Adjuvant Chemotherapy Does Not Improve Recurrence-Free Survival in Patients With Stage 2 or Stage 3 Rectal Cancer After Neoadjuvant Chemoradiotherapy and Total Mesorectal Excision.

BACKGROUND: Current guidelines for locally advanced stage 2/3 rectal cancer recommend neoadjuvant chemoradiotherapy followed by total mesorectal excision and adjuvant chemotherapy. The oncologic benefit of adjuvant chemotherapy has not been consistently demonstrated. OBJECTIVE: The purpose of this study was to evaluate disease recurrence and survival in patients with rectal cancer who received adjuvant chemotherapy after chemoradiotherapy and total mesorectal excision. DESIGN: This was a retrospective review of patients with stage 2/3 rectal cancer after chemoradiotherapy and surgery, based on receipt of adjuvant chemotherapy. SETTINGS: The study was conducted at the Kaiser Permanente Southern California system of 14 hospitals and associated clinics. PATIENTS: A total of 862 patients with stage 2/3 rectal cancer diagnosed and treated between January 1, 2005, and December 31, 2016, were included in this study. INTERVENTIONS: The study involved neoadjuvant chemoradiotherapy followed by total mesorectal excision with or without adjuvant chemotherapy. MAIN OUTCOME MEASURES: The primary end point was recurrence-free survival. RESULTS: A total of 348 stage 2 and 514 stage 3 patients were included; 660 patients (76.6%) underwent adjuvant chemotherapy. Mean patient follow-up after surgery was 63.0 months (range, 3-160). Multivariable analysis showed that yp stage (HR for yp stage 2 = 4.74; yp stage 3 = 8.83) and en bloc resection (HR = 1.76) were the only variables that significantly predicted disease recurrence. Neither pretreatment tumor stage nor receipt of adjuvant chemotherapy was significantly associated with recurrence-free survival. Log-rank testing failed to demonstrate significant recurrence-free survival improvement after receipt of adjuvant chemotherapy in any patient subgroup. LIMITATIONS: The study was limited by selection bias attributed to the nature of a retrospective study without patient randomization or predefined treatment protocol. CONCLUSIONS: In stage 2/3 rectal cancer treated with chemoradiotherapy and surgery, the addition of adjuvant chemotherapy was not associated with decreased recurrence-free survival in the entire cohort or in any subgroup, whereas tumor response to chemoradiotherapy is closely associated with disease recurrence. These findings have important consequences for treatment and surveillance decisions for patients with rectal cancer. Presurgical efforts that maximize tumor downstaging, such as total neoadjuvant therapy, may produce better oncologic outcomes than traditional adjuvant chemotherapy. See Video Abstract at http://links.lww.com/DCR/B134. LA QUIMIOTERAPIA ADYUVANTE NO MEJORA LA SOBREVIDA LIBRE DE RECURRENCIA EN PACIENTES CON CÁNCER DE RECTO ESTADÍOS II O III DESPUÉS DE RADIO-QUIMIOTERAPIA NEOADYUVANTE Y ESCISIÓN TOTAL DEL MESORRECTO: Las guías actuales para el tratamiento de cáncer rectal en estadio II-III localmente avanzado, recomiendan la radio-quimioterapia neoadyuvante con escisión total del mesorrecto seguidas de quimioterapia adyuvante. El beneficio oncológico de la quimioterapia adyuvante no ha sido demostrado de manera fehaciente.Evaluar la recurrencia y sobrevida a la enfermedad en pacientes con cáncer rectal que recibieron quimioterapia adyuvante después de radio-quimioterapia y escisión total del mesorrecto.Revisión retrospectiva de pacientes con cáncer rectal en estadios II-III después de radio-quimioterapia y cirugía, basada en la recepción de quimioterapia adyuvante.Sistema Permanente de Kaiser Sur-Californiano de 14 hospitales y clínicas asociadas.862 pacientes con cáncer rectal en estadio II-III diagnosticados y tratados entre el 1 de Enero 2005 y el 31 de Diciembre 2016.Radio-quimioterapia neoadyuvante seguida de escisión total del mesorrecto +/- quimioterapia adyuvante.El objetivo primario fue la sobrevida libre de recurrencia.Fueron incluidos 348 pacientes en estadio II y 514 en estadio III. 660 pacientes (76,6%) se sometieron a quimioterapia adyuvante. El seguimiento medio de cada paciente después de la cirugía fué de 63.0 meses (rango, 3-160). El análisis multivariable mostró que la etapa yp (Cociente de riesgo para estadío yp II = 4.74 y estadío yp III = 8.83) y la resección en bloque (Cociente de riesgo = 1.76) fueron las únicas variables que predijeron significativamente la recurrencia de la enfermedad. Ni el estadío tumoral previo al tratamiento ni la recepción de quimioterapia adyuvante se asociaron significativamente con la sobrevida libre de recurrencia. Las pruebas de rango logarítmico no pudieron demostrar una mejoría significativa de la sobrevida libre de recurrencia después de recibir quimioterapia adyuvante en cualquier subgrupo de pacientes.Sesgo de selección, debido al estudio retrospectivo sin aleatorización de los pacientes o protocolo de tratamiento predefinido.En casos de cáncer de recto estadíos II-III tratados con radio-quimioterapia y cirugía, la adición de quimioterapia adyuvante no se asoció con una disminución de la sobrevida libre de recurrencia en toda la cohorte o en ningún subgrupo, mientras que la respuesta tumoral a la radio-quimioterapia está estrechamente asociada con la recurrencia de la enfermedad. Estos hallazgos tienen consecuencias importantes en la decisión del tratamiento y la vigilancia en pacientes con cáncer de recto. Los esfuerzos pre-quirúrgicos que maximizan la reducción del tamaño del tumor, como la terapia neoadyuvante total, pueden producir mejores resultados oncológicos que la quimioterapia adyuvante tradicional. Consulte Video Resumen en http://links.lww.com/DCR/B134.

