ABSTRACT
OBJECTIVE: Esophageal cancers that invade the submucosa (T1b) have increased risk for occult lymph node metastases. To avoid the morbidity and recovery from esophagectomy, patients with cT1bN0 tumors have been increasingly managed endoscopically. We hypothesized that tumor attributes could predict upstaging and outcome associated with surgical and endoscopic treatment. Our objective was to evaluate the comparative effectiveness of esophagectomy across different cT1bN0 tumor attributes. METHODS: Treatment-naïve patients who underwent endoscopic management or esophagectomy for a clinical stage cT1bN0 esophageal cancer diagnosed between 2010-2018 in the National Cancer Database were identified. Factors associated with upstaging were assessed by logistic regression. Adjusted survival was assessed by Kaplan Meier analysis of 528 propensity matched pairs and accelerated time failure models, stratified across tumor attributes. RESULTS: Overall, 1469 cT1bN0 patients were identified, 926 underwent esophagectomy and 543 were managed endoscopically. In general, endoscopic patients were older (median 71 IQR 63-78 vs.66 IQR 60-72, P<0.0001) with smaller tumors compared to the esophagectomy patients. Nodal upstaging was associated with lymphovascular invasion, OR= 6.88, CI (4.39-10.77) P<0.0001, poor tumor differentiation, OR=2.77, CI (1.30-5.88), P=0.0081, and tumor size >1cm, OR=3.19, CI (1.49-6.83), P=0.0028. Overall survival was better among propensity-matched esophagectomy patients (5-year 68.4% vs. 59.7% endoscopic, P<0.001). However, accelerated time failure models suggested similar outcomes among patients with well-differentiated tumors managed surgically or endoscopically. CONCLUSION: Esophagectomy was associated with improved survival for cT1bN0 esophageal cancer, however endoscopic treatment may achieve similar survival in patients with favorable tumor attributes. Further study is warranted.
ABSTRACT
PURPOSE: To assess the effect of type of insurance coverage on the ability of a pediatric patient to obtain an outpatient orthopedic appointment for trigger thumb. METHODS: A list of 200 orthopedic practices in 4 states were contacted and presented with a fictitious 3-year-old patient with trigger thumb. The patient was presented as having Blue Cross Blue Shield Insurance during the first call and Medicaid during the second call. Data regarding whether an appointment was offered or denied were recorded. RESULTS: Of the 200 practices, 81 were excluded, 22 because they did not answer the calls, 25 needed the patient's social security number, 19 needed medical records, 5 had no hand surgeon in the practice, and 10 would not see any children at all. Of the 119 practices included in the analysis, the private insurance patient was able to get an appointment 51.3% of the time whereas the Medicaid patient was able to get an appointment in 26.9% of instances. CONCLUSIONS: There is a significant effect of insurance status on the ability of pediatric patients with trigger thumb to obtain outpatient orthopedic appointments. CLINICAL RELEVANCE: Pediatric patients with Medicaid face greater barriers to accessing proper care for trigger thumb than patients with private insurance.
