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Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability.Patients with HCC65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability.Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability.Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels.

Background Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD. Methods Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008–2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications. Results In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165–1.783; mixed-low: OR 1.374, 95%CI 1.085–1.740; mixed-high: OR 1.418, 95%CI 1.098–1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454–3.209; mixed-low: OR 2.068, 95%CI 1.347–3.175; mixed-high: OR 1.96, 95%CI 1.245–3.086). Discussion Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center.

The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs).The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations.Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.

The coronavirus pandemic has profoundly impacted all facets of surgical care, including surgical residency training. The objective of this study was to assess the operative experience and overall case volume of surgery residents before and during the pandemic.Using data from the Accreditation Council for Graduate Medical Education annual operative log reports, operative volume for 2015 to 2021 graduates of Accreditation Council for Graduate Medical Education -accredited general, orthopedic, neuro- and plastic surgery residency programs was analyzed using nonparametric Kendall-tau correlation analysis. The period before the pandemic was defined as AY14-15 to AY18-19, and the pandemic period was defined as AY19-20 to AY20-21.Operative data for 8556 general, 5113 orthopedic, 736 plastic, and 1278 neurosurgery residency graduates were included. Between 2015 and 2021, total case volume increased significantly for general surgery graduates (Kendall's tau-b: 0.905, p = 0.007), orthopedic surgery graduates (Kendall's tau-b: 1.000, p = 0.003), neurosurgery graduates (Kendall's tau-b: 0.905, p = 0.007), and plastic surgery graduates (Kendall's tau-b: 0.810, p = 0.016). Across all specialties, the mean total number of cases performed by residents graduating during the pandemic was higher than among residents graduating before the pandemic, though no formal significance testing was performed. Among general surgery residents, the number of cases performed as surgeon chief among residents graduating in AY19-20 decreased for the first time in 5 years, though the overall volume remained higher than the prior year, and returned to prepandemic trends in AY20-21.Over the past 7 years, the case volume of surgical residents steadily increased. Surgical trainees who graduated during the coronavirus pandemic have equal or greater total operative experience compared to trainees who graduated prior to the pandemic.

To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer.Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980.In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region.Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty.The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.

Clinical staging guides decisions about optimal treatment sequence in patients with gastric cancer, although the preoperative accuracy is not strongly established. This study investigates concordance of clinical and pathologic stage as well as its impact on the survival of patients with gastric adenocarcinoma. Patients with clinical stage T2-4, N0, M0 gastric adenocarcinoma who underwent surgery without neoadjuvant therapy were identified from the National Cancer Database (2010–2015). The primary outcome was up-staging, defined as cT < pT, pN1-3, and/or pM1 (AJCC 7th edition). Multivariable logistic regression analysis was performed to predict up-staging. Survival analysis was performed using the Kaplan-Meier method. In total, 2254 patients were identified. cTNM staging was discordant with pTNM staging in 65.6% of cases, with 50.4% up-staged and 15.2% down-staged. On multivariable logistic regression, younger age (OR 0.991, 95% CI 0.984–0.999, p=0.0188), male sex (versus female; OR 1.392, 95% CI 1.158–1.673, p=0.0004), poor or undifferentiated tumor grade (versus well differentiated or moderately differentiated; OR 2.399, 95% CI 1.987–2.896; p

As fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted. Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon’s National Surgical Quality Improvement Program database (2007–2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow. 5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted. Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety.

Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer. Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004–2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan–Meier and Cox proportional hazard methods. The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p

In octogenarians with carotid stenosis, data supporting the decision to intervene and choice of intervention with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) have been conflicting. The purpose of this study was to compare the perioperative outcomes of CEA and CAS in octogenarians, and to identify patients at high risk for unfavorable outcomes.The American College of Surgeons National Surgical Quality Improvement Program database (2011-2018) was queried for patients aged ≥80 years who underwent CAS or CEA. Propensity scores were created for the odds of undergoing CAS. Patients were matched 1:1 based on propensity score and outcomes were compared after matching. Multivariable logistic regression analyses were used to identify risk factors for unfavorable postoperative outcomes.In total, 15,858 and 527 patients who underwent CEA and CAS were identified. After matching, there was no difference between CEA and CAS in perioperative stroke (2.3% vs. 2.9%; P = 0.56), cardiac complications (2.3% vs. 2.3%; P = 0.99), mortality (1.1% vs. 1.7%; P = 0.44), length of stay (median [interquartile range], 2 [1-4] vs. 1 [1-4] days; P = 0.13), and 30-day readmission (11.8% vs. 11.6%; P = 0.92). On multivariable analysis, the following were predictive for postoperative stroke: urgent operation (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.68-2.69; P 0.001), chronic obstructive pulmonary disease (COPD; OR, 1.52; 95% CI, 1.11-2.09; P = 0.009), and American Society of Anesthesiologists class III (OR, 1.46; 95% CI, 1.15-1.86; P = 0.002). Urgent procedure (OR, 2.86; 95% CI, 2.11-3.87; P 0.001), COPD (OR, 2.31; 95% CI, 1.61-3.32; P 0.001), dependent functional status (OR, 2.05; 95% CI, 1.35-3.1; P 0.001), and age ≥ 85 years (OR, 1.92; 95% CI, 1.43-2.57; P 0.001) were predictive for 30-day mortality.Outcomes of CEA and CAS were similar in octogenarians. Risk factors for worse intervention outcomes were identified, which may guide risk-benefit discussions and shared decision-making.