Treatment sequencing strategy for hepatic epithelioid haemangioendothelioma.

BACKGROUND: The biology of hepatic epithelial haemangioendothelioma (HEHE) is variable, lying intermediate to haemangioma and angiosarcoma. Treatments vary owing to the rarity of the disease and frequent misdiagnosis. METHODS: Between 1989 and 2013, patients retrospectively identified with HEHE from a single academic cancer centre were analysed to evaluate clinicopathological factors and initial treatment regimens associated with survival. RESULTS: Fifty patients with confirmed HEHE had a median follow-up of 51 months (range 1-322). There was no difference in 5-year survival between patients presenting with unilateral compared with bilateral hepatic disease (51.4% versus 80.7%, respectively; P = 0.1), localized compared with metastatic disease (69% versus 78.3%, respectively; P = 0.7) or an initial treatment regimen of Surgery, Chemotherapy/Embolization or Observation alone (83.3% versus 71.3% versus 72.4%, respectively; P = 0.9). However, 5-year survival for patients treated with chemotherapy at any point during their disease course was decreased compared with those who did not receive any chemotherapy (43.6% versus 82.9%, respectively; P = 0.02) and was predictive of a decreased overall survival on univariate analysis [HR 3.1 (CI 0.9-10.7), P = 0.02]. CONCLUSIONS: HEHE frequently follows an indolent course, suggesting that immediate treatment may not be the optimal strategy. Initial observation to assess disease behaviour may better stratify treatment options, reserving surgery for those who remain resectable/transplantable. Prospective cooperative trials or registries may confirm this strategy.

Treatment options for metaplastic breast cancer.

Metaplastic breast cancer (MBC) is a malignancy characterized by the histologic presence of two or more cellular types, commonly a mixture of epithelial and mesenchymal components. MBC is rare relative to invasive ductal carcinoma (IDC), representing less than 1% of all breast cancers. Other than a lower rate of lymph node metastases, MBC tumors display poorer prognostic features relative to IDC. Due to its low incidence and pathological variability, the ideal treatment paradigm for MBC is unknown. Because of its rarity, MBC has been treated as a variant of IDC. Despite similar treatment regimens, however, patients with MBC have worse outcomes. Recent research is focused on biological differences between MBC and IDC and potential novel targets for chemotherapeutic agents. This paper serves as a summation of current literature on approaches to the multidisciplinary treatment of patients with MBC.

Rural-urban disparities in use of post-lumpectomy radiation.

We hypothesized that breast cancer (BCa) patients in urban counties would have higher rates of post-lumpectomy radiation therapy (RT) relative to patients in near-metro and rural counties. We used the Surveillance, Epidemiology, and End Results (SEER) database to identify women diagnosed with BCa treated with lumpectomy in the Sacramento area between 2000 and 2006. Patient counties were categorized as urban and near-metro. Multivariate logistic regression models predicted treatment with RT. Likelihood of undergoing RT was reported as odds ratios (OR) with 95 % confidence intervals (CI). Of 7,953 patients meeting entry criteria, 5,858 (73.7 %) underwent RT. On multivariate analysis, patients from near-metro (OR, 0.66; CI, 0.59-0.75; P < 0.001) and rural (OR 0.39, CI 0.30-0.52; P < 0.001) areas had a decreased likelihood of undergoing RT relative to patients from urban areas. Patients from near-metro and rural areas are less likely to receive RT following lumpectomy for BCa than their urban counterparts.

Urban and non-urban disparities in the use of post-mastectomy radiation for breast cancer.

Post-mastectomy radiation therapy (PMRT) is indicated for local-regionally advanced breast cancer (LABC). We hypothesized that candidates for PMRT from non-urban areas would receive lower rates of RT than urban patients and would have poorer overall survival (OS) and disease-specific survival (DSS). We used the Surveillance, Epidemiology, and End Results database to identify patients diagnosed with LABC and treated with mastectomy in Sacramento and its surrounding 13 counties between 2000 and 2006. All patients were eligible to receive RT according to established guidelines, with tumors >5 cm size, ≥ 4 metastatic lymph nodes, or both. According to a United States Department of Agriculture scale, we designated counties as urban or non-urban and used multivariate logistic regression and Cox proportional hazards models to predict the use of RT, overall survival (OS), and disease-specific survival (DSS). Density of radiation oncologists in non-urban and urban counties was determined using the American Medical Association database in relation to census-derived populations of the respective counties. Entry criteria were met by 1,507 patients. Most (56.5%) were from urban counties; only 61% received RT. There was no radiation oncologist listed for 8/10 non-urban counties and 2/4 urban counties. Each radiation oncologist served 88,804 people in non-urban counties and 68,624 residents in urban counties. On multivariate analysis, non-urban patients (OR 0.56, CI 0.44-0.72) and increasing age were the only factors predicting a decreased likelihood of receiving RT (OR 0.97, CI 0.96-0.98). Patients not receiving PMRT experienced poorer OS (HR 1.77, CI 1.39-2.25; P < 0.001) and DSS (HR 1.62, CI 1.23-2.15; P = 0.001); however, non-urban status did not predict OS or DSS. Non-urban residents with LABC are less likely to receive indicated PMRT. This discrepancy may be due to limited RT access in non-urban areas. The lack of poorer OS and DSS due to this disparity requires further study.

Predicting survival for well-differentiated liposarcoma: the importance of tumor location.

BACKGROUND: Although well-differentiated liposarcoma (WD Lipo) is a low grade neoplasm with a negligible risk of metastatic disease, it can be locally aggressive. We hypothesized that survival for WD Lipo varies significantly based on tumor location. METHODS: We identified 1266 patients with WD Lipo in the Surveillance, Epidemiology, and End Results database from 1988-2004. After excluding patients diagnosed by autopsy only, those lacking histologic confirmation, those lacking data on tumor location, and those with metastatic disease or unknown staging information, we arrived at a final study cohort of 1130 patients. Clinical, pathologic, and treatment variables were analyzed for their association with overall survival (OS) and disease-specific survival (DSS) using Kaplan-Meier analysis and Cox proportional hazards multivariate models. RESULTS: Mean age was 61 y (± 14.6), 72.2% were white, and 60.4% were male. Eighty-one percent of patients were treated with surgical therapy alone, 4.6% were treated with radiotherapy (RT) alone, and 12.9% were treated with both surgery and RT. Extremity location was most common (41.6%), followed by trunk (29%), retroperitoneal/intra-abdominal (RIA, 21.6%), thorax (4.2%), and head/neck (3.6%). With a median follow-up of 45 mo, median OS was 115 mo (95% confidence interval [CI] 92-138 mo) for RIA tumors compared to not reached for other tumor locations (P = 0.002). On multivariate analysis, increasing age and RIA location both predicted worse OS and DSS while tumor size, race, sex, receipt of RT, and Surveillance, Epidemiology, and End Results (SEER) stage did not. Tumor size became a significant predictor of worse DSS, but not OS, only when site, SEER stage, and extent of resection were removed from the multivariate model. Non-RIA locations, including extremity, experienced statistically similar OS, but 5-y DSS for trunk location was intermediate [92.3%, (95% CI 88.5%-96.1%) compared with 98.0% (95% CI, 96.2%-99.8%) for extremity and 86.6 (95% CI 81.1%-92.1%) for RIA, P < 0.001]. CONCLUSIONS: Among patients with WD Lipo, RIA location is associated with significantly worse outcomes independent of tumor size. Future studies should focus on the anatomic and biologic reasons for these differences.

Do radiation use disparities influence survival in patients with advanced breast cancer?

BACKGROUND: The authors previously identified racial/ethnic disparities in the use of radiation therapy (RT) in patients with advanced breast cancer (BC). They hypothesized that disparities in the use of RT were associated with survival differences favoring white patients. METHODS: The authors used the Surveillance, Epidemiology, and End Results database to identify white, black, Hispanic, and Asian patients with BC associated with ≥ 10 metastatic lymph nodes diagnosed between 1988 and 2005. Multivariate analyses of overall survival (OS) and disease-specific survival (DSS) assessed age, sex, race, tumor size, histology, estrogen receptor status, progesterone receptor status, RT, and type of surgery. The authors further stratified for use of RT and type of surgery. Risk of mortality was reported as hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: Of 15,895 patients with advanced BC, 12,653 met entry criteria. On multivariate analysis, RT was associated with a decreased risk of all-cause (HR, 0.78; 95% CI 0.74-0.83; P < .001) and disease-specific (HR, 0.81; 95% CI, 0.76-0.86; P < .001) mortality; black race was associated with an increased risk of all-cause (HR, 1.54; 95% CI, 1.42-1.68; P < .001) and disease-specific (HR, 1.53; 95% CI, 1.39-1.68; P < .001) mortality. After stratifying by type of surgery and use of RT, blacks demonstrated poorer survival than their white counterparts, regardless of surgery type or receipt of RT. CONCLUSIONS: Only black patients had poorer OS and DSS relative to whites. When stratified by type of surgery and use of RT, blacks continued to demonstrate poorer survival. This survival disparity is unlikely to be because of lack of RT.

Nomogram to predict risk of 30-day morbidity and mortality for patients with disseminated malignancy undergoing surgical intervention.

OBJECTIVE: To estimate individual risk of 30-day surgical morbidity and mortality after surgical intervention for patients with disseminated malignancy (DMa). BACKGROUND: Patients with DMa frequently require surgical consultation for palliative operations. Although these patients are at high risk for surgical morbidity and mortality, limited data exist allowing individual risk stratification. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2005 to 2007, we identified 7447 patients with DMa. Each of the 53 preoperative ACS NSQIP variables was analyzed to assess risk of morbidity and mortality. Logistic regression models were developed using stepwise model selection and generalized additive models. Covariates were evaluated for nonlinearity and interactions among variables. We constructed nomograms utilizing clinically and statistically significant covariates to predict 30-day risk of morbidity and mortality. RESULTS: Overall 30-day unadjusted morbidity and mortality rates were 28.3% and 8.9%, respectively. Mortality rates reached 18.4% for vascular procedures and 27.9% for emergent operations. Increasing age, impaired functional status, Do-Not-Resuscitate status, impaired respiratory function, ascites, hypoalbuminema, elevated creatinine, and abnormal WBC were all significant predictors (P < 0.0001) of increased morbidity and mortality on multivariate analysis. Nomograms to predict individual 30-day risk of complications and death based on preoperative factors were developed and validated by bootstrapping. Concordance indices were 0.704 and 0.861 for morbidity and mortality, respectively. CONCLUSIONS: Surgical intervention among patients with DMa is associated with substantial morbidity and mortality. We have constructed nomograms to predict individual risk of 30-day morbidity and mortality. These have significant implications for surgical decision-making in this group of patients.

Outcomes for lymph node-positive cutaneous melanoma over two decades.

BACKGROUND: Our aim was to demonstrate that, despite advances in treatment and surveillance of node-positive cutaneous melanoma, rates of overall survival (OS) and melanoma-specific survival (MSS) have not changed over the last two decades. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify patients with node-positive cutaneous melanoma. Patients were categorized by treatment era; the first era encompassed patients diagnosed from 1988 to 1999 and the second era 2000 to 2006. Multivariate Cox proportional hazards models compared rates of OS and MSS between treatment eras while controlling for known prognostic factors. We reported risks of death as hazard ratios (HR) with 95% confidence intervals (CI) and set significance at P≤0.05. RESULTS: Entrance criteria were met by 6,868 patients, 1,631 (23.8%) treated in era I and 5,237 (76.3%) treated in era II. On multivariate analysis, era II patients did not demonstrate a significantly different risk of death from any cause (HR 0.89, CI 0.79-1.01; P<0.08), but they did have a lower risk of melanoma-specific mortality (HR 0.81, CI 0.71-0.93; P=0.003) relative to their era I counterparts. CONCLUSIONS: Over nearly two decades, MSS but not OS has improved for AJCC stage III melanoma patients. Stage migration is likely responsible for any improvement in MSS among patients in the most recently diagnosed era.

Surgical resident involvement is safe for common elective general surgery procedures.

BACKGROUND: Outcomes of surgical resident training are under scrutiny with the changing milieu of surgical education. Few have investigated the effect of surgical resident involvement (SRI) on operative parameters. Examining 7 common general surgery procedures, we evaluated the effect of SRI on perioperative morbidity and mortality and operative time (OpT). STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2007) was used to identify 7 cases of nonemergent operations. Cases with simultaneous procedures were excluded. Logistic regression was performed across all procedures and within each procedure incorporating SRI, OpT, and risk-stratifying American College of Surgery National Surgical Quality Improvement Program morbidity and mortality probability scores, which incorporate multiple prognostic individual patient factors. Procedure-specific, SRI-stratified OpTs were compared using Wilcoxon rank-sum tests. RESULTS: A total of 71.3% of the 37,907 cases had SRI. Absolute 30-day morbidity for all cases with SRI and without SRI were 3.0% and 1.0%, respectively (p < 0.001); absolute 30-day mortality for all cases with SRI and without SRI were 0.1% and 0.08%, respectively (p < 0.001). After multivariate analysis by specific procedure, SRI was not associated with increased morbidity but was associated with decreased mortality during open right colectomy (odds ratio 0.32; p = 0.01). Across all procedures, SRI was associated with increased morbidity (odds ratio 1.14; p = 0.048) but decreased mortality (odds ratio 0.42; p < 0.001). Mean OpT for all procedures was consistently lower for cases without SRI. CONCLUSIONS: SRI has a measurable impact on both 30-day morbidity and mortality and OpT. These data have implications to the impact associated with surgical graduate medical education. Further studies to identify causes of patient morbidity and prevention strategies in surgical teaching environments are warranted.

Lack of survival benefit following adjuvant radiation in patients with retroperitoneal sarcoma: a SEER analysis.

BACKGROUND: The benefit of radiation therapy (RT) among patients with retroperitoneal sarcoma (RPS) is controversial. We performed a retrospective analysis of the effect of RT on survival among RPS patients using a nationwide cancer registry. METHODS: Utilizing data from the Surveillance, Epidemiology, and End Results (SEER) database, we identified 2308 cases of RPS from 1988 to 2004. We excluded 773 cases for age < 18, identification by autopsy only, absence of histologic confirmation, presence of metastatic disease, or lack of surgical intervention. Overall survival (OS) and disease-specific survival (DSS) were estimated using the Kaplan-Meier method. Multivariate analysis was performed using a Cox proportional hazards model, adjusting for significant covariables. RESULTS: Among 1535 patients who met entry criteria, RT was administered to 373 patients (24.3%). The majority of RT (n = 300, 80.4%) was administered postoperatively. Median OS was 60 and 60 mo, respectively, for patients receiving and not receiving RT (P = 0.59). Median DSS was 86 and 117 mo, respectively, for patients receiving and not receiving RT (P = 0.84). On multivariate analysis, younger age, female gender, low and intermediate histologic grade, liposarcoma histology, tumor size 5-10 cm, and completeness of resection all independently predicted better OS and DSS, while RT did not (HR for OS with RT 0.92, 95% CI 0.78-1.09 and HR for DSS with RT 0.96, 95% CI 0.78-1.17). On subgroup analysis by histology, patients with malignant fibrous histiocytoma (MFH) receiving RT demonstrated statistically improved OS (P = 0.002) and DSS (P = 0.01), respectively. CONCLUSIONS: With the possible exception of MFH, postoperative RT offers no survival benefit in RPS. Further studies are necessary to determine if the selective application of RT is indicated.

Contiguous organ resection is safe in patients with retroperitoneal sarcoma: An ACS-NSQIP analysis.

BACKGROUND AND OBJECTIVES: The practice of aggressive contiguous organ resection (COR) of retroperitoneal sarcoma (RPS) is controversial. We examined rates of 30-day morbidity and mortality following resection of RPS utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS: From 2005 to 2007, we identified 156 cases of primary malignant neoplasm of the retroperitoneum. Univariate and multivariate analyses were performed using all pre-operative ACS-NSQIP variables for likelihood of post-operative overall morbidity or severe morbidity (composite endpoint including organ space infection, septic shock, acute renal failure requiring dialysis, reoperation, and death). Insufficient events precluded multivariate analysis of mortality as an independent outcome. RESULTS: Overall 30-day morbidity, severe morbidity, and mortality were 26% (N = 40), 11.5% (N = 18), and 1.3% (N = 2), respectively. Fifty-eight patients (37%) underwent COR, most commonly kidney. American Society for Anesthesiologists classification predicted overall morbidity (OR 3.23, 95% CI 1.33-7.84), while increasing operative time predicted severe morbidity (OR 1.38 per hour, 95% CI 1.05-1.81). COR was not associated with increased 30-day overall morbidity (OR 1.38, 95% CI 0.49-3.89) or severe morbidity (OR 0.78, 95% CI 0.05-13.18). CONCLUSIONS: Rates of post-operative morbidity and mortality are acceptable following RPS resection, even in the setting of multi-visceral resection. COR should not be viewed as a contraindication to complete RPS resection.

Metaplastic breast cancer: to radiate or not to radiate?

BACKGROUND: The role of radiation therapy (RT) is unclear for metaplastic breast cancer (MBC). We hypothesized that RT would improve overall survival (OS) and disease-specific survival (DSS). MATERIALS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify MBC patients diagnosed from 1988 to 2006. Univariate analyses of patient, tumor, and treatment-specific factors on OS and DSS were performed using the Kaplan-Meier method and differences among survival curves assessed via log rank. Variables assessed included patient age, race/ethnicity, histologic subtype, tumor grade, T stage, N stage, M stage, hormone receptor status, surgery type, and use of RT. Cox proportional hazards models used all univariate covariates. Risks of mortality were reported as hazard ratios (HR) with 95% confidence intervals (95% CI); significance was set at P ≤ 0.05. RESULTS: Among 1501 patients, RT was given to 580 (38.6%). Ten-year OS and DSS were 53.2, and 68.3%, respectively. In the overall analysis, RT provided an OS (HR 0.64; 95% CI, 0.51-0.82; P < 0.001) and DSS (HR 0.74; CI, 0.56-0.96; P < 0.03) benefit. When patients were stratified according to type of surgery, RT provided an OS but not a DSS benefit to lumpectomy (HR 0.51; CI, 0.32-0.79, P < 0.01) and mastectomy patients (HR 0.67; CI, 0.49-0.90; P < 0.01). CONCLUSIONS: Our findings support the use of RT for patients with MBC following lumpectomy or mastectomy. These retrospective findings should be confirmed in a prospective clinical trial.

