Hypercalcemia and Postoperative Joint Symptoms Following Joint Replacement for Osteoarthritis.

INTRODUCTION: Calcium metabolism dysregulation in the setting of primary hyperparathyroidism (PHPT) mediated chondrocalcinosis is implicated in joint pain, a key element in the decision regarding arthroplasty for osteoarthritis. The relationship between hypercalcemia and joint pain, before and after arthroplasty, is unknown. This study investigates the association between preoperative hypercalcemia and postoperative outcomes following total knee (TKA) and total hip arthroplasty (THA). METHODS: A retrospective chart review was conducted on patients who underwent initial elective THA or TKA. Patients with a preoperative serum calcium >10.2 mg/dL were matched (1:2-1:4) with nearest neighbor to patients with normal serum calcium. THA and TKA functional outcomes were measured at baseline and 1-y postoperatively using patient-reported Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores surveys. Postoperative complications, readmissions, length of stay, and functional outcome scores were compared. RESULTS: Four hundred ninety-five patients (106 hypercalcemic cases, 389 matched controls) were included. Of these, 223 patients underwent THA (46 cases; 177 controls) and 272 patients underwent TKA (61 cases; 211 controls). There were no differences in Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores scores, postoperative complications, readmissions, or length of stay between cases and controls. Only 19/106 (18%) hypercalcemic patients had a parathyroid hormone (PTH); of these, 9 (47%) had possible PHPT (PTH > 40). CONCLUSIONS: Patients with hypercalcemia undergoing arthroplasty have similar functional and postoperative outcomes as normocalcemic patients. As PTH was obtained in <20% of hypercalcemic cases and 50% had possible PHPT, we recommend that hypercalcemic patients undergo PHPT workup. Additional investigation is needed to determine the effect of PHPT on arthroplasty outcomes.

Effects of housing stability and contemporary mortgage lending bias on breast cancer stage at diagnosis among older women in the United States.

BACKGROUND: Interventions aimed at upstream factors contributing to late-stage diagnoses could reduce disparities and improve breast cancer outcomes. This study examines the association between measures of housing stability and contemporary mortgage lending bias on breast cancer stage at diagnosis among older women in the United States. METHODS: We studied 67,588 women aged 66-90 from the SEER-Medicare linked database (2010-2015). The primary outcome was breast cancer stage at diagnosis. Multinomial regression models adjusted for individual and neighborhood socio-economic factors were performed using a three-category outcome (stage 0, early stage, and late stage). Key census tract-level independent variables were residence in the same house as the previous year, owner-occupied homes, and an index of contemporary mortgage lending bias. RESULTS: In models adjusted for individual factors, higher levels of mortgage lending bias were associated with later stage diagnosis (RR = 1.10, 95% CI 1.02-1.20; RR = 1.31, 95% CI 1.16-1.49; RR = 1.41, 95% CI 1.24-1.60 for least to high, respectively). In models adjusted for individual and neighborhood socio-economic factors, moderate and high levels of mortgage lending bias were associated with later stage diagnosis (RR = 1.16, 95% CI 1.02-1.33 for moderate and RR = 1.18, 95% CI 1.02-1.37 for high). Owner occupancy and tenure were not associated with later stage diagnosis in adjusted models. CONCLUSIONS: Contemporary mortgage lending bias demonstrated a significant gradient relationship with later stage at diagnosis of breast cancer. Policy interventions aimed at reducing place-based mortgage disinvestment and its impacts on local resources and opportunities should be considered as part of an overall strategy to decrease late-stage breast cancer diagnosis and improve prognosis.

The Role of Demographic and Clinical Factors in Germline Mutation Testing for Patients with Primary Hyperparathyroidism.

