Palliative care for patients with gastrointestinal cancer dying under surgical care: A case for acute palliative care units?

Background and aimsPatients with advanced gastrointestinal cancer may present late to hospital services and die under surgical care. The aim of this study was to examine end of life care in patients dying of gastrointestinal cancer in Scottish hospital surgical wards.MethodsThe Scottish Audit of Surgical Mortality prospectively peer reviews all inpatient deaths under the care of a consultant surgeon. Patients who died with gastrointestinal cancer under surgical care from 1994 to 2006 were evaluated for operative interventions, adverse events, and palliative care provision. Data was compared with inpatient data from the Information Statistics Division of NHS Scotland.ResultsA total of 8019 patients died with gastrointestinal cancer on a surgical ward over 12 years. For 4350 (54%), no operation or endoscopy was performed during the final admission and adverse events were identified in only 86 (2%) of these patients, most commonly due to a complication of an interventional procedures. Specialist palliative care was provided to 57% of patients and was not influenced by cancer site.ConclusionA substantial proportion of patients die with gastrointestinal cancer on general surgical wards without operative or endoscopic intervention and may receive better end of life care in an acute palliative care setting.     

Characteristics and follow-up of metastatic breast cancer in Ethiopia: A cohort study of 573 women

ObjectivesThere is little information on characteristics, treatment and outcome of metastatic breast cancer (mBC) patients in low-income countries. This study aims to describe mBC in the setting of Ethiopia.Materials and MethodsA retrospective cohort study was conducted among all female mBC patients from the only oncologic hospital in Addis Ababa 01/2006 to 12/2010. Time between first metastasis and known death or loss to follow-up for more than six months as surrogate for death were used for Cox proportional hazards model.ResultsA total of 573 patients were included; 188 (32.8%) women with de novo mBC (dnmBC) and 385 women with recurrent mBC (rmBC). The average age at time of first metastasis was 43.7 (standard deviation 11.9) years with an average survival probability of twelve months. Negative hormone receptor status, only present in 29% (Hazard ratio HR = 2.28 [95% confidence interval CI 1.56–3.32] p < 0.001), and grade 3 (HR = 1.72 [95% CI 1.15–2.55] p = 0.008) had significant influence on survival. Patients with initial bone metastasis (HR = 0.63 [95% CI 0.48–0.83] p = 0.001) had best chances of survival compared to more common initial visceral metastasis. About 35% of the patients received chemotherapy and 30.5% were on endocrine therapy.ConclusionThe lower survival for mBC in Addis Ababa compared to that from Western countries is presumably due to the later presentation at the hospital and lack of standard therapy. An unexpected high proportion of patients with hormone receptor positive mBC encourage consequent utilization of endocrine therapy to improve the quality of palliative care in this cohort.     

COVID-19 in Kidney Transplant Patients From a Large UK Transplant Center: Exploring Risk Factors for Disease Severity

BackgroundThe novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised concern for the health of immunocompromised individuals, who are potentially at higher risk of more severe infection and poorer outcomes. As a large London transplant center serving a diverse patient population, we report the outcomes of SARS-CoV-2 infection in our cohort of 2848 kidney and/or pancreas transplant patients.MethodsData were obtained retrospectively for all transplant patients who attended hospital during the peak of the pandemic and had a positive nasopharyngeal SARS-CoV-2 test.ResultsSixty-six patients were found to be positive for SARS-CoV-2. Twenty percent were treated as outpatients, 59% were admitted to the general ward, and 21% required intensive care. Treatment consisted of reduced immunosuppression, antibiotics for pneumonia or sepsis, and other supportive treatments. Within our cohort, 12 patients died (18%), with an overall mortality of 0.4%. Predictive risk factors for COVID-19 severity were explored.ConclusionsSevere disease was associated with lower hemoglobin prior to COVID-19 diagnosis and lower lymphocyte count at the time of diagnosis but not age, sex, ethnicity, or preexisting comorbidities. Lower glomerular filtration rate and higher C-reactive protein were associated with more severe disease. Despite no use of hydroxychloroquine, azithromycin, antiviral, or immunomodulatory medications, our mortality rate (kidney and pancreas transplant patients) is similar to current international rates.     