The purpose of this study was to assess the impact of number of lymph nodes examined on survival in patients with esophageal adenocarcinoma who underwent neoadjuvant chemoradiation. The National Cancer Database was queried for patients who underwent neoadjuvant chemoradiation followed by surgery for esophageal adenocarcinoma. Propensity scores were created predicting the odds of undergoing resection of ≥ 25 nodes. Patients were matched on propensity score. Overall survival analyses were performed using the Kaplan-Meier method. Sensitivity analyses were performed using various nodal cutoffs. In total, 3953 patients who underwent neoadjuvant chemoradiation were identified. The median number of resected nodes was 14 nodes (IQR, 8–20 nodes). Resection of ≥ 15 (vs.

Randomized controlled clinical trials (RCTs) are at the heart of “evidence-based” medicine. However, in surgical practice, RCTs remain uncommon. Conducting well-designed RCTs for surgical procedures is often challenged by inadequate recruitment accrual, blinding, or standardization of the surgical procedure, as well as lack of funding and evolution of the treatment strategy during the many years over which such trials are conducted. In addition, most clinical trials are performed in academic high-volume centers in highly selected patients, which may not necessarily reflect a “real-world” practice setting. Over the past decades, surgical outcomes research using nationwide administrative and registry databases has become increasingly common. Large databases provide easy and inexpensive access to data on a large and diverse patient population at a variety of treatment centers. Furthermore, large database studies provide the opportunity to answer questions that would be impossible or very arduous to answer using RCTs, including questions regarding health policy efficacy, trends in surgical practice, access to health care, impact of hospital volume, and adherence to practice guidelines, as well as research questions regarding rare disease, infrequent surgical outcomes, and specific subpopulation. Prospective data registries may also allow for quality benchmarking and auditing. This review outlines the role, advantages, and limitations of RCTs and large database studies in answering important research questions in surgery.

BACKGROUND: Postoperative gastrointestinal leak and venous thromboembolism (VTE) are devastating complications of bariatric surgery. The performance of currently available predictive models for these complications remains wanting, while machine learning has shown promise to improve on traditional modeling approaches. The purpose of this study was to compare the ability of two machine learning strategies, artificial neural networks (ANNs) and gradient boosting machines (XGBs), to conventional models using logistic regression (LR) in predicting leak and VTE after bariatric surgery. METHODS: ANN, XGB, and LR prediction models for leak and VTE among adults undergoing initial elective weight loss surgery were trained and validated using preoperative data from the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Data was randomly split into training, validation, and testing populations. Model performance was measured by the area under the receiver-operating characteristic curve (AUC) on the testing data for each model. RESULTS: The study cohort contained 436,807 patients. The incidences of leak and VTE were 0.70% and 0.46%. ANN (AUC 0.75, 95% CI, 0.73 – 0.78) was the best-performing model for predicting leak, followed by XGB (AUC 0.70, 95% CI, 0.68 – 0.72) and then LR (AUC 0.63, 95% CI, 0.61 – 0.65, p < 0.001 for all comparisons). In detecting VTE, ANN, XGB, and LR achieved similar AUCs of 0.65 (95% CI, 0.63–0.68), 0.67 (95% CI, 0.64–0.70), and 0.64 (95% CI, 0.61–0.66) respectively; the performance difference between XGB and LR was statistically significant (p = 0.001). CONCLUSIONS: ANN and XGB outperformed traditional LR in predicting leak. These results suggest that ML has the potential to improve risk stratification for bariatric surgery, especially as techniques to extract more granular data from medical records improve. Further studies investigating the merits of machine learning to improve patient selection and risk management in bariatric surgery are warranted.