INTRODUCTION: Guidelines recommending genetic counseling in primary hyperparathyroidism (PHPT) vary. To further delineate current recommendations, this study examined genetic counseling referral patterns and rates of mutations in surgical patients with PHPT. PATIENTS AND METHODS: A single-institution review was performed of adult patients who underwent parathyroidectomy for presumed sporadic PHPT. Genetic testing indications of hypercalcemia onset ≤ 40 years, multigland disease (MGD), family history (FHx) of PHPT, or other clinical indications suspicious for a PHPT-related endocrinopathy were examined by demographics and mutation detection rates. RESULTS: Genetic counseling was performed in 237 (37.9%) of 625 patients. Counseling was discussed but not performed in 121 (19.4%) patients. No evidence was noted of genetic referral discussion in the remaining 267 (42.7%). Of these groups, patients who received genetic counseling were youngest, p < 0.001 [median age 55.3 (IQR 43.2, 66.7) years]. The majority of patients with indications of age ≤ 40 years (65.7%), FHx (78.0%), and other clinical indications (70.7%) underwent genetic counseling, while most with MGD (57.0%) did not. Eight mutations were detected in 227 patients (3.5%). Mutations included: MEN1 (n = 2), CDC-73 (n = 4), and CASR (n = 2). Detection was most common in patients with FHx (4/71, 5.6%), then age ≤ 40 years (3/66, 4.5%), and other clinical indications (3/80, 3.8%). No mutations were identified in 48 patients tested solely for MGD. CONCLUSIONS: Most patients with onset of hypercalcemia age ≤ 40 years, positive FHx, or other clinical concerns underwent genetic counseling, while most with MGD did not. As no germline mutations were identified in patients with MGD alone, further investigation of MGD as a sole indication for genetic counseling may be warranted.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context: Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy. Objective: This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy. Methods: A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons. Results: Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively. Conclusion: Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.

Impact of state telehealth policies on telehealth use among patients with newly diagnosed cancer.

BACKGROUND: Telehealth restrictions were relaxed under the COVID-19 public health emergency. We examined telehealth use before and during the pandemic among patients with newly diagnosed cancers and the association between state policies and telehealth use. METHODS: The study cohort was constructed from Optum's deidentified Clinformatics Data Mart and included patients with lymphoma, female breast cancer, colorectal cancer, prostate cancer, and lung cancer diagnosed between March 1, 2019, and March 31, 2021. We performed an interrupted time series analysis to examine the trend of cancer-related telehealth use within 1 month of diagnosis relative to the timing of the COVID-19 public health emergency and multivariable logistic regressions to examine factors-specifically, state parity laws and regulations on cross-state practice-associated with telehealth. RESULTS: Of 110 461 patients, the rate of telehealth use peaked at 33.4% in April 2020, then decreased to 12% to 15% between September 2020 and March 2021. Among the 53 982 patients diagnosed since March 2020, telehealth use was statistically significantly lower for privately insured patients residing in states with coverage-only parity or no or unspecified parity than those in states with coverage and payment parity (adjusted rate = 20.2%, 19.1%, and 23.3%, respectively). The adjusted rate was lower for patients in states with cross-state telehealth policy limitations than for those in states without restrictions (14.9% vs 17.8%). CONCLUSIONS: Telehealth use by patients diagnosed with cancer during the pandemic was higher among those living in states with more generous parity and less restrictive rules for cross-state practice. Policy makers contemplating whether to permanently relax certain telehealth policies must consider the impact on vulnerable patient populations who can benefit from telehealth.

Isolation and survival: The impact of local and MSA isolation on survival among non-Hispanic Black women diagnosed with breast cancer in the United States using a SEER-Medicare cohort.

BACKGROUND: Residential segregation is an important factor that negatively impacts cancer disparities, yet studies yield mixed results and complicate clear recommendations for policy change and public health intervention. In this study, we examined the relationship between local and Metropolitan Statistical Area (MSA) measures of Black isolation (segregation) and survival among older non-Hispanic (NH) Black women with breast cancer (BC) in the United States. We hypothesized that the influence of local isolation on mortality varies based on MSA isolation-specifically, that high local isolation may be protective in the context of highly segregated MSAs, as ethnic density may offer opportunities for social support and buffer racialized groups from the harmful influences of racism. METHODS: Local and MSA measures of isolation were linked by Census Tract (CT) with a SEER-Medicare cohort of 5,231 NH Black women aged 66-90 years with an initial diagnosis of stage I-IV BC in 2007-2013 with follow-up through 2018. Proportional and cause-specific hazards models and estimated marginal means were used to examine the relationship between local and MSA isolation and all-cause and BC-specific mortality, accounting for covariates (age, comorbidities, tumor stage, and hormone receptor status). FINDINGS: Of 2,599 NH Black women who died, 40.0% died from BC. Women experienced increased risk for all-cause mortality when living in either high local (HR = 1.20; CI = 1.08-1.33; p < 0.001) or high MSA isolation (HR = 1.40; CI = 1.17-1.67; p < 0.001). A similar trend existed for BC-specific mortality. Pairwise comparisons for all-cause mortality models showed that high local isolation was hazardous in less isolated MSAs but was not significant in more isolated MSAs. INTERPRETATION: Both local and MSA isolation are independently associated with poorer overall and BC-specific survival for older NH Black women. However, the impact of local isolation on survival appears to depend on the metropolitan area's level of segregation. Specifically, in highly segregated MSAs, living in an area with high local isolation is not significantly associated with poorer survival. While the reasons for this are not ascertained in this study, it is possible that the protective qualities of ethnic density (e.g., social support and buffering from experiences of racism) may have a greater role in more segregated MSAs, serving as a counterpart to the hazardous qualities of local isolation. More research is needed to fully understand these complex relationships. FUNDING: National Cancer Institute.

Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery.

OBJECTIVE: To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. BACKGROUND: Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. METHODS: Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. RESULTS: This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. CONCLUSIONS: Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Severity of Prior COVID-19 Infection is Associated with Postoperative Outcomes Following Major Inpatient Surgery.

Objective: To determine the association between severity of prior history of SARS-CoV-2 infection and postoperative outcomes following major elective inpatient surgery. Summary Background Data: Surgical guidelines instituted early in the COVID-19 pandemic recommended delay in surgery up to 8 weeks following an acute SARS-CoV-2 infection. Given that surgical delay can lead to worse medical outcomes, it is unclear if continuation of such stringent policies is necessary and beneficial for all patients, especially those recovering from asymptomatic or mildly symptomatic COVID-19. Methods: Utilizing the National Covid Cohort Collaborative (N3C), we assessed postoperative outcomes for adults with and without a history of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from SARS-CoV-2 infection to surgery were each used as independent variables in multivariable logistic regression models. Results: This study included 387,030 patients, of which 37,354 (9.7%) had a diagnosis of preoperative COVID-19. History of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of mortality and other complications. Conclusions: Impact of COVID-19 on postoperative outcomes is dependent on severity of illness, with only moderate and severe disease leading to higher risk of adverse outcomes. Existing wait time policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Current Trends in the Utilization of Preoperative Breast Magnetic Resonance Imaging Among Women With Newly Diagnosed Breast Cancer.

PURPOSE: The clinical benefit of preoperative breast magnetic resonance imaging (MRI) for early-stage breast cancer (BC) remains controversial. We examined trends and the associated factors of preoperative breast MRI use. METHODS: This study cohort, constructed from Optum Clinformatics database, included women with early-stage BC who had a cancer surgery between March 1, 2008, and December 31, 2020. Preoperative breast MRI was performed between the date of BC diagnosis and index surgery. Multivariable logistic regressions, one for elderly (65 years and older) and the other for non-elderly patients (younger than 65 years), were performed to examine factors associated with the use of preoperative MRI. RESULTS: Among 92,077 women with early-stage BC, the crude rate of preoperative breast MRI increased from 48% in 2008 to 60% in 2020 for nonelderly and from 27% to 34% for elderly women. For both age groups, non-Hispanic Blacks were less likely (odds ratio [OR]; 95% CI, younger than 65 years: 0.75, 0.70 to 0.81; 65 years and older: 0.77, 0.72 to 0.83) to receive preoperative MRI than non-Hispanic White patients. Across Census divisions, the highest adjusted rate was observed in Mountain division (OR compared with New England; 95% CI, younger than 65 years: 1.45, 1.27 to 1.65; 65 years and older: 2.42, 2.16 to 2.72). Other factors included younger age, fewer comorbidities, family history of BC, axillary node involvement, and neoadjuvant chemotherapy for both age groups. CONCLUSION: The use of preoperative breast MRI has steadily increased. Aside from clinical factors, age, race/ethnicity, and geographic location were associated with preoperative MRI use. This information is important for future implementation or deimplementation strategies of preoperative MRI.

