Gastric Adenocarcinoma: A Multimodal Approach

Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies

Vulnerable hospitals and cancer surgery readmissions: Insights into the unintended consequences of the patient protection and affordable care act

© 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. Background Penalties from the Hospital Readmission Reduction Program can push financially strained, vulnerable patient-serving hospitals into additional hardship. In this study, we quantified the association between vulnerable hospitals and readmissions and examined the respective contributions of patient- and hospital-related factors. Methods A total of 110,857 patients who underwent major cancer operations were identified from the 2004-2011 State Inpatient Database of California. Vulnerable hospitals were defined as either self-identified safety net hospitals (SNHs) or hospitals with a high percentage of Medicaid patients (high Medicaid hospitals [HMHs]). We used multivariable logistic regression to determine the association between vulnerable hospitals and readmission. Patient and hospital contributions to the elevation in odds of readmission were assessed by comparing estimates from models with different subsets of predictors. Results Of the 355 hospitals, 13 were SNHs and 31 were HMHs. After adjusting for Hospital Readmission Reduction Program variables, SNHs had higher 30-day (odds ratio [OR] = 1.32; 95% CI, 1.18-1.47), 90-day (OR = 1.28; 95% CI, 1.18-1.38), and repeated readmissions (OR = 1.33; 95% CI, 1.18-1.49); HMHs also had higher 30-day (OR = 1.18; 95% CI, 1.05-1.32), 90-day (OR = 1.28; 95% CI, 1.16-1.42), and repeated readmissions (OR = 1.24; 95% CI, 1.01-1.54). Compared with patient characteristics, hospital factors accounted for a larger proportion of the increase in odds of readmission among SNHs (60% to 93% vs 24% to 39%), but a smaller proportion among HMHs (9% to 15% vs 60% to 115%). Conclusions Vulnerable status of hospitals is associated with higher readmission rates after major cancer surgery. These findings reinforce the call to account for socioeconomic variables in risk adjustments for hospitals who serve a disproportionate share of disadvantaged patients

Hospital-level resource use by the oldest-old for pancreaticoduodenectomy at high-volume hospitals

© 2015 Elsevier Inc. All rights reserved. Introduction Owing to limited data on hospital resources consumed in caring for the oldest-old, we examined the use of pancreaticoduodenectomy (PD)-relevant hospital resources in patients of increasing age treated in high-volume hospitals participating in the University HealthSystem Consortium. Methods Perioperative outcomes, resource use, and direct costs were compared across increasing age groups in 12,766 PDs (\u3c70 years, n = 8,564; 70-79 years, n = 3,302; ≥ 80 years, n = 900) performed in 79 high-volume hospitals between 2010 and 2014. Linear regression models with and without covariate adjustments were used to assess the impact of older age. Results The oldest-old experienced fewer readmissions and had equivalent intensive care unit use and mortality rates compared with both younger cohorts. However, those ≥ 80 years experienced more complications, blood transfusions, greater total parenteral nutrition (TPN) use, longer duration of stay, and higher direct hospital costs compared with those \u3c70 years No differences were found between patients ≥ 80 years and those 70-79 years with respect to the administration of blood products, TPN, or the direct cost of PD. Conclusion Our findings suggest the ability to deliver quality pancreatic surgical care to an aging population without strong associations to increased resource utilization. As the number of octogenarians undergoing PD continues to grow, the impact of this technically complex procedure on other important cancer care metrics, including patient-reported outcomes and quality of life, requires further assessment

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals

© 2017 American College of Surgeons Background The Affordable Care Act\u27s Medicaid expansion has been heavily debated due to skepticism about Medicaid\u27s ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure. Study Design We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion. Results Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p \u3c 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p \u3c 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion. Conclusions Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized

Emergence of imatinib resistance associated with downregulation of c-kit expression in recurrent gastrointestinal stromal tumor (GIST): optimal timing of resection

Gastrointestinal stromal tumors (GISTs) are the most common gastrointestinal mesenchymal tumors. The activating mutation in the KIT (c-kit; CD117) proto-oncogene with subsequent tyrosine kinase activation plays a central role in the pathogenesis of GIST. Tyrosine kinase inhibitors are an integral part of GIST therapy. Initial response to neoadjuvant imatinib can be expected in up to 70% of the patients, thus offering an opportunity to surgically treat those with locally advanced primary or recurrent GIST. This favorable response to imatinib, however, is plagued with development of secondary resistance during the course of therapy. We herein report a case of recurrent locally advanced GIST in an elderly man, with excellent performance status, successfully managed with the integration of neoadjuvant targeted therapy and surgery. Continued monitoring by a multidisciplinary team, including a surgeon, is vital for the success of neoadjuvant imatinib therapy for unresectable primary or recurrent GIST in the context of emergence of secondary resistance. As such, surgeons should participate in managing imatinib-treated GIST, as resection may become a viable curative option. This case also highlights that major oncologic resections can be safely performed in older persons when their performance status and comorbidities are carefully considered

Medicaid beneficiaries undergoing complex surgery at quality care centers: Insights into the Affordable Care Act

© 2016 Elsevier Inc. All rights reserved. Background Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. Methods Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. Results A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). Conclusions Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries