Why Do Long-Distance Travelers Have Improved Pancreatectomy Outcomes?

BACKGROUND: Centralization of complex surgical care has led patients to travel longer distances. Emerging evidence suggested a negative association between increased travel distance and mortality after pancreatectomy. However, the reason for this association remains largely unknown. We sought to unravel the relationships among travel distance, receiving pancreatectomy at high-volume hospitals, delayed surgery, and operative outcomes. STUDY DESIGN: We identified 44,476 patients who underwent pancreatectomy for neoplasms between 2004 and 2013 at the reporting facility from the National Cancer Database. Multivariable analyses were performed to examine the independent relationships between increments in travel distance mortality (30-day and long-term survival) after adjusting for patient demographics, comorbidity, cancer stage, and time trend. We then examined how additional adjustment of procedure volume affected this relationship overall and among rural patients. RESULTS: Median travel distance to undergo pancreatectomy increased from 16.5 to 18.7 miles (p for trend < 0.001). Although longer travel distance was associated with delayed pancreatectomy, it was also related to higher odds of receiving pancreatectomy at a high-volume hospital and lower postoperative mortality. In multivariable analysis, difference in mortality among patients with varying travel distance was attenuated by adjustment for procedure volume. However, longest travel distance was still associated with a 77% lower 30-day mortality rate than shortest travel among rural patients, even when accounting for procedure volume. CONCLUSIONS: Our large national study found that the beneficial effect of longer travel distance on mortality after pancreatectomy is mainly attributable to increase in procedure volume. However, it can have additional benefits on rural patients that are not explained by volume. Distance can represent a surrogate for rural populations.

Predicting postoperative morbidity following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) with preoperative FACT-C (Functional Assessment of Cancer Therapy) and patient-rated performance status.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) is associated with significant perioperative morbidity. One goal of our ongoing patient-reported health-related quality of life (HRQoL) program is to describe the prognostic value of HRQoL measures for predicting postoperative morbidity and mortality following CS+HIPEC. METHODS: A retrospective analysis of a prospectively collected clinical database for all patients treated for peritoneal carcinomatosis and who participated in our patient-reported HRQoL program from 2001 to 2011 was done. Patients completed the Functional Assessment of Cancer Therapy questionnaire plus the colon symptom subscale, in addition to the Eastern Cooperative Oncology Group (ECOG) performance status rating prior to CS+HIPEC. The trial outcome index (TOI), a specific measure of function, symptoms, and physical well being of the patient, was analyzed. The TOI is a combination of the physical and functional well being subscales + the colon-specific subscale of the FACT-C. RESULTS: Of 855 patients, 387 (45.2 %) participated in the HRQoL trials. Mean age was 53.3 years, and 213 (55 %) were female versus 174 (45 %) males. There were 240 patients (62 %) who had a complication versus 147 (38 %) who had no complication. A 30-day mortality rate of 7.7 % (30) was documented. Patients who suffered a 30-day postoperative mortality demonstrated a lower mean preoperative score in the FACT-C TOI 52.7 versus 61.7; P < 0.001. Independent predictors of 30-day mortality on multivariate analysis included TOI (0.05), age (0.001), and smoking (0.001). Patients with a higher TOI score were less likely to suffer a mortality (95 % CI 0.9-1.0, P = 0.05). Patients with a higher emotional well being (EWB) score were less likely to suffer a complication 0.9 (95 % CI 0.87-1.0, P = 0.04). Other independent predictors of postoperative morbidity included diabetic status (P = 0.05), ECOG performance status (0.001), and gender (0.02). CONCLUSIONS: Preoperative HRQoL, as measured by FACT-C and ECOG performance status and added to traditional factors, helps predict postoperative morbidity and mortality following CS+HIPEC.

Management of peritoneal carcinomatosis from colorectal cancer.

The management of peritoneal carcinomatosis from colorectal cancer is evolving. The introduction of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients with metastatic colorectal cancer. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. However, patients with metastasis localized to the peritoneum have been shown to be candidates for metastasectomy with improved clinical outcomes. Cytoreductive surgery with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) in this cohort of patients offers the only chance for long-term survival. Complete cytoreduction in combination with HIPEC for peritoneal surface disease has been demonstrated to produce survival outcomes similar to liver resection for hepatic metastases. This review will examine recent evidence pertaining to the evolving surgical oncology paradigm for management of colorectal peritoneal carcinomatosis.

Clinical significance of p53 and bcl-2 protein coexpression phenotypes in molecular breast cancer subtypes of pre-menopausal and post-menopausal African-American women.

With the current classification of breast carcinoma into molecular subtypes with distinct prognosis and response to therapy, we sort to assess the clinical significance of p53 and bcl-2 coexpression phenotypes in invasive breast tumors and correlate this to the different molecular breast cancer subtypes in African-American women. We performed a retrospective analysis of data on p53 and bcl-2 expression. Results were correlated to molecular breast cancer subtypes, and clinicopathologic variables of prognostic significance. Our study sample included all African-American women diagnosed with breast cancer from 1998 to 2005. Twenty-seven (27.6%) per cent of cases in our study sample over-expressed p53, whereas 69.3 per cent over-expressed bcl-2 protein. A significant inverse correlation was observed between expression of p53 and bcl-2. Combined analysis of p53 and bcl-2 showed that 53.2 per cent of the tumors displayed p53(-)bcl-2(+) phenotype which was significantly associated with the luminal A subtype, whereas 11.6 per cent displayed the p53(+)bcl-2(-) phenotype which was significantly associated with the basal cell-like and Her-2/neu. Neither p53 expression nor bcl-2 expression individually or in combination were of independent prognostic significance. p53(+)bcl-2(-) phenotype is significantly correlated with the basal cell-like subtype and may be associated with the biologic aggressiveness of this cohort of molecular breast cancer.

Trends in clinicopathologic characteristics and prognostic predictors of survival outcome in black patients with gastric carcinoma: a single institution's experience.

BACKGROUND: Age, gender, and ethnic group-related differences influence the outcome of gastric cancer. Our aim was to analyze the trends and association of clinicopathologic characteristics and prognostic factors of gastric cancer in black patients over a period of 28 y. METHODS: A retrospective analysis of all black patients treated for gastric cancer from 1979 to 2007 at Howard University Teaching Hospital. This period was divided into two time frames, 1979-1993 and 1994-2007. RESULTS: Of 286 patients in our study, there were 160 (55.9%) males versus 126 (44.1%) females. For the period 1979-1993, there were a total of 169 (59.1%) patients versus 117 (40.9%) for 1994-2007. A significant increase in the incidence of cardia/fundus tumors and stage IV tumors was noted between the two periods (P<0.02, P<0.004), 8.9% versus 12% and 71.4% versus 50.8%. The median survival time for the period 1979-1993 was 30.5 mo versus 39.2 mo for 1994-2007. The median survival time for males was 35.7 mo versus 34.9 mo for females. Significant independent predictors of a shorter gastric cancer-specific survival include tumor stage IV (HR 8.4 95% CI 2.0-35.0, P<0.003), female gender (HR 2.3 95% CI 1.0-4.9, P<0.02). CONCLUSION: Increased incidence of cardia/fundus tumors and stage IV disease may contribute to the sustained higher gastric cancer-specific mortality observed amongst black patients. Female gender emerged as an independent predictor of a shorter survival time.

Treatment and survival outcome for molecular breast cancer subtypes in black women.

OBJECTIVE: To analyze whether the local-regional surgical treatments (breast-conserving therapy, mastectomy) resulted in different overall survival, distant metastasis-free survival, and locoregional recurrence-free survival rates for the various molecular breast cancer subtypes. SUMMARY BACKGROUND DATA: Molecular gene expression profiling has been proposed as a new classification and prognostication system for breast cancer. Current recommendation for local-regional treatment of breast cancer is based on traditional clinicopathologic variables. METHODS: Retrospective analysis of 372 breast cancer cases with assessable immunohistochemical data for ER, PR, and Her-2/neu receptor status, diagnosed from 1998 to 2005. Molecular subtypes analyzed were luminal A, luminal B, basal like, and Her-2/neu. RESULTS: No substantial difference was noted in overall survival, and locoregional recurrence rate between the local-regional treatment modalities as a function of the molecular breast cancer subtypes. The basal cell-like subtype was an independent predictor of a poorer overall survival (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.28-4.97, P < 0.01) and a shorter distant metastasis-free survival time (HR = 3.61, 95% CI 1.27-10.2, P < 0.01), and showed a tendency toward statistical significance as an independent predictor of locoregional recurrence (HR = 3.57, 95% CI 0.93-13.6, P = 0.06). CONCLUSIONS: The basal cell-like subtype is associated with a worse prognosis, a higher incidence of distant metastasis, and may be more prone to local recurrence when managed with breast-conserving therapy.

Basal cell-like (triple-negative) breast cancer, a predictor of distant metastasis in African American women.