Current AJCC guidelines recommend evaluating ≥6 lymph nodes during gallbladder cancer resection but real world data suggest this is rarely achieved. We evaluated the extent of lymphadenectomy and survival among patients with gallbladder adenocarcinoma.Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified from the NCDB (2004-2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method.Overall, 4760 patients were identified: 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51-2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p 0.0001) after matching.The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence.

OBJECTIVE This study assesses how the volume of pancreatic-adjacent operations (PAO) impacts the outcomes of pancreaticoduodenectomy (PD). SUMMARY BACKGROUND DATA It is well-established that regionalization benefits outcomes after PD. However, due to a multitude of factors, including geographic, financial and personal, not all patients receive their care at high-volume pancreas surgery centers. METHODS The National Cancer Database was queried for pancreatic cancer patients who underwent pancreaticoduodenectomy. Hospital volume was calculated for PD and PAO (defined as gastric, hepatic, complex biliary, or pancreatic operations other than PD) and dichotomized as low- and high-volume centers based on the median. Three study cohort were created: low-volume hospitals (LVH) for both PD and PAO, mixed-volume hospital (MVH) with low-volume PD but high-volume PAO, and high-volume PD hospital (HVH). RESULTS In total, 24,572 patients were identified, with 41.5%, 7.2%, and 51.3% patients treated at LVH, MVH, and HVH, respectively. 30-day mortality for PD was 5.6% in LVH, 3.2% in MVH, and 2.5% in HVH. On multivariable analyses, LVH was predictive for higher 30-day mortality compared to HVH (OR, 2.068; 95% CI, 1.770-2.418; p < 0.0001). However, patients at MVH demonstrated similar 30-day mortality to patients treated at HVH (OR, 1.258; 95% CI, 0.942-1.680; p = 0.1203). CONCLUSIONS PD outcomes at low-volume centers that have experience with complex cancer operations near the pancreas are similar to PD outcomes at hospitals with high PD volume. MVH provide a model for PD outcomes to improve quality and access for patients who cannot, or choose not to, receive their care at high-volume centers.

The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5 + 2) and integrated vascular surgery training programs (0 + 5) using contemporary operative case log data.The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5 + 2 trainees or "surgeon chief" (post graduate year-4,5) by 0 + 5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures.The 5 + 2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P = 0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P = 0.004) at the fellow level compared to 0 + 5 surgeon chief cases. Additionally, 5 + 2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P 0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P = 0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P 0.0001). The 5 + 2 fellows performed more vein bypasses than 0 + 5 chief residents (femoral-popliteal 9.8 vs. 6.4, P = 0.002; infrapopliteal 13.9 vs. 8.8, P = 0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P = 0.0004; femoral-femoral 5.6 vs. 3.1, P = 0.034), carotid endarterectomies (47.3 vs. 29.3, P 0.0001), carotid artery stenting (9.6 vs. 4.5, P = 0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P 0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P = 0.0006), thoracic outlet decompression (5.4 vs. 1.9, P 0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P 0.0001), neck vessels (0.7 vs. 0.3, P = 0.0004), abdominal vessels (3.0 vs. 1.7, P = 0.0005), and peripheral vessels (6.6 vs. 3.1, P = 0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P 0.0001), AV grafts (10.7 vs. 5.1, P 0.0001), and revision of AV access (16.1 vs. 8.0, P = 0.0003).Although both pathways graduate trainees with a similar overall surgical experience, 5 + 2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary.

The purpose of this study was to determine whether racial or other demographic characteristics were associated with declining surgery for early stage gastric cancer.Patients with clinical stage I-II gastric adenocarcinoma were identified from the NCDB. Multivariable logistic models identified predictors for declining resection. Patients were stratified based on propensity scores, which were modeled on the probability of declining. Overall survival was evaluated using the Kaplan-Meier method.Of 11,326 patients, 3.68% (n = 417) declined resection. Patients were more likely to refuse if they were black (p 0.001), had Medicaid or no insurance (p 0.001), had shorter travel distance to the hospital (p 0.001) or were treated at a non-academic center (p = 0.001). After stratification, patients who declined surgery had worse overall survival (all strata, p 0.001).Racial and sociodemographic disparities exist in the treatment of potentially curable gastric cancer, with patients who decline recommended surgery suffering worse overall survival.

Survival in pancreatic cancer remains poor with curative potential dependent on operative resection. We reviewed national adherence to practice guidelines to evaluate regional variation in the treatment and survival of patients with pancreatic cancer.Retrospective cohort review of adults with pancreatic adenocarcinoma using the National Cancer Data Base from 2006 to 2013. Overall survival was compared by the Kaplan-Meier method and Cox proportional hazards models. Sequential multivariate logistic regression models were generated for odds of: a) diagnosis in stage I/II, b) resection, and c) receipt of multimodality therapy, defined as operative resection plus chemotherapy with or without radiation. Five geographic regions of the United States were used for analyses.A total of 115,952 patients were identified. At least 22% of patients in all stages received no treatment, with only 38.4% and 32.3% of stage I and II patients receiving multimodality therapy. On unadjusted analysis, the Northeast had the greatest survival for all stages of disease, most pronounced for stage I where patients lived 2 to 3 more months (log-rank P .0001). While adjusted odds of early diagnosis and resection were comparable or greater across regions relative to the Northeast, patients who underwent resection in the Northeast were significantly more likely to receive multimodality therapy. Multivariate Cox modeling for patients receiving multimodality therapy accounted for differences in 3 of 4 remaining regions.Regional variations exist in pancreatic cancer treatment and survival. While providing multimodality cancer-directed therapy can help mitigate these differences, survival with pancreatic cancer needs to be interpreted in the context of overall health, underlying risk factors, and life expectancy.

BACKGROUND The role of conventional radiotherapy in the management of pancreatic cancer has yet to be elucidated. Over the past decade, stereotactic body radiotherapy (SBRT) has emerged as a novel therapeutic option in pancreatic cancer care. This study evaluated the survival impact of SBRT on patients with unresected pancreatic cancer. METHODS The National Cancer Data Base was queried for unresected patients who received chemotherapy for nonmetastatic pancreatic adenocarcinoma between 2004 and 2012. Four treatment groups were identified: chemotherapy alone, chemotherapy combined with external-beam radiotherapy (EBRT), chemotherapy combined with intensity-modulated radiotherapy (IMRT), and chemotherapy combined with SBRT. Propensity score models predicting the odds of receiving SBRT were created to control for potential selection bias, and patients were matched by propensity scores. The survival analysis was performed with the Kaplan-Meier method. RESULTS A total of 14,331 patients met the inclusion criteria. Chemotherapy alone was delivered to 5464 patients (38.1%); 6418 (44.8%), 322 (2.3%), and 2127 (14.8%) received chemotherapy along with EBRT, IMRT, and SBRT, respectively. The unadjusted median survival before matching was 9.9, 10.9, 12.0, and 13.9 months for patients treated with chemotherapy, EBRT, IMRT, and SBRT, respectively. In separate matched analyses, SBRT remained superior to chemotherapy alone (log-rank P < .0001) and EBRT (log-rank P = .0180). After matching, survival did not differ between patients receiving IMRT and patients receiving SBRT (log-rank P = .0492). CONCLUSIONS SBRT is associated with a significantly better outcome than chemotherapy alone or in conjunction with traditional EBRT. These results support the idea that SBRT is a promising treatment approach for patients with unresected pancreatic cancer. Cancer 2017;123:4158-4167. © 2017 American Cancer Society.

Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage.A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method.In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer (n = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank P .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I (n = 3,149; median survival, 26.2 vs 25.7 months; P = .4418) and II (n = 5,065; median survival, 23.5 vs 23.0 months; P = .7751) disease after matching.The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.

This study proposes a novel strategy to reduce fibrotic barrier and enhance efficacy of chemotherapy in pancreatic cancer., Abundant desmoplastic stroma is the hallmark for pancreatic ductal adenocarcinoma (PDAC), which not only aggravates the tumor growth but also prevents tumor penetration of chemotherapy, leading to treatment failure. There is an unmet clinical need to develop therapeutic solutions to the tumor penetration problem. In this study, we investigated the therapeutic potential of integrin α5 (ITGA5) receptor in the PDAC stroma. ITGA5 was overexpressed in the tumor stroma from PDAC patient samples, and overexpression was inversely correlated with overall survival. In vitro, knockdown of ITGA5 inhibited differentiation of human pancreatic stellate cells (hPSCs) and reduced desmoplasia in vivo. Our novel peptidomimetic AV3 against ITGA5 inhibited hPSC activation and enhanced the antitumor effect of gemcitabine in a 3D heterospheroid model. In vivo, AV3 showed a strong reduction of desmoplasia, leading to decompression of blood vasculature, enhanced tumor perfusion, and thereby the efficacy of gemcitabine in co-injection and patient-derived xenograft tumor models.