Increased mortality after anterior shoulder dislocation: 255 patients aged 12–40 years followed for 25 years

Background?No data exist regarding mortality rate in young patients with a first–time anterior shoulder dislocation. A cohort of 255 patients aged 12–40 years had a primary anterior shoulder dislocation during the years 1978 and 1979. After 10 years, 9 of the patients had died—which is a high figure for this cohort of patients. The question thus arose as to whether these patients had an increased mortality rate. In this study we have examined the mortality rate in these patients 25 years after the primary dislocation, relative to that of the Swedish population in general.

Patients and methods?In 1978 and 1979, 255 patients aged 12–40 years (257 shoulders) with first–time anterior shoulder dislocation were treated with or without immobilization. During 2003 and 2004, a follow-up of all patients who were alive was undertaken and the certificates of causes of death of 27 deceased patients were also analyzed.

Results?The mortality rate (SMR) for the patients in this study was more than double that of the general Swedish population (p < 0.001). A higher proportion of the deceased patients had etiology other than sportsrelated activity as a cause of their initial dislocation (p = 0.04). 11 of the 27 who were deceased had died from injury or intoxication (S00–T98, ICD10), which was more than expected relative to the causes of death for the general Swedish population in 2003 and 2004 (p < 0.001)

Interpretation?The doubled mortality rate in our cohort of patients is most probably explained by the inclusion of a disproportionate number of patients with alcoholic behavior, which may affect the long-term outcome in trauma series.     

Palliative resections versus palliative bypass procedures in pancreatic cancer--a systematic review

BackgroundAlthough resection is the only treatment option that offers a chance for prolonged survival in pancreatic cancer, R2 resections are controversial and not a generally accepted approach.MethodsA systematic review and meta-analysis of studies of patients with pancreatic cancer was performed to analyze R2 resections in comparison with palliative surgical bypass procedures. Trials were identified by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to February 2011.ResultsFour cohort studies were identified comparing 138 patients with R2 resections with 261 patients undergoing surgical bypass procedures. Morbidity and mortality were increased in the R2 resection group, with pooled risk ratios of 1.75 (95% confidence interval [CI], 1.35–2.26; P < .0001) and 2.98 (95% CI, 1.31–6.75; P = .009), respectively. R2 resections were associated with longer operating times (mean difference, 164 minutes; 95% CI, 127–201 minutes; P < .00001) and hospital stays (mean difference, 5 days; 95% CI, 1–9 days; P = .02). Pooled median survival times were 8.2 months for R2 resection and 6.7 months for palliative bypass procedures.ConclusionsPlanned palliative R2 resections are not justified in patients with pancreatic cancer.     

Manejo multidisciplinar y optimización del paciente oncofrágil o de elevado riesgo quirúrgico en cirugía del cáncer colorrectal. Análisis observacional prospectivo

IntroductionFrailty is associated with greater postoperative morbidity and mortality. Individualized multidisciplinary management of these patients can improve the quality of care. The objectives of this study are to determine the percentage of frail patients with colorectal cancer in our population, and to describe the morbidity and mortality associated with surgery and the evolution of palliative treatment.MethodsA prospective, observational study of patients with surgical colorectal cancer (February 1, 2018-April 30, 2019). Frail patients were screened and classified according to degrees of frailty. Therapeutic decision-making (surgery or palliative treatment) was determined by the degree of fragility and explicit will of the patient. Postoperative comorbidities were analyzed (according to Clavien-Dindo and Comprehensive Complication Index), as were mortality and oncological follow-up.ResultsThe study included 193 patients with surgical colorectal cancer, with a mean age of 74 years (44-92). Screening identified 46 frail patients (24%), with a mean age of 80 years (57-92). Twenty-two patients were optimized and underwent surgery (48%), with a mean age of 78 years (57-89). Relevant adverse effect rate was 27.7% (4 grade iva adverse effects, one ivb and one v, according to Clavien-Dindo). Comprehensive Complication Index was 17.5. Palliative treatment was administered in 24 patients (52%), with a mean age of 82 years (59-92). Mean follow-up was 7.8 months. There were 2 deaths due to disease progression (8.3%), 5 re-consultations due to complications of colorectal cancer (20.1%).ConclusionsThe multidisciplinary and individualized management of frail patients with colorectal cancer is key to improve the quality of care in the treatment of this patient group.     