Historical redlining and breast cancer treatment and survival among older women in the United States.

BACKGROUND: Breast cancer (BC) is the most common cancer among US women, and institutional racism is a critical cause of health disparities. We investigated impacts of historical redlining on BC treatment receipt and survival in the United States. METHODS: Home Owners' Loan Corporation (HOLC) boundaries were used to measure historical redlining. Eligible women in the 2010-2017 Surveillance, Epidemiology, and End Results-Medicare BC cohort were assigned a HOLC grade. The independent variable was a dichotomized HOLC grade: A and B (nonredlined) and C and D (redlined). Outcomes of receipt of various cancer treatments, all-cause mortality (ACM), and BC-specific mortality (BCSM) were analyzed using logistic or Cox models. Indirect effects by comorbidity were examined. RESULTS: Among 18 119 women, 65.7% resided in historically redlined areas (HRAs), and 32.6% were deceased at a median follow-up of 58 months. A larger proportion of deceased women resided in HRAs (34.5% vs 30.0%). Of all deceased women, 41.6% died of BC; a larger proportion resided in HRAs (43.4% vs 37.8%). Historical redlining is a statistically significant predictor of poorer survival after BC diagnosis (hazard ratio = 1.09, 95% confidence interval [CI] = 1.03 to 1.15 for ACM, and hazard ratio = 1.26, 95% CI = 1.13 to 1.41 for BCSM). Indirect effects via comorbidity were identified. Historical redlining was associated with a lower likelihood of receiving surgery (odds ratio = 0.74, 95% CI = 0.66 to 0.83, and a higher likelihood of receiving palliative care odds ratio = 1.41, 95% CI = 1.04 to 1.91). CONCLUSION: Historical redlining is associated with differential treatment receipt and poorer survival for ACM and BCSM. Relevant stakeholders should consider historical contexts when designing and implementing equity-focused interventions to reduce BC disparities. Clinicians should advocate for healthier neighborhoods while providing care.

Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19.

BACKGROUND: The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS: American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS: Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION: Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Long-term Quality of Life After Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review.

Importance: Definitive treatment of primary hyperparathyroidism (pHPT) with curative parathyroidectomy has been shown to improve nonspecific neurocognitive symptoms and may improve long-term quality of life (QOL). However, QOL is not currently routinely assessed preoperatively, and as a result, diminished QOL may be overlooked as an indication for surgery. Objective: To examine results for measures of long-term QOL after parathyroidectomy in patients with pHPT. Evidence Review: A systematic, English-language literature review was performed to assess the long-term association of parathyroidectomy, defined as a minimum of 1-year postoperative follow-up, with QOL in patients with pHPT. We conducted a search of PubMed and Scopus using Medical Subject Heading (MeSH) terms for hyperparathyroidism, parathyroid hormone, parathyroidectomy, hypercalcemia, and quality of life. All relevant literature published between June 1998 and February 15, 2021, was included. Study selection was guided by the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) strategy. Findings: Thirty-one studies conducted in 14 countries with a minimum of 1 year of follow-up were included, comprising 3298 patients with pHPT (2975 underwent parathyroidectomy; 323 were observed), 5445 age- and sex-matched control participants, and 386 control patients with benign thyroid disease. To assess QOL, 21 studies (68%) used a general tool, the 36-item Short Form Survey (SF-36), and 8 (26%) used the disease-specific tool Parathyroidectomy Assessment of Symptoms (PAS). The remaining studies used a combination of 10 additional QOL tools. The median follow-up period was 1 year (range, 1-10 years). Of the 31 studies, 27 (87%) demonstrated significant score improvement in long-term QOL after parathyroidectomy, including 1 study that showed continued improvement in QOL 10 years after parathyroidectomy. The remaining 4 studies (13%) reported mixed results. Conclusions and Relevance: This systematic review suggests that parathyroidectomy is associated with improved and sustained QOL in patients with pHPT. Patients with pHPT should be screened with a validated QOL tool such as the SF-36 or PAS at the time of diagnosis to guide discussion of these symptoms in the preoperative setting and the potential for long-term improvement after curative parathyroidectomy.