Tumor location predicts survival in cutaneous head and neck melanoma.

BACKGROUND: Prior studies documented poorer outcomes in patients with cutaneous head and neck melanoma (CHNM) relative to those with melanoma at other sites. We evaluated survival differences attributable to tumor location in patients with CHNM. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients undergoing surgery for CHNM from 1988 to 2006, excluding patients without biopsy-proven diagnoses, those diagnosed at autopsy, and patients with distant metastases. Using the Kaplan-Meier method, we assessed patient, tumor, and treatment-specific factors on overall survival (OS) and melanoma specific survival (MSS). Cox proportional hazards models assessed the role of tumor location (ear, eyelid, face, lip, scalp/neck) on OS and MSS, while controlling for patient age, gender, race, tumor thickness, tumor ulceration, lymph node status, histologic subtype, type of surgery, and use of radiation. Risks of overall and melanoma-specific mortality were reported as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Among 27,097 patients, 10-y rates of OS and MSS were 56.1% and 84.7%, respectively. On multivariate analysis, scalp/neck primary site was associated with an increased risk of overall (HR 1.20, CI 1.14-1.26; P < 0.001) and melanoma-specific mortality (HR 1.64, CI 1.49-1.80, P < 0.001) relative to melanomas of the face. Tumors of the lip had poorer MSS (HR 1.55; CI 1.05-2.28, P = 0.03) but not OS (HR 1.03, CI 0.80-1.34; P = 0.80). CONCLUSIONS: Patients with melanomas of the scalp/neck have poorer OS and MSS and those with lip melanomas have poorer MSS. These anatomic areas should not be overlooked when performing skin examinations.

Sacramento area breast cancer epidemiology study: use of postmastectomy breast reconstruction along the rural-to-urban continuum.

BACKGROUND: Health care disparities have been documented in rural populations. The authors hypothesized that breast cancer patients in urban counties would have higher rates of postmastectomy breast reconstruction relative to patients in surrounding near-metro and rural counties. METHODS: The authors used the Surveillance, Epidemiology, and End Results database to identify patients diagnosed with breast cancer and treated with mastectomy in the greater Sacramento area between 2000 and 2006. Counties were categorized as urban, near-metro, or rural. Univariate models evaluated the relationship of rural, near-metro, or urban location with use of breast reconstruction by means of the chi-square test. Multivariate logistic regression models controlling for patient, tumor, and treatment-related factors predicted use of breast reconstruction. The likelihood of undergoing breast reconstruction was reported as odds ratios with 95 percent confidence intervals; significance was set at p≤0.05. RESULTS: Complete information was available for 3552 breast cancer patients treated with mastectomy. Of these, 718 (20.2 percent) underwent breast reconstruction. On univariate analysis, differences in the rates of breast reconstruction were noted among urban, near-metro, and rural areas (p<0.001). On multivariate analysis, patients from rural (odds ratio, 0.51; 95 percent confidence interval, 0.28 to 0.93; p<0.03) and near-metro (odds ratio, 0.73; 95 percent confidence interval, 0.59 to 0.89; p=0.002) areas had a decreased likelihood of undergoing breast reconstruction relative to patients from urban areas. CONCLUSIONS: Patients from near-metro and rural areas are less likely to undergo breast reconstruction following mastectomy for breast cancer than their urban counterparts. Differences in use of breast reconstruction detected at a population level should guide future interventions to increase rates of breast reconstruction at the local level.