Gynecologic surgery has potential for adjunct vascular interventions, given the proximity of major intra-abdominal and pelvic blood vessels. Our goal was to determine contemporary incidence, associations, and outcomes of vascular repairs in gynecologic operations.The American College of Surgeons National Surgical Quality Improvement Program database (2005-2017) was queried for patients undergoing elective gynecologic operations. Vascular repairs were performed concurrently or during reoperation. Univariable and multivariable analyses evaluated associations with vascular repairs and 30-day morbidity.A total of 201,224 gynecologic operations were identified: hysterectomy (88.3%), myomectomy (5.9%), adnexal surgery (3.5%), vulvovaginectomy/other (1.1%), nonadnexal tumor or cyst excision (0.5%), ectopic pregnancy treatment (0.4%), and pelvic lymphadenectomy (0.3%). There were 187 vascular repairs in 176 (0.09%) patients. Repairs were typically concurrent (89.8%) and most commonly included open abdominal blood vessel repair (51.8%), major abdominal artery ligation (25%), vena cava reconstruction/ligation (6%), common iliac vein ligation (4.2%), and aorta/great vessel repair (4.2%). A minority were performed endovascularly (1.7%). Patients undergoing vascular repairs were older (56 vs 46 years), were more likely to have an open vs minimally invasive/vaginal operation (71.6% vs 28.4%), and were more likely to have a hysterectomy (85.2%; P .001 for all). In multivariable analysis, vascular repairs were observed more often with hysterectomy (odds ratio [OR]; 7.63, 95% confidence interval [CI], 2.28-25.55; P = .001) and open vs minimally invasive/vaginal operations (OR, 5.24; 95% CI, 2.64-10.42; P .001). Vascular repairs were also more common for patients with malignant disease (OR, 2.84; 95% CI, 1.78-4.53; P .001), patients assigned to American Society of Anesthesiologists class 3 or class 4 (OR, 1.85; CI, 1.36-2.53; P = .002), and patients without obesity (OR, 1.45; 95% CI, 1.08-1.96; P = .014). Vascular repairs independently predicted major morbidity and mortality (OR, 7.26; 95% CI, 5.26-10.03; P .001) after adjustment for open operative approach, American Society of Anesthesiologists class 3 or class 4, and hysterectomy.Whereas vascular repairs during gynecologic operations are rare, they are associated with morbidity and mortality. These findings provide an evidence base for risk assessment and informed consent.

The optimal treatment for biliary obstruction in pancreatic cancer remains controversial between surgical bypass and endoscopic stenting.Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project Florida State Inpatient and Ambulatory Surgery databases (2007-2011). Propensity score matching by procedure. Primary outcome was reintervention, and secondary outcomes were readmission, overall length of stay (LOS), discharge home, death and cost. Multivariate analyses performed by logistic regression.In a matched cohort of 622, 20.3% (63) of endoscopic and 4.5% (14) of surgical patients underwent reintervention (p 0.0001) and 56.0% (174) vs. 60.1% (187) were readmitted (p = 0.2909). Endoscopic patients had lower median LOS (10 vs. 19 days, p 0.0001) and cost ($21,648 vs. $38,106, p 0.0001) as well as increased discharge home (p = 0.0029). No difference in mortality on index admission. On multivariate analysis, initial procedure not predictive of readmission (p = 0.1406), but early surgical bypass associated with lower odds of reintervention (OR = 0.233, 95% CI 0.119, 0.434).Among propensity score-matched patients receiving bypass vs. stenting, readmission and mortality rates are similar. However, candidates for both techniques may experience fewer subsequent procedures if offered early biliary bypass with the caveats of decreased discharge home and increased cost/LOS.

