Disparity Outcomes in Patients Undergoing Pancreas Surgery at an Urban Tertiary Care Center

INTRODUCTION: Previous studies have shown significant disparities in pancreas cancer outcomes in African American (AA) compared to non-AA patients. Pancreas surgery continues to be associated with significant morbidity, however, there is little reported data on pancreas surgical outcomes by race. We sought to evaluate how race would affect surgical outcomes in an urban tertiary care center for patients undergoing pancreas surgery. METHODS: A retrospective single-center analysis of patients undergoing pancreas surgery between January 2013 and September 2021 was performed. Patient demographics and post-surgical complications were collected and stratified by race. Area Deprivation Index (ADI) was used to determine patient socioeconomic status. Charlson Comorbidity Index (CCI) was calculated for comorbidities. Clavien-Dindo (CD) complications, as well as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH) were evaluated. Patient reoperation, readmission, and mortality in the 30- and 90- day period were collected and univariate and multivariate analyses were performed. RESULTS: Among 461 patients, 82% (N = 378) were nonAA and 18% (N = 83) were AA. Age and sex were found to be significantly different between the two groups, while ADI and CCI were not. Length of stay (LOS), POPF, PPH, PPH grade C and intra-abdominal abscess (IAA) were found to be significant on univariate analysis in the AA cohort. On multivariate analysis, LOS (OR 4.0; 95% CI 2.0-5.7; p \u3c 0.001), POPF (OR 0.6; 95% CI 0.4-1.0; p = 0.043), PPH (OR 0.5; 95% CI 0.2-0.9; p = 0.022), PPH grade C (OR 0.2; 95% CI 0.1-0.7; p = 0.017) and IAA (OR 0.4; 95% CI 0.2-0.9; p = 0.017) were still significantly higher in the AA cohort. CONCLUSIONS: AA patients undergoing pancreas surgery were noted to have a longer LOS, higher incidence of POPF, PPH and IAA compared to non-AA patients. However, no significant difference was seen in reoperation rates, major CD complications, or 30- and 90-day readmission. Elucidating patient selection, tumor biology, and preoperative treatment algorithms may shed additional insight on the differences in surgical outcomes in this particular patient cohort

Non-pharmacological interventions engaging organ transplant caregivers: A systematic review

INTRODUCTION: Lay-caregivers in organ transplantation (to candidates, recipients, and donors) are essential to pre- and postoperative care, but report significant caregiving-related stressors. This review aims to summarize studies testing nonpharmacological interventions aimed at improving organ transplant caregiver-reported outcomes. METHODS: In accordance with PRISMA, we conducted a systematic review (searched PubMed, Embase, Cochrane Central, PsycInfo, and CINAHL, no start-date restriction through 7/1/2021). Quality of comparative studies assessed by ROBS-2 or ROBINS. RESULTS: Twelve studies met inclusion. Study designs, interventions, and outcomes varied. Sample sizes were small across caregivers to adults (nine studies, five with caregiver samples ns≤50) and pediatric patients (three studies, caregiver samples ns≤16). Study designs included seven single-arm interventions, two prepost with comparison cohorts, and three randomized-controlled trials. Eight studies included transplant-specific education as the intervention, an interventional component, or as the comparison group. Outcomes included transplant specific knowledge, mental health, and intervention acceptability. Of the nine prepost caregiver assessments and/or comparison groups, four studies demonstrated no statistically significant intervention effects. CONCLUSION: Few interventions addressing the needs of organ transplant caregivers have been empirically evaluated. Existing interventions were well-received by caregivers. Given complexities of care in transplantation, research is needed evaluating interventions using rigorous trial methodology with adequate samples

Magnetic Resonance Guided Stereotactic Ablative Radiation Therapy vs. Chemoradiation for Borderline and Locally Advanced Pancreatic Cancer: Single Institution Overall Survival Comparison

Purpose/Objective(s): Several academic institutions have investigated stereotactic MR guided adaptive radiation therapy (SMART) to safely dose escalate for locally advanced and borderline resectable pancreatic cancer with initial favorable toxicity and survival outcomes. In 2018 our institution began to evaluate SMART on trial in borderline and locally advanced patients. We previously presented toxicity outcomes for standard fractionated chemoradiation (chemoRT) and SMART groups with acute grade 3+ GI toxicity in 28% vs 11% (P = 0.18) and late toxicity 43% vs 36% (P = 0.77). The purpose of this abstract was to compare overall survival (OS) between chemoRT and SMART. Materials/Methods: In this IRB approved analysis, we retrospectively reviewed 115 consecutive patients from 2017-2020 with locally advanced or borderline resectable pancreatic cancer who were treated with neoadjuvant radiation therapy. Initially all patients received chemoRT to a dose of 50.4 Gy in 28 fractions. In September 2018 we began to investigate SMART (50Gy in 5 fractions) for these patients. OS was evaluated by Kaplan-Meier and log-rank test. Univariate and multivariate analysis was also performed on multiple treatment variables. Results: Of the patients included, 30 received chemoRT and 85 received SMART. Median follow up for the chemoRT group was 32.8 months and for SMART was 14.9 months from last day of RT. Groups did not have significant differences in age, gender, tumor location, or initial CA 19-9. Pancreatectomy was performed in 13.3% vs 18.8% of patients in chemoRT and SMART groups. Per NCCN.1.2021 staging in the chemoRT group 33.3% were borderline (BL), 50% were locally advanced (LA), and 16.7% medically unresectable (MU) as compared to 24.7% BL, 49.4% LA, and 25.9% MU in the SMART group. Mean months of neoadjuvant chemo was slightly higher in the SMART group at 3.6 vs 2.3 months. Patients in the chemoRT arm were 36.7% African American vs 15.3% in the SMART group. When evaluated using Kaplan-Meier and log-rank test there was no difference in OS between groups (P = 0.95). Median OS from last day of RT in chemoRT and SMART groups was 10.7 vs 12.1 months. On univariate and multivariate analyses pancreatectomy was associated with improved OS, and both N2 disease at diagnosis and poor performance status (ECOG 2+) were associated with worse OS. Conclusion: Dose escalated SMART for locally advanced, borderline, and medically inoperable pancreatic cancer shows similar OS to standard fractionated chemoRT at a median 14.9 month follow up in our single institution analysis. With similar toxicity and OS between treatment modalities, SMART may be preferred due to the single week treatment course in a disease with overall very poor prognosis

Magnetic Resonance Guided Stereotactic Ablative Radiation Therapy vs. Chemoradiation for Borderline and Locally Advanced Pancreatic Cancer: Single Institution Overall Survival Comparison

Purpose/Objective(s): Several academic institutions have investigated stereotactic MR guided adaptive radiation therapy (SMART) to safely dose escalate for locally advanced and borderline resectable pancreatic cancer with initial favorable toxicity and survival outcomes. In 2018 our institution began to evaluate SMART on trial in borderline and locally advanced patients. We previously presented toxicity outcomes for standard fractionated chemoradiation (chemoRT) and SMART groups with acute grade 3+ GI toxicity in 28% vs 11% (P = 0.18) and late toxicity 43% vs 36% (P = 0.77). The purpose of this abstract was to compare overall survival (OS) between chemoRT and SMART. Materials/Methods: In this IRB approved analysis, we retrospectively reviewed 115 consecutive patients from 2017-2020 with locally advanced or borderline resectable pancreatic cancer who were treated with neoadjuvant radiation therapy. Initially all patients received chemoRT to a dose of 50.4 Gy in 28 fractions. In September 2018 we began to investigate SMART (50Gy in 5 fractions) for these patients. OS was evaluated by Kaplan-Meier and log-rank test. Univariate and multivariate analysis was also performed on multiple treatment variables. Results: Of the patients included, 30 received chemoRT and 85 received SMART. Median follow up for the chemoRT group was 32.8 months and for SMART was 14.9 months from last day of RT. Groups did not have significant differences in age, gender, tumor location, or initial CA 19-9. Pancreatectomy was performed in 13.3% vs 18.8% of patients in chemoRT and SMART groups. Per NCCN.1.2021 staging in the chemoRT group 33.3% were borderline (BL), 50% were locally advanced (LA), and 16.7% medically unresectable (MU) as compared to 24.7% BL, 49.4% LA, and 25.9% MU in the SMART group. Mean months of neoadjuvant chemo was slightly higher in the SMART group at 3.6 vs 2.3 months. Patients in the chemoRT arm were 36.7% African American vs 15.3% in the SMART group. When evaluated using Kaplan-Meier and log-rank test there was no difference in OS between groups (P = 0.95). Median OS from last day of RT in chemoRT and SMART groups was 10.7 vs 12.1 months. On univariate and multivariate analyses pancreatectomy was associated with improved OS, and both N2 disease at diagnosis and poor performance status (ECOG 2+) were associated with worse OS. Conclusion: Dose escalated SMART for locally advanced, borderline, and medically inoperable pancreatic cancer shows similar OS to standard fractionated chemoRT at a median 14.9 month follow up in our single institution analysis. With similar toxicity and OS between treatment modalities, SMART may be preferred due to the single week treatment course in a disease with overall very poor prognosis

