Multi-institution analysis of racial disparity among African- American men eligible for prostate cancer active surveillance

There is a significant controversy on whether race should be a factor in considering active surveillance for low-risk prostate cancer. To address this question, we analyzed a multi-institution database to assess racial disparity between African-American and White-American men with low risk prostate cancer who were eligible for active surveillance but underwent radical prostatectomy. A retrospective analysis of prospectively collected clinical, pathologic and oncologic outcomes of men with low-risk prostate cancer from seven tertiary care institutions that underwent radical prostatectomy from 2003–2014 were used to assess potential racial disparity. Of the 333 (14.8%) African-American and 1923 (85.2%) White-American men meeting active surveillance criteria, African-American men were found to be slightly younger (57.5 vs 58.5 years old; p = 0.01) and have higher BMI (29.3 v 27.9; p \u3c 0.01), pre-op PSA (5.2 v 4.7; p \u3c 0.01), and maximum percentage cancer on biopsy (15.1% v 13.6%; p \u3c 0.01) compared to White-American men. Univariate and multivariate analysis demonstrated similar rates of upgrading, upstaging, positive surgical margin, and biochemical recurrence between races. These results suggest that single institution studies recommending more stringent AS enrollment criteria for AA men with a low-risk prostate cancer may not capture the complete oncologic landscape due to institutional variability in cancer outcomes. Since all seven institutions demonstrated no significant racial disparity, current active surveillance eligibility should not be modified based upon race until a prospective study has been completed. © Dinizo et al

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Adherence to adjuvant endocrine therapy in seniors with breast cancer, predictors and challenges