Palliative care knowledge,attitudes, and experiences amongst patients with bladder cancer and their caregivers

ObjectivesPalliative care is underutilized amongst patients with bladder cancer despite guideline recommendations and known benefits. In order to uncover potential access barriers, we sought to describe patient and caregiver knowledge, attitudes and experiences surrounding palliative care.MethodsWe surveyed 272 patients with bladder cancer and their caregivers through the Bladder Cancer Advocacy Network Patient Survey Network. In addition to collecting demographic, socioeconomic, and clinical characteristics, previously studied and validated questionnaires on palliative care knowledge and beliefs were administered. Patients and caregivers were also queried regarding their experiences with palliative care consultation.ResultsSurvey respondents demonstrated highly accurate knowledge of palliative care services. Attitudes and beliefs surrounding palliative care were overall positive. Caregivers demonstrated better knowledge and more positive beliefs of palliative care compared to patients. Despite an overall positive sentiment toward palliative care, only 9% of the cohort had palliative care consultation as part of their cancer treatment plan. Most patients with muscle-invasive or metastatic bladder cancer wished that palliative care had been discussed by their providers.ConclusionsA subset of bladder cancer patients possess accurate knowledge and positive beliefs of palliative care. Palliative care is infrequently discussed during the treatment of bladder cancer, with patients and their caregivers expressing desire for palliative care to be discussed more often. Provider education surrounding palliative care services is imperative to improving access for bladder cancer patients and caregivers.     

Characterization of clinical course and usual care patterns in female metastatic breast cancer patients treated with zoledronic acid

PurposeTo describe usual care received by women with bony metastatic breast cancer (ICD-9: 174.xx and 198.5) treated in a United States specialty cancer hospital, an Electronic Medical Record (EMR)-based retrospective review identified 111 deceased female breast cancer patients ≥18 years of age treated with zoledronic acid (ZOL).ResultsBaseline symptoms included bone pain/fracture (58.6%), breathing difficulties (24.3%), or mental status changes (11.7%). ZOL was started at/after metastatic diagnosis for 75.7% of women (N = 84), with average administration of 15.9 months (median 11.3). Nearly 20% required reduced ZOL doses, most (54.5%) due to impaired renal function; 61.3% discontinued ZOL due to patient death/disease progression. Adverse events were reported in 10.8%, while 0.9% (N = 1) had a documented osteonecrosis of the jaw.ConclusionsInitiation of palliative care should be considered early in patients with a history of metastatic breast cancer who report bone pain or other skeletal-related events.     

A Prospective Evaluation of Palliative Outcomes for Surgery of Advanced Malignancies

Background: We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.Methods: Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.Results: Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients.Conclusions: Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.     

Endoscopic palliative treatment for esophageal and gastric cancer: techniques,complications, and survival in a population-based cohort of 948 patients

Background Under the auspices of the Scottish Audit of Gastric and Esophageal Cancer, we investigated treatment techniques, complications, and survival in a population-based cohort of patients undergoing endoscopic palliative therapy for esophageal or gastric cancer.Methods A total of 948 patients undergoing endoscopic palliative therapy were identified prospectively and followed for a minimum of 1 year.Results Expandable metal stent placement (506 patients) and LASER (117 patients) were the most frequently used treatment options. Stent placement was more common for grade 3 or 4 dysphagia. Delivery of endoscopic palliative therapy varied by region of residence (from 18% to 38% of patients, p < 0.001) but not by deprivation category. Complications were recorded in 16% of patients (155 of 948). Overall survival was 40% (95% confidence interval [CI], 36–43) at 6 months, 17% (95% CI, 14–19) at 12 months, and 10% (95% CI, 8–12%) at 18 months.Conclusions These data define the reality of endoscopic palliative therapy for patients with advanced esophageal or gastric cancer and provide a baseline against which future improvements in care can be measured.     