331 Background: Multiple randomized controlled trials have shown that both neoadjuvant chemotherapy (CT) and chemoradiation (CRT) convey survival benefit as compared to upfront surgery in patients with esophageal adenocarcinoma. However, international practice remains variable. Therefore, the present study compares the outcomes of first-line CT to CRT for patients with adenocarcinoma arising from the distal esophagus. Methods: Patients with clinical stage T2-T3, N0-N+ esophageal adenocarcinoma originating from the distal esophagus who received first-line CT or CRT were identified from the National Cancer Data Base (2006-2014). Propensity-score were created for the odds of receiving CRT. Patients were matched 1:1 based on propensity score. Subset analysis was performed in patients who underwent esophagectomy. Pathological complete response was defined as ypT0N0M0. Results: In total, 709 and 8,877 patients who received first-line CT and CRT were identified, respectively. CT was associated with stage cT2 (27.2% vs. 23.3%; p = 0.017), and treatment at a high-volume center (27.2% vs. 20.2%; p < 0.001). After matching, resection rates were comparable for patients who received first-line CT and CRT (62.2% vs. 63.7%; p = 0.545). However, median overall survival was slightly lower for patients who receive CT compared to CRT (23.7 vs. 28.4 months; p = 0.044). Among patients who underwent esophagectomy, time to surgery (135 vs. 134 days; p = 0.689) and median overall survival (37.0 vs. 40.5 months; p = 0.630) was similar between matched cohorts. However, complete response (15.8% vs. 25.8%; p < 0.001) and negative margin (94.3% vs. 88.9%; p = 0.004) rates were significantly lower after CT compared to CRT. Conclusions: In patients with esophageal adenocarcinoma, first-line CRT results in significantly higher pathological complete response rates, negative resection margins rates, and improved survival. These findings suggest that first-line CRT is preferable over CT when tolerated in patients with esophageal adenocarcinoma.

330 Background: Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. Despite ACGME dictums, attending surgeons may favor either residents or fellows assisting on operations of greater complexity, depending upon a variety of factors, including local surgical culture. This study investigates whether participation of a senior resident versus a fellow impacts outcomes of complex cancer surgery. Methods: Patients who underwent esophagectomy, or gastrectomy with assistance from either a senior resident (PGY-4 or 5) or a fellow (PGY-6 to 8) were identified from the American College of Surgeon’s National Surgical Quality Improvement Program (2007-2012). Analyses were performed separately for each operation. Propensity-scores were created for the odds of undergoing the operation assisted by a fellow. Patients were matched based on propensity score, and outcomes were compared after matching. Results: In total, 1,160 esophagectomies and 2,432 gastrectomies were identified. Senior resident participation was reported in 60.2% and 86.6%, respectively. Resident involvement was associated with non-white race (17.0% vs. 13.8%; p < 0.001), and lower rates of neoadjuvant chemotherapy (6.4% vs. 11.7%; p < 0.001). After matching, rates major complication rates were slightly higher for patients who underwent esophagectomies involving a resident compared to fellow (38.1% vs. 31.8%; p = 0.0447). However, major complications rates were similar for gastrectomy (21.2% vs. 22.1%; p = 0.775). In addition, operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.009) involving a resident compared to a fellow, but comparable for patients who underwent esophagectomy (327 vs. 337 min; p = 0.310). Conclusions: The results of this study suggest that senior resident participation in complex cancer operations does not negatively impact operative time or outcomes, compared to involvement of a surgical oncology fellow. Although confounding by operative autonomy may exist, these findings indicate that senior residents should be given the same opportunities as fellows to participate in these potentially more challenging operations.

Background Resection margin status is an important prognostic factor in pancreatic cancer; however, the impact of positive resection margins in those who received neoadjuvant therapy remains unclear. The current study investigates the prognostic impact of resection margin status after neoadjuvant therapy and pancreaticoduodenectomy for patients with pancreatic adenocarcinoma. Methods Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma between 2006 and 2013 were identified from the National Cancer Database. Multivariable logistic regression analysis was utilized to examine the predictive value of neoadjuvant therapy for resection margin status. Long-term outcomes were compared using a Cox proportional hazards model. Results 7917 patients were identified in total: 1077 (13.6%) and 6840 (86.4%) patients received neoadjuvant therapy and upfront surgery, respectively. Upfront surgery was independently predictive of a positive margin (25.7% vs. 17.7%; OR, 1.54) compared to neoadjuvant therapy. After receipt of neoadjuvant therapy, positive margins (median overall survival, 18.5 vs. 25.9 months; HR, 1.58) remained significantly associated with poor survival on multivariable analysis. Discussion While neoadjuvant therapy is associated with decreased R1/R2-resection rates after pancreaticoduodenectomy, the poor prognostic impact of positive margins is not abrogated by neoadjuvant therapy, stressing the need for complete tumor clearance and postoperative treatment even after neoadjuvant therapy.