Variation in parathyroid adenoma size in patients with sporadic, primary hyperparathyroidism: small gland size does not preclude single gland disease.

PURPOSE: Small, abnormal parathyroid glands are usually associated with multigland hyperplasia in patients with primary hyperparathyroidism (pHPT). The purpose of this study was to determine the association between parathyroid adenoma size and biochemical cure rates in patients undergoing single gland parathyroidectomy. METHODS: The study included patients with sporadic pHPT who underwent initial parathyroidectomy and met intraoperative PTH criteria for cure after resection of a single adenoma (SGD). Patients were divided into quartiles (Q1 = smallest) based on gland weight and maximum dimension; cure rates were compared across groups. RESULTS: A single parathyroid adenoma was removed in 517 patients, with a median gland weight of 500 mg (range 50-11890). Median maximum gland dimension was 15 mm (range 5-55). With median follow-up of 28 months (range 6-81), the biochemical cure rate was 97.1%. There was no difference in cure rate by gland weight (Q1 94.6%, Q2 96.9%, Q3 98.4%, Q4 98.5%, p = 0.217) or maximum gland dimension (Q1 95.6%, Q2 97.6%, Q3 97.1%, Q4 98.2%, p = 0.641). When Q1 patients (by gland weight) were divided by quartile, there was no difference in cure rates (93.1% [50-140 mg]; 95.2% [150-190 mg]; 97.1% [200-230 mg]; 93.3% [240-280 mg]; p = 0.665). CONCLUSION: For patients with pHPT who underwent single gland parathyroidectomy, there was no difference in cure rates by gland weight or maximum dimension. These data suggest that the removal of parathyroid adenomas as small as 50 mg with an appropriate decline in ioPTH likely represent single gland disease and additional exploration may not be necessary.

Underdiagnosis of primary hyperparathyroidism in patients with osteoarthritis undergoing arthroplasty.

BACKGROUND: Primary hyperparathyroidism (HPT) is commonly underdiagnosed and undertreated. Joint pain is a nonspecific symptom associated with osteoarthritis or primary HPT. We hypothesize that patients treated for osteoarthritis are underdiagnosed with primary HPT. METHODS: Adult patients diagnosed with hip/knee osteoarthritis at the Medical College of Wisconsin from January 2000 to October 2020 were queried. Patients with a calcium level drawn within 1 year of diagnosis of osteoarthritis were included. Patients who had undergone prior parathyroidectomy were excluded. Patients were stratified by serum calcium level, HPT diagnosis, and PTH level. Arthroplasty rates were compared between groups. RESULTS: Of 54,788 patients, 9,967 patients (18.2%) had a high serum calcium level, of whom 1,089 (10.9%) had a diagnosis of HPT. Only 76 (7.0%) patients with HPT underwent parathyroidectomy, 208 (19.1%) underwent knee/hip arthroplasty, and 14 (1.3%) underwent both. Arthroplasty was performed in 1,793 patients without evaluation and/or definitive treatment for HPT. There were higher rates of arthroplasty performed in patients with a high serum calcium level compared with those without (21.2% vs 17.4%, P < .001). CONCLUSION: Patients with high serum calcium levels were more likely to undergo arthroplasty than those with normocalcemia. Hypercalcemia in the setting of hip or knee osteoarthritis should prompt a full evaluation for primary HPT.

Breast cancer-related lymphedema rates after modern axillary treatments: How accurate are our estimates?

BACKGROUND: Clinical trials have demonstrated methods to minimize the risk of breast cancer-related lymphedema while preserving regional control. We sought to determine the percent lifetime-risk of breast cancer-related lymphedema that surgeons and radiation oncologists discuss with patients before axillary interventions. METHODS: A nationwide survey of surgeons and radiation oncologists was performed from July to August 2020. Participants were asked to identify what number they discuss with patients when estimating the percent lifetime-risk of breast cancer-related lymphedema after different axillary interventions. RESULTS: Six hundred and eighty surgeons and 324 radiation oncologists responded (14% response rate). While the estimated rate after sentinel lymph node biopsy was clinically similar between surgeons and radiation oncologists, statistically surgeons quoted a higher percent lifetime-risk (5.7% vs 5.0%, P = .03). Surgeons estimated significantly higher rates of breast cancer-related lymphedema compared with radiation oncologists (P < .001) for axillary lymph node dissection (21.8% vs 17.5%), sentinel lymph node biopsy with regional nodal irradiation (14.1% vs 11.2%), and axillary lymph node dissection with regional nodal irradiation (34.8% vs 26.2%). CONCLUSION: There is variability in the estimated rates of breast cancer-related lymphedema providers discuss with patients. These findings highlight the need for physician education on the current evidence of percent lifetime-risk of breast cancer-related lymphedema to provide patients with accurate estimates before axillary interventions.

Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism.

OBJECTIVE: In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS: This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS: AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION: Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States.

PURPOSE: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States. METHODS: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates. RESULTS: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality. CONCLUSION: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.

An Institutional experience with primary hyperparathyroidism in the elderly over two decades.

BACKGROUND: Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (pHPT) and is associated with low morbidity. This study examined the severity of disease and outcomes of parathyroidectomy based on patient age at a high-volume institution. METHODS: This is a retrospective review of sporadic pHPT patients who underwent initial parathyroidectomy. To study disease severity over time, patients were divided into timeframes: 1999-2007, 2007-2012, and 2013-2018. Elderly was defined as age ≥75 years. RESULTS: Over time, the elderly had progressively lower preoperative calcium (11.0, 10.7, 10.7; p = 0.05) and PTH (150.4, 111.9, 107.9; p < 0.001) levels. By age, there was no difference in preoperative calcium (10.8, 10.9; p = 0.91) or in rates of recurrent laryngeal nerve injury, hypoparathyroidism, or persistent/recurrent pHPT. CONCLUSIONS: Over the 3 time periods of the study, elderly patients had progressively lower calcium and PTH levels. There was no difference in endocrine-specific complications between the age groups, suggesting that parathyroidectomy in the elderly is safe and therefore, age-associated morbidity should not preclude parathyroidectomy.

Guideline-concordant treatment predicts survival: a National Cancer Database validation study of novel composite locoregional and systemic treatment scores among women with early stage breast cancer.

BACKGROUND: The aim of this large nationwide study was to validate two novel composite treatment scores that address guideline-concordant locoregional and systemic breast cancer care. We examined the relationship between these two scores and their association with survival. METHODS: Women with Stage I-III unilateral breast cancer were identified within the National Cancer Database. For each woman, a locoregional and a systemic treatment score (0, 1, 2) was assigned based on receipt of guideline-concordant care. Multivariable Cox regression models evaluated the association between the scores and survival. RESULTS: 623,756 women were treated at 1,221 different American College of Surgeons Commission on Cancer (CoC) facilities. Overall, 86% had a locoregional treatment score of 2 (most guideline-concordant), 75% had a systemic treatment score of 2, and 72% had both scores of 2. Median follow-up was 4.5 years. Compared to women with a locoregional treatment score of 2, those with a score of 1 or 0 had a 1.7-fold and 2.0-fold adjusted greater risk of death. Compared to women with a systemic treatment score of 2, those with a score of 1 or 0 had a 1.5-fold and 2.1-fold adjusted greater risk of death. Risk-adjusted 5-year overall survival was 91.6% when both scores were 2 compared to 73.4% when both scores were 0. CONCLUSIONS: In this large national study of CoC facilities, two composite scores capturing guideline-concordant breast cancer care had independent and combined robust effects on survival. These clinically constructed novel scores are promising tools for health services research and quality-of-care studies.