3%), and OW-SO (2.7%). Compared to N-N, the N-OW (HR=1.12, 95% CI 1.03-1.21), N-O (1.22, 1.11-1.35) and N-SO (1.22, 1.04-1.45) groups were at significantly increased risk for PDAC. Compared to the sex-specific maintainer groups, men in the N-OW (1.14, 1.02-1.28), N-HOW (1.16, 1.04-1.29), and N-SO (1.39, 1.15-1.67) groups were significantly associated with PDAC, while only women in the N-OW (1.12, 1.00-1.29) group showed a borderline significant association. Adding diabetes to the models slightly attenuated the associations by less than 10% with the greatest attenuation observed in the SO groups. The overall associations were not significantly modified by sex (P-interaction = 0.10) or smoking status (never, former, current, P-interaction = 0.17). Conclusions: In this large prospective cohort study, increasing BMI throughout adulthood was associated with a greater risk for PDAC. Citation Format: Simran Arjani, Pedro F. Saint-Maurice, Sachelly Julian-Serrano, Rachael Stolzenberg-Solomon. Body mass index trajectories across the adult life course and pancreatic cancer risk [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 853.

e16079 Background: The most commonly used treatment options for gastric cancer include complete resection with adequate margins with either perioperative chemotherapy (PCT) or adjuvant chemoradiotherapy (CRT). While both treatment strategies have shown superiority over surgical resection alone, it is not clear which treatment strategy is more optimal. Methods: Our decision tree model was built to analyze the survival and costs associated with the two major management methods: perioperative chemotherapy and adjuvant chemoradiation therapy. Costs were obtained from Medicare reimbursement rates using a third-party payer perspective. Our model’s effectiveness was represented using quality-adjusted life years (QALYs). Our analysis tested the robustness of our conclusions by utilizing one-way, two-way, and probabilistic sensitivity analyses. Results: PCT was the preferred treatment strategy for diagnosed gastric cancer over CRT, with a cost of $54,326.10 and 4.08 QALYs. CRT was the costliest economic strategy with a cost of $77,987.52 and 4.28 QALYs and an ICER of 115,907.48. We set a threshold of $100,000 per QALYs gained which CRT surpassed making PCT the preferred treatment modality. Over 100,000 simulations, 51.4% of simulations favored PCT. CRT became favored when CRT non-curative procedure rates rose 3% higher than PCT non-curative procedure rates and when PCT complication rates rose 15% higher than CRT complication rates. Conclusions: In our simulated patients with diagnosed gastric cancer, the most cost-effective treatment strategy was PCT. We see cost-effectiveness alternating to favor CRT with changes in non-curative procedure rates and adjuvant therapy complication rates.[Table: see text]