A single-center analysis of 30- and 90-day post-pancreatectomy complications in patients undergoing neoadjuvant radiation with EBRT versus MRI-guided SBRT

Background: Stereotactic MRI -guided adaptive radiation therapy (SMART) is being investigated for enhanced efficacy in locally advanced, borderline resectable and medically inoperable pancreatic cancer. Traditionally, conventionally fractioned chemoradiation (EBRT) has been used for operable patients. We sought to evaluate whether there would be differences in surgical complications and outcomes in the 30- and 90- day postoperative period in patients who received either neoadjuvant EBRT or SMART followed by definitive surgery. Methods: A retrospective single-center analysis of patients with either resectable, borderline resectable or locally advanced tumors of the pancreas or duodenum, treated with neoadjuvant radiation and surgical management between 2014 and 2021 was performed. Patient demographics and postsurgical complications were collected and stratified according to both treatment arms. The International Study Group of Pancreatic Surgery (ISGPS) classifications were used to define and grade postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH). A univariate analysis was done followed by a multivariate analysis. Results: Among the 65 patients (mean age 62.6 years, 46% female) who underwent definitive surgical intervention, 44 (67.7%) received EBRT, and 21 (32.3%) received SMART. Baseline characteristics including age, sex, race, ASA, and Charlson comorbidity index (CCI) scores were found to be similar. Onunivariate analysis, PPH was significantly higher in SMART (OR, 6.6; 95% CI, 1.2 to 37.3; p = 0.034). After adjusting for confounders on multivariate analysis, it appears there is a trend towards higher PPH in the SMART cohort (p = 0.052). Conclusions: Neoadjuvant SMART followed by definitive surgery is not associated with worse outcomes in the 30- and 90- day postoperative period vs. neoadjuvant EBRT. Although there was a trend towards PPH on multivariate analysis, further discussion is warranted involving vascular resection, vascular stents and anticoagulation

Racial Disparities Among Pancreatic Adenocarcinoma Patients: A Retrospective Survival Analysis of Non-Metastatic Pancreatic Cancer Patients