BACKGROUND: The aim of this study was to evaluate the prognostic significance of the basal cell-like molecular breast cancer subtype with respect to locoregional recurrence and distant metastasis in African American women treated for breast cancer. METHODS: A retrospective analysis was performed of the tumor registry database for all African American women diagnosed and treated for breast cancer from 1998 to 2005 who had assessable data for all 3 markers: estrogen, progesterone, and Her-2/neu. RESULTS: A total of 372 patients were included in our study sample. Of these, 22 (6.1%) had locoregional recurrence, 35 (9.8%) had distant metastasis, and 301 (84.1%) had no evidence of breast tumor recurrence. The median follow-up time was 36 months. Compared with the other molecular subtypes the basal cell-like subtype showed a statistically significant association to distant metastasis: 15 (42.9%) vs 13 (37.1%), 4 (11.4%), and 3 (8.6%) (P < .001), respectively, for luminal A, Her-2/neu, and luminal B subtypes. The basal cell-like subtype was an independent predictor of distant metastasis (odds ratio, 5.8; 95% confidence interval, 1.5-22.0, P = .009). The molecular subtypes showed no statistically significant difference with respect to locoregional treatment administered and tumor stage at time of diagnosis. CONCLUSIONS: The basal cell-like molecular breast cancer subtype is an independent predictor of distant metastasis in African American women.

Molecular breast cancer subtypes in premenopausal and postmenopausal African-American women: age-specific prevalence and survival.

BACKGROUND: Breast cancer is currently regarded as a heterogeneous disease classified into various molecular subtypes using gene expression analysis. These molecular subtypes include: basal cell-like, Her-2/neu, luminal A, and luminal B. OBJECTIVES: To analyze the prevalence and clinicopathologic associations for molecular breast cancer subtypes in premenopausal and postmenopausal African-American women. DESIGN: A retrospective analysis of all African-American women diagnosed with breast cancer from 1998 to 2005, who had assessable data for ER, PR, and Her-2/neu status. Molecular subtype classification was done based on immunohistochemical surrogates for ER, PR, and Her-2/neu status obtained from Howard University tumor registry for each patient. The molecular subtypes were defined as: luminal A (ER+ and/or PR+, HER2-), luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-), and Her-2/neu (ER-, PR-, and HER2+). OUTCOME MEASURES: We analyzed the prevalence of molecular breast cancer subtypes in a population of African-American women and determined their associations with patient demographics and clinicopathologic variables: node status, tumor size, histological grade, p53 mutation status, and breast cancer-specific survival. RESULTS: The luminal A subtype was the most prevalent in our study sample (55.4%) compared with (11.8%) luminal B, (21.2%) basal cell-like, and (11.6%) Her-2/neu subtypes. The molecular subtypes did not differ by menopausal status. However, when stratified into age-specific groups, the basal cell-like subtype (57.1%) was the most prevalent in the age group <35 y compared with luminal A, luminal B, and Her-2/neu subtypes at 25.0%, 14.3%, and 3.6%, respectively. The basal cell-like subtype also showed an age-specific bimodal distribution with a peak in the <35 y and 51 to 65 y age groups. The basal cell-like and the Her-2/neu subtypes showed an increased association with clinicopathologic variables portending a more aggressive clinical course when compared with luminal A subtype. A paradoxical inverse relationship between the expression of p53 and Bcl-2 protooncoprotein was noted in the molecular subtypes. Breast cancer-specific survival differed significantly among the molecular subtypes (P < 0.04), with the basal cell-like and Her-2/neu subtypes having the poorest outcome. CONCLUSIONS: The high prevalence of the basal cell-like subtype in the young premenopausal African-American women aged <35 y could be a contributory factor to the poorer prognosis of breast cancer observed in this cohort of patients.

Molecular breast cancer subtypes in premenopausal African-American women, tumor biologic factors and clinical outcome.

INTRODUCTION: Breast cancer is currently viewed as a heterogeneous disease made up of various subtypes, with distinct differences in prognosis. Our goal was to study the distribution and to characterize the clinical and biological factors that influence the behavior and clinical management of the different molecular breast cancer subtypes in premenopausal African-American women. METHODS: A retrospective analysis of Howard University Hospital tumor registry, for all premenopausal African-American women aged less than 50 years, diagnosed with breast cancer from 1998-2005, was performed. RESULTS: The luminal A subtype was the most prevalent (50.0%), vs basal-cell-like (23.2%), luminal B (14.1%), and HER-2/neu (12.7%). However when stratified by age groups, results showed that in the age group <35 years the basal-cell-like subtype was the most prevalent (55.6%), vs 25.9%, 14.8%, and 5.6% for luminal A, luminal B, and HER-2/neu subtypes, respectively (P < .000). P53 mutation was more prevalent in the basal-cell-like subtype compared to luminal A (48.0% vs 18.6%, P < .01). The expression of the Bcl-2 gene differed by subtype, with the luminal A and luminal B subtypes more likely to overexpress the Bcl-2 gene (89.1% luminal A, 80.0% luminal B vs 47.6% basal-cell-like and 40.0% HER-2/neu, P < .000). Though not statistically significant, HER-2/neu and basal-cell-like subtypes had the shortest survival time (P < .31). CONCLUSION: The high prevalence of the basal-cell-like subtype in young premenopausal African-American women aged <35 years may contribute to the poorer prognosis observed in this cohort of African-American women.