BACKGROUND: Nearly one-third of breast cancers (BC) occur in women 65 years and older. Anti-estrogen therapy (AET) significantly reduces BC recurrence and death in these patients, as they more often have hormone receptor positive tumors. However, prior studies suggest that adherence to AET in older women is a challenge. OBJECTIVE: To characterize AET adherence in seniors with BC and identify factors influencing it. METHODS: Cancer registry data and administrative claims for all non-metastatic BC diagnosed in Quebec between 1998 and 2005 were accessed from the provincial health insurance program. Patients ≥ 65 years who started AET (Tamoxifen, Anastrozole, Exemestane or Letrozole) and had 5 years of follow up were studied. Five-year medication possession ratio (MPR) was calculated and multivariate linear regression was used to assess the association between patient, disease, and physician characteristics and MPR. RESULTS: 4,715 women were included. Mean age was 72.9. 66.77% had no other significant comorbidities and only 4.16% had 3 or more comorbidities. Stage distribution was: 6.43% in situ, 74.13%localized and 19.45% regional disease. Mean MPR was 83.5% (SD 26.8%). 1596 (34%) women had AET interruption at some point during the entire period of follow up. The cumulative probability of therapy interruption was 33.8% and the mean time to interrupt was 833.4 days. Among those who had therapy interruptions, 39.1% reinstituted AET (mean time to reinstitute was 185.6 days), of which, 48.2% re-interrupted AET again. 5-year MPR decreased with increasing age (p=0.05) and hospitalizations not related to BC (0.73% per each hospitalization, p-value=0.009). Compared to women with node positive disease, those with in situ disease had on average an MPR lower by 6.5%(p-value=0.0003). Having more active prescriptions at baseline increased the MPR by 0.6% for each medication, (p-value< 0.0001). However, adding further new medications after the start of AET affected the MPR negatively (0.3% decrease in MPR for each new medication added, p-value< 0.0001). Among psychotropes, antidepressants were the only group that did show a significant effect, resulting in a MPR decrease of 4.7% among those who were known to take antidepressants prior to the diagnosis and treatment of breast cancer (p-value= 0.003). Women on Tamoxifen, compared to those on Anastrozole, had on average a MPR that is lower by 6%, (p-value= 0.002). Compared to those who never switched their AET type, those who switched early in their treatment course, during the first year, had lower MPR by 5.3% (p-value=0.003). On the other hand, those who switched later had on average an MPR higher by 7.4% (p-value<0.0001). CONCLUSION: Most seniors with BC had high adherence to AET. Patients with more advanced age, less advanced disease and more non-BC related health service use, and women treated with antidepressants prior to their breast cancer were at higher risk of suboptimal adherence.CONTEXTE: Près d'un tiers des cancers du sein surviennent chez les femmesde 65 ans et plus. La thérapie anti-estrogènique (TAE) réduit de manière significative le risque de récidive tumorale et de décès chez les patientes, ayant des tumeurs à récepteurs hormonaux positifs. Cependant, des etudes antérieures suggèrent que l'adhérence à la TAE chez les patientes âgées est sous-optimale. OBJECTIF: Caractériser l'adhérence à la TAE chez les personnes âgées atteintes d'un cancer du sein et identifier les facteurs qui l'influencent. MÉTHODES: Les données du registre du cancer et de reclamations administratives pour tous les cas de cancer du sein non-métastatique diagnostiqués au Québec entre 1998 et 2005 ont été accédées à partir du programme provinciald'assurance-santé. Les patientes âgés de 65 ans ou plus qui ont commencé une TAE (tamoxifène,anastrozole, exémestane oulétrozole) et ont eu 5 ans de suivi ont été étudiées. Le ratio de possession de médicaments à cinq ans (RPM) a été calculé et l'analyse par régression linéaire multivariée a été utilisée pour évaluer l'association entre les caractéristiques des patientes,de leur maladie, les caractéristiques et des médecins traitants. RÉSULTATS: 4,715 femmes ont été inclus. L'âge moyen était de 72,9. 66,77% n'avaient pas d'autres morbidités significatives et seulement 4,16% avaient 3 ou plus des comorbidités. La distribution par stade était: 6,43% in situ, 74.13% cancer localisé et 19.45% maladie régionale. Le RPM moyen était de 83,5% (SD 26,8%). 1596 (34%) des femmes ont eu une interruption de TAE durant la période de suivi. La probabilité cumulée d'interruption était de 33,8% et le temps moyen àa l'interruption était de 833,4 jours. Parmi ceux qui ont subi des interruptions de thérapie, 39,1% ont par la suite réétabli leur TAE (temps moyen de 185,6 jours). De ceux-ci, 48,2% re-interrompu leur TAE. Le RPM avait tendance à diminuer avec l'âge (p = 0,05) et les hospitalisations non-liées au cancer du sein (0,73% pour chaque hospitalisation, p = 0,009). Comparativement aux femmes atteintes d'un cancer à ganglions positifs, celles avec une maladie in situ avaient en moyenne un RPM inférieure de 6,5% (valeur p = 0,0003). Un plus grand nombre de prescriptions actives au depart augmentait le RPM de 0,6% pour chaque médicament, (p <0,0001). Toutefois, l'ajout de nouveaux médicaments après le début de la TAE affectait négativement le RPM (0,3% de baisse en MPR pour chaque nouveau medicament ajouté, p <0,0001). Parmi les psychotropes, les antidépresseurs étaient le seul groupe qui a démontré un impact significatif, entraînant unediminution de 4,7% du RPM chez celles sur antidépresseurs avant le diagnostic et le traitement du cancer du sein (p = 0,003). Les patients sur tamoxifène, comparativement à ceux de l'anastrozole, avaient en moyenne un RPM inférieur de 6%, (p 0,002). Comparé à ceux qui n'ont jamais changé leur type de AET, ceux qui ont changé en début de traitement avaient un RPM plus faible de 5,3% (p = 0,003). D'autre part, celles ayant changé de type de TAE plus tard, avaient en moyenne un RPM supérieur de 7,4% (p <0,0001). CONCLUSION: La plupart des personnes âgées atteintes de cancer du sein hormonosensibl avaient une bonne adhérence à la TAE. Les patientes avec un âge plus avancé, une tumeur précoce, l'usage accru de services de santé, et les femmes traitées avec des antidépresseurs avant leur cancer du sein étaient plus à risque de adhérence sous-optimale

Delayed Guillain-Barré Syndrome after Bariatric Surgery: A Report of Three Cases

Surgeries carry a risk of complications. Polyneuropathies, including Guillain-Barré syndrome (GBS), are potential complications of bariatric surgery. The incidence of these conditions is expected to increase as these surgeries become increasingly popular. We present a case report of three patients who developed a polyneuropathy after bariatric surgery. GBS was diagnosed in each patient, with nutritional deficiencies being suspected as a contributing factor. All patients began a 5-day intravenous immunoglobulin course in addition to receiving rehabilitative support, multivitamins, intravenous thiamine, vitamin D (therapeutic dose), and selenium. The patients’ symptoms improved but did not completely resolve. GBS can be a complication of bariatric surgery. Although a clear cause-effect relationship cannot be established for the present cases, the cumulative literature on the subject suggests that it is important to include it as a potential risk when counseling patients for such surgeries

Surgical confidence when operating among residents in surgery – a cross-sectional study (SCAR study)

Abstract Background Self-confidence, is one of the critical variables influencing surgical resident’s abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it. Methods Cross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05. Results Response rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program. Conclusion The study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it’s important to recognize that confidence doesn’t necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit