Disparities in Pancreas Cancer Care

Prior literature shows demographic differences in patients surgically treated for pancreatic cancer (PC). We hypothesized that socioeconomic disparities also exist across all aspects of PC care, in both surgically and non-surgically treated patients.We identified a cohort of patients with American Joint Committee on Cancer (AJCC) stage I–IV PC in the 1994–2008 California Cancer Registry. We used multivariate logistic regression to examine the impact of race, sex, and insurance status on (1) resectability (absence of advanced disease), (2) receipt of surgery, and (3) receipt of adjuvant/primary chemotherapy (+/– radiotherapy).Among 20,312 patients, 7,585 (37 %) had resectable disease; 40 % who met this definition received surgery (N = 3,153). On multivariate analysis, males were less likely to present with resectable tumors [odds ratio (OR) 0.91, 95 % confidence interval (CI) 0.85–0.96], but sex did not otherwise predict treatment. Black patients were as likely as White patients to show resectable disease, yet were less likely to receive surgery (OR 0.66, 95 % CI 0.54–0.80), and adjuvant (OR 0.75, 95 % CI 0.58–0.98) or primary chemotherapy +/– radiation. Compared with Medicaid recipients, non-Medicare/Medicaid enrollees were more likely to receive surgery (OR 1.7, 95 % CI 1.4–2.2), and the uninsured were less likely to receive adjuvant therapy (OR 0.54, 95 % CI 0.30–0.98).Though Black patients appear to present with comparable rates of resectability, they receive care that deviates from current guidelines. Insurance status is associated with inferior profiles of resectability and treatments. Future policies and research should identify effective strategies to ensure receipt of standard care

Is there a role for surgery with adequate nodal evaluation alone in gastric adenocarcinoma

INTRODUCTION: The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival. METHODS: Using 2001-2008 California Cancer Registry, we identified 2,229 patients who underwent gastrectomy with adequate nodal evaluation (\u3e/=15 lymph nodes) for American Joint Committee on Cancer stage I-IV M0 gastric adenocarcinoma. Cox proportional hazard analyses were used to evaluate the impact of surgery alone on survival. RESULTS: Nearly 70% of our cohort had T1/2 tumors and 29% had N0 disease. Forty-nine percent of the cohort underwent surgery alone. These patients were more likely to be older, Medicare-insured, with T1 and N0 disease. On unadjusted analyses, persons who underwent surgery alone for stage I or N0 disease experienced 1- and 3-year overall and cancer-specific survival comparable to those who received adjuvant therapy. On multivariate analyses for stage I or N0 disease, surgery alone predicted superior survival outcomes than when combined with adjuvant therapies. CONCLUSION: Surgery alone with adequate nodal evaluation may have a role in low-risk gastric cancer. To corroborate these findings, surgery with adequate lymphadenectomy alone (as treatment arm) deserves consideration in the design of gastric cancer trials to provide effective yet resource-conserving, rather than maximally tolerated, treatments

Wound infection following stoma takedown: primary skin closure versus subcuticular purse-string suture.

Abstract: Background Stoma closure has been associated with a high rate of surgical site infection (SSI) and the ideal stoma-site skin closure technique is still debated. The aim of this study was to compare the rate of SSI following primary skin closure (PC) versus a skin-approximating, subcuticular purse-string closure (APS). Methods All consecutive patients undergoing stoma closure between 2002 and 2007 by two surgeons at a single tertiary-care institution were retrospectively assessed. Patients who had a new stoma created at the same site or those without wound closure were excluded. The end point was SSI, determined according to current CDC guidelines, at the stoma closure site and/or the midline laparotomy incision. Results There were 61 patients in the PC group (surgeon A: 58 of 61) and 17 in the APS group (surgeon B: 16 of 17). The two groups were similar in baseline and intraoperative characteristics, except that patients in the PC group were more often diagnosed with benign disease (p = 0.0156) and more often had a stapled anastomosis (p = 0.002). The overall SSI rate was 14 of 78 (18%). All SSIs occurred in the PC group (14 of 61 vs. 0 of 17, p = 0.03). Conclusions Our study suggests that a skin-approximating closure with a subcuticular purse-string of the stoma site leads to less SSI than a primary closure. Randomized studies are needed to confirm our findings and assess additional end points such as healing time, cost, and patient satisfaction