Despite the increasing use of neoadjuvant treatment, the question of whether preoperatively treated, successfully resected patients should receive additional postoperative adjuvant treatment remains unanswered. We evaluate the impact of adjuvant therapy following neoadjuvant treatment and pancreatectomy in pancreatic cancer patients in a large national study. We used the National Cancer Data Base between 2006 and 2013 to identify resected, non-metastatic pancreatic adenocarcinoma patients who received neoadjuvant chemo(radio)therapy followed by pancreatectomy. Kaplan-Meier and multivariate Cox proportional hazard regression analyses were performed to compare survival between groups. In total, 1357 patients were identified. Of the patients, 38.6% (n = 524) were treated with postoperative therapy. There was no difference in unadjusted median overall survival between patients who did and did not receive postoperative therapy (median survival, 27.5 vs. 27.1 months, log-rank p = 0.5409). Postoperative therapy was not significantly associated with favorable prognosis in patients with positive resection margins (log-rank p = 0.6452) or positive lymph nodes (log-rank p = 0.6252). On multivariate analysis, receipt of postoperative therapy was not predictive of survival (hazard ratio 0.972; 95% CI 0.848–1.115; p = 0.6876). Our results using national data suggest that after receipt of neoadjuvant therapy and pancreatectomy, additional postoperative therapy may not provide additional survival benefit. These data warrant further prospective data collection and consideration for clinical trials.

Importance: The recently released eighth edition of the American Joint Committee on Cancer TNM staging system for pancreatic cancer seeks to improve prognostic accuracy but lacks international validation. Objective: To validate the eighth edition of the American Joint Committee on Cancer TNM staging system in an international cohort of patients with resected pancreatic ductal adenocarcinoma. Design, Setting, and Participants: This international multicenter cohort study took place in 5 tertiary centers in Europe and the United States from 2000 to 2015. Patients who underwent pancreatoduodenectomy for nonmetastatic pancreatic ductal adenocarcinoma were eligible. Data analysis took place from December 2017 to April 2018. Exposures: Patients were retrospectively staged according to the seventh and eighth editions of the TNM staging system. Main Outcomes and Measures: Prognostic accuracy on survival rates, assessed by Kaplan-Meier and multivariate Cox proportional hazards analyses and concordance statistics. Results: A total of 1525 consecutive patients were included (median [IQR] age, 66 (58-72) years; 802 (52.6%) male). Distribution among stages via the seventh edition was stage IA in 41 patients (2.7%), stage IB in 42 (2.8%), stage IIA in 200 (13.1%), stage IIB in 1229 (80.6%), and stage III in 12 (0.8%); this changed with use of the eighth edition to stage IA in 118 patients (7.7%), stage IB in 144 (9.4%), stage IIA in 22 (1.4%), stage IIB in 643 (42.2%), and stage III in 598 (39.2%). With the eighth edition, 774 patients (50.8%) migrated to a different stage; 183 (12.0%) were reclassified to a lower stage and 591 (38.8%) to a higher stage. Median overall survival for the entire cohort was 24.4 months (95% CI, 23.4-26.2 months). On Kaplan-Meier analysis, 5-year survival rates changed from 38.2% for patients in stage IA, 34.7% in IB, 35.3% in IIA, 16.5% in IIB, and 0% in stage III (log-rank P

BackgroundBile duct reconstruction (BDR) is used to manage benign and malignant neoplasms, congenital anomalies, bile duct injuries and other non-malignant diseases. BDR outcomes overall, by year, and by indication were compared.MethodsRetrospective analysis of Nationwide Inpatient Sample discharges (2004–2011) including ICD-9 codes for BDR. All statistical testing was performed using survey weighting. Univariate analysis of admission characteristics by chi square testing. Multivariate modelling for inpatient complications and inpatient death by logistic regression.ResultsIdentified 67 160 weighted patient admissions: 2.5% congenital anomaly, 37.4% malignant neoplasm, 2.3% benign neoplasm, 9.9% biliary injury, 47.9% other non-malignant disease. Most BDRs were performed in teaching hospitals (69.6%) but only 25% at centres with a BDR volume more than 35/year. 32.3% involved ≥ 1 complication, and 84.7% were discharges home. There was a 4.2% inpatient death rate. The complication rate increased but the inpatient death rate decreased over time. The rates of acute renal failure increased. Significant multivariate predictors of inpatient death include indication of biliary injury or malignancy, and predictors of any complication include public insurance and non-elective admission.ConclusionThis is the first national description of BDRs using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.