Purpose/Objective(s): It is predicted that in 2020, approximately 57,600 individuals will be diagnosed with pancreatic cancer (PaC). Based on SEER database analysis, there are conflicting opinions in literature about the overall treatment and outcomes in African-American patients with PaC. The purpose of this study was to determine if there was a racial disparity in overall survival rates between African Americans (AAs) and non-African Americans (non-AAs) diagnosed with PaC who received neoadjuvant radiation therapy (RT) in a tertiary-care cancer center with an established multi-disciplinary PaC tumor board and clinic. Materials/Methods: An IRB-approved retrospective chart analysis was completed on 100 patients who were diagnosed with pancreatic adenocarcinoma and treated with neoadjuvant RT between 2017-2019. Patients who were deemed resectable, borderline resectable (BR), or locally advanced/unresectable (LA) at initial diagnosis were included in the analysis. The following baseline characteristics were collected for each patient: staging, gender, age and ECOG score at initial diagnosis, tumor site and size, clinical T and N stage, CA19-9, and treatment variables (i.e., surgery, chemotherapy, and RT type). Overall survival was calculated from the RT start date. In order to identify any baseline differences among the AA group and the non-AA group, a two-sample t-test and Chi-square were employed. A log-rank test and Kaplan-Meier were used to determine any differences in overall survival among the two groups. Results: Of the 100 patients included in the analysis, 25 were AA and 58 were female. There were 17 (68%) BR and 8 (32%) LA patients in the AA group. In the non-AA group, there were 2 (3%) resectable, 47 (63%) BR, and 26 (35%) LA patients. There were no statistically significant differences detected in any of the baseline characteristics except a trend for increased CA19-9 values of 399.8 U/mL for AAs and 229 U/mL for non-AAs. There was no statistically significant difference in receipt of chemotherapy and RT between the two groups. The estimated median survival rates were 11.5 months for non-AAs and 8.4 months for AAs. One-year overall survival was 45% for AAs versus 48% for non-AAs (p = 0.57). Conclusion: There was no difference in overall survival among AAs and non-AAs who received neoadjuvant RT+/- chemotherapy for PaC at our institution between 2017-2019. Contrary to previous publications based on large SEER database analysis, there does not appear to be any difference in overall survival based on race if patients receive treatment in a comprehensive multi-disciplinary collaborative center

A single-center analysis of 30- and 90-day post-pancreatectomy complications in patients undergoing neoadjuvant radiation with EBRT versus MRI-guided SBRT

Background: Stereotactic MRI -guided adaptive radiation therapy (SMART) is being investigated for enhanced efficacy in locally advanced, borderline resectable and medically inoperable pancreatic cancer. Traditionally, conventionally fractioned chemoradiation (EBRT) has been used for operable patients. We sought to evaluate whether there would be differences in surgical complications and outcomes in the 30- and 90- day postoperative period in patients who received either neoadjuvant EBRT or SMART followed by definitive surgery. Methods: A retrospective single-center analysis of patients with either resectable, borderline resectable or locally advanced tumors of the pancreas or duodenum, treated with neoadjuvant radiation and surgical management between 2014 and 2021 was performed. Patient demographics and postsurgical complications were collected and stratified according to both treatment arms. The International Study Group of Pancreatic Surgery (ISGPS) classifications were used to define and grade postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH). A univariate analysis was done followed by a multivariate analysis. Results: Among the 65 patients (mean age 62.6 years, 46% female) who underwent definitive surgical intervention, 44 (67.7%) received EBRT, and 21 (32.3%) received SMART. Baseline characteristics including age, sex, race, ASA, and Charlson comorbidity index (CCI) scores were found to be similar. Onunivariate analysis, PPH was significantly higher in SMART (OR, 6.6; 95% CI, 1.2 to 37.3; p = 0.034). After adjusting for confounders on multivariate analysis, it appears there is a trend towards higher PPH in the SMART cohort (p = 0.052). Conclusions: Neoadjuvant SMART followed by definitive surgery is not associated with worse outcomes in the 30- and 90- day postoperative period vs. neoadjuvant EBRT. Although there was a trend towards PPH on multivariate analysis, further discussion is warranted involving vascular resection, vascular stents and anticoagulation

Magnetic Resonance Guided Stereotactic Ablative Radiation Therapy Versus External Beam RT with Chemotherapy For Pancreatic Cancer: Single Institution Toxicity Analysis Of Patients Treated In An Urban Academic Center

Purpose/Objective(s): Several academic institutions have investigated stereotactic MR guided adaptive radiation therapy (SMART) to safely dose escalate for locally advanced and borderline resectable pancreatic cancer with initial favorable toxicity and survival outcomes. However, it is not clear that this treatment is safe or effective in more challenging populations, such as in an urban academic center. The purpose of this abstract was to review outcomes immediately before and after implementing dose escalated MR guided adaptive radiation therapy for pancreatic cancer. Materials/Methods: In this IRB approved analysis, we retrospectively reviewed 57 consecutive patients from 2017-2019 with locally advanced or borderline resectable pancreatic cancer who were treated with neoadjuvant radiation therapy. Initially all patients received standard fractionated chemoradiation (chemoRT) to a dose of 50.4 Gy in 28 fractions. In September 2018 our institutional treatment guidelines were changed to recommend SMART (50Gy in 5 fractions) for these patients. Toxicity outcomes evaluated were grade 3+ GI toxicity based on CTCAE v5.0 as well as unplanned hospital admissions, both at 90 and 180 days. Treatment differences were analyzed using two sample t-test and chi-square test. Overall survival was evaluated at 180 days, and by Kaplan-Meier and log-rank test and was calculated from first day of radiation therapy. Results: 29 patients received chemoRT and 28 received SMART. Median follow up for the chemoRT group was 294 days and for SMART was 185 days. Groups did not have significant differences in age, performance status, stage, gender, CA 19-9, or neoadjuvant chemotherapy. Grade 3+ GI toxicity at 90 days was seen in 28% and 11% (p = 0.11) in the chemoRT and SMART groups, respectively. Types of toxicity were overall comparable with most being abdominal pain and duodenal bleeds. Hospital admissions at 90 days occurred in 38% and 21% of patients (p = 0.17) and at 180 days in 33% and 44% (p = 0.48). Surgical resection was achieved in 24% of chemoRT and 36% of SMART patients (p = 0.34). When evaluated using Kaplan-Meier and log-rank test there was a trend to overall survival benefit in the SMART group (p = 0.07). There was also a statistically significant 180-day survival improvement in SMART patients of 94% vs 70% in chemoRT patients (p = 0.046). Conclusion: Dose escalated SMART for locally advanced and borderline pancreatic cancer does not cause significant increase in GI grade 3+ GI toxicity at 90 days or hospitalization at 90 or 180 days as compared to chemoRT. Dose escalated SMART appears to be both safe and effective in our urban population. OS in the chemoRT group was comparable to previous trials such as LAP07. There is a trend to OS improvement on Kaplan-Meier analysis in the SBRT group (p = 0.07), as well as statistically significant improvement in 180-day survival; which supports the ongoing multi-institutional SMART study (NCT03621644). Updated results to be presented at the meeting

Prerenal Transplant Education and Evaluation Positively Impacts Outcomes

Introduction: An outstanding question in kidney transplantation is how to prepare candidates and their social supports for optimal posttransplant outcomes. Project Aims: This program evaluation assessed whether a pretransplant quality improvement clinic improved clinical outcomes in the year posttransplant compared to recipients receiving standard of care. Design: The Countdown to Transplant Clinic was implemented with kidney transplant candidates expected to receive a transplant within the next few months. The clinic included an enhanced education session on posttransplant lifestyle management, confirmation of support (≥2 adults), and evaluations by transplant social work, psychology, and nephrology. Results: Seventy-five patients participated in the clinic and underwent a transplant. A retrospective chart review of posttransplant laboratory values, rehospitalizations (within 3-months posttransplant), biopsy-confirmed graft failure, and mortality (within 1-year posttransplant) were collected from both groups. Univariate and multivariate propensity score-weighted linear or logistic regression models were used to evaluate the association between clinic participation and outcomes. In models adjusting for relevant covariates, participation in The Countdown to Transplant Clinic (vs standard care) was associated with a lower coefficient of variation of serum tacrolimus (all values collected 3-12 months posttransplant), 30-day posttransplant white blood cell counts (but not 90-day), 90-day posttransplant potassium, and 30 and 31 to 90 days rehospitalizations. Clinic participation did not predict serum glucose levels at 30- or 90-days posttransplant. Due to low rates of rejection and mortality, meaningful comparisons were not possible. Conclusion: Participation in a pretransplant, multicomponent clinic may improve certain outcomes of interest posttransplantation. Pilot testing for feasibility for randomized controlled trials is a necessary next step