BACKGROUND: Surgical site infections (SSIs) are common following pancreatectomy and associated with significant morbidity and economic burden. We sought to identify distinct predictors for the development of superficial versus deep/organ space SSIs and their effects on surgical outcomes. METHODS: ACS-NSQIP targeted pancreatectomy 2014 and 2015 databases were queried. Univariate and multivariate models were developed for both types of SSI, length of stay (LOS), and readmission. Costs were estimated based on the Centers for Medicare & Medicaid Services (CMS) recommendations. RESULTS: Of 8 093 patients, there were 422 (5.2%) superficial and 1 005 (12.4%) deep/organ space SSIs. On multivariate analyses, preoperative biliary stenting was a predictor only for superficial SSI (OR: 2.21), while BMI of 25–29.9 (OR: 1.25) and BMI ≥30kg/m(2) (OR: 1.53), pancreatic duct size

The urokinase plasminogen activator receptor (uPAR) has been proposed as a potential prognostic factor for various malignancies. The aim of this study is to assess the prognostic value of uPAR expression in neoplastic and stromal cells of patients with pancreatic adenocarcinoma. Urokinase plasminogen activator receptor expression was determined by immunohistochemistry in 122 pancreatic ductal adenocarcinomas. Kaplan-Meier and Cox regression analyses were used to determine the association with survival. Respectively 66%, 82% and 62% of patients with pancreatic cancer expressed uPAR in neoplastic cells, stromal, and in both combined. Multivariate analysis showed a significant inverse association between uPAR expression in both neoplastic and stromal cells and overall survival. The prognostic impact of uPAR in stromal cells is substantial, but not as pronounced as that of uPAR expression in neoplastic cells. This study suggests a role for uPAR as a biomarker to single out higher risk subgroups of patients with pancreatic cancer.

457 Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p < 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p < 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p < 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions. We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group. This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ2. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries. The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002–2012) and the Nationwide Inpatient Sample (2002–2011). Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded. Massachusetts health care reform was the study intervention. We measured the rate of emergent colectomy, complications, and mortality. The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes. The study was limited by its retrospective design and unadjusted analysis. There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.

Background Insufficient examination of lymph nodes after pancreaticoduodenectomy can lead some pancreatic cancer patients with N1 disease to be misclassified as N0. We examined trends in lymph node dissection throughout time and investigated how these changes affect lymph node status and its prognostic value. Methods The National Cancer Data Base was queried for patients with nonmetastatic pancreatic adenocarcinoma (2004–2013) who underwent classic pancreaticoduodenectomy with antrectomy. Logistic regression was performed for odds of node positivity. Kaplan-Meier curves and Cox proportional hazards models were used to assess the impact of lymph node status on overall survival for patients diagnosed during 2-year intervals from 2004–2012. Results Median number of examined lymph nodes was 10 (interquartile range 6–15) in 2004 vs 17 (interquartile range 12–24) in 2013. Number of lymph nodes examined was a significant predictor of N1 disease (P

Purpose: The purpose of this study was to identify suitable molecular targets for tumor-specific imaging of pancreatic adenocarcinoma. Procedures: The expression of eight potential imaging targets was assessed by the target selection criteria (TASC)—score and immunohistochemical analysis in normal pancreatic tissue (n = 9), pancreatic (n = 137), and periampullary (n = 28) adenocarcinoma. Results: Integrin αvβ6, carcinoembryonic antigen (CEA), epithelial growth factor receptor (EGFR), and urokinase plasminogen activator receptor (uPAR) showed a significantly higher (all p < 0.001) expression in pancreatic adenocarcinoma compared to normal pancreatic tissue and were confirmed by the TASC score as promising imaging targets. Furthermore, these biomarkers were expressed in respectively 88 %, 71 %, 69 %, and 67 % of the pancreatic adenocarcinoma patients. Conclusions: The results of this study show that integrin αvβ6, CEA, EGFR, and uPAR are suitable targets for tumor-specific imaging of pancreatic adenocarcinoma.

Tumor targeting is a booming business: The global therapeutic monoclonal antibody market accounted for more than $78 billion in 2012 and is expanding exponentially. Tumors can be targeted with an extensive arsenal of monoclonal antibodies, ligand proteins, peptides, RNAs, and small molecules. In addition to therapeutic targeting, some of these compounds can also be applied for tumor visualization before or during surgery, after conjugation with radionuclides and/or near-infrared fluorescent dyes. The majority of these tumor-targeting compounds are directed against cell membrane-bound proteins. Various categories of targetable membrane-bound proteins, such as anchoring proteins, receptors, enzymes, and transporter proteins, exist. The functions and biological characteristics of these proteins determine their location and distribution on the cell membrane, making them more, or less, accessible, and therefore, it is important to understand these features. In this review, we evaluate the characteristics of cancer-associated membrane proteins and discuss their overall usability for cancer targeting, especially focusing on imaging applications.