Patterns of health care use of injured adults: A population-based matched cohort study

BackgroundHealthcare use by traumatically injured individuals prior to and subsequent to their injury are not often explored for different types of injuries. This study aims to describe health care use 12 months preceding and 12 months following a traumatic injury by injury type and injury severity.MethodHospital and mortality data from three Australian states were linked in a population-based matched cohort study. Individuals ≥18 years who had an injury-related hospital admission in 2009 were identified as the injured cohort. A comparison cohort of non-injured people, matched 1:1 on age, gender and postcode of residence, was randomly selected from the electoral roll. Twelve-month pre- and post-index injury health service use was examined. Rates, adjusted rate ratios and attributable risk proportions were calculated by injury type and severity.ResultsThe injury cohort experienced higher 12-month pre- and post-injury hospital admissions than the non-injured group. By 6 to 7 months post-injury, the injury cohort had largely returned to their pre-injury health service use levels, except for injuries involving dislocations, sprains and strains and injury to nerves and spinal cord. Hip fracture (17.69 per 100 person-months) and poisoning (16.09 per 100 person-months) had the highest rates of post-injury hospitalisation in the injured cohort. The adjusted rate ratios (ARR) for post-injury hospitalisation were highest for poisoning (ARR: 3.77; 95% CI: 3.38–4.21) and injury to nerves and spinal cord (ARR: 2.73; 95% CI: 2.27–3.28). Poisoning also had the highest ARR for post-injury LOS (ARR: 5.31; 95% CI: 4.51–6.27).ConclusionsAfter sustaining a traumatic injury, many individuals are readmitted to hospital and require ongoing care up to 12 months post-injury. That injured individuals post-injury largely return to their pre-index injury hospital use by 6 to 7 months could imply a return to pre-injury function and/or that other measures of health service use should be explored. Trauma services should consider long-term follow-up and support services for seriously injured patients post-hospital discharge.     

Concurrent urologic and palliative care after cystectomy for treatment of muscle-invasive bladder cancer

PurposeTo characterize the effect of palliative care provided concurrently with usual urologic care for patients with bladder cancer undergoing cystectomy.Materials and methodsProspective, 6-month, serial cohort study comparing 33 participants receiving usual care with cystectomy for muscle-invasive bladder cancer, with 30 participants also receiving concurrent palliative care. Patients and family caregivers completed validated symptom assessment and satisfaction surveys preoperatively and at 2, 4, and 6 months postoperatively.ResultsThe intervention group saw improvements in most symptom measures over the 6 months following cystectomy compared with the control group. Depression and anxiety decreased over the 6-month period for the intervention group patients but increased over this time among the controls (P = 0.01). Fatigue decreased to a minimum for the intervention group participants at 4 months, whereas it peaked at this time for control participants (0.002). Quality-of-life and posttraumatic growth scores followed a similar pattern, with scores peaking at 4 months for the intervention group whereas controls reported their lowest scores at this time (P = 0.01 and P = 0.03, respectively). Changes in pain scores did not reach statistical significance. Neither family caregiver burden nor patient satisfaction showed statistically significant changes over time.ConclusionsPatients who received concurrent palliative care in addition to usual urologic care following radical cystectomy for muscle-invasive bladder cancer had better outcomes, including improved fatigue, depression, quality of life, and posttraumatic growth. Although further research on this topic is needed, our results suggest that providing palliative care services in addition to usual urologic care for patients with bladder cancer may significantly reduce postoperative symptoms.     

Palliative care use among bladder cancer patients treated with radical cystectomy

IntroductionPractice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution.MethodsA retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model.ResultsOver the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025).ConclusionRates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.     

Fall Risk Identification Throughout the Continuum of Care for Elderly Trauma Patients: An Injury Prevention Initiative

IntroductionFalls are the second leading cause of trauma-related deaths worldwide. Identifying fall risk patients and initiating interventions reduces injuries and mortality, particularly in the elderly. The primary aim of this retrospective study was to identify missed opportunities for fall risk identification and intervention for geriatric trauma patients.Patients and methodsIn this retrospective observational cohort study, the trauma registry was queried to identify geriatric patients admitted for a fall over 36 months. The electronic medical record (EMR) was reviewed to evaluate patients’ fall risk in the 12 months prior to the index fall admission. The EMR was also queried for repeat falls within 12 months after discharge, and to determine if fall prevention education was provided at discharge.Results597 patients met inclusion criteria; 68.3% were female. 64.7% were at risk for falling in the year before admission. 2% had documented fall prevention education at discharge. 32% of patients fell again within a year of discharge and 19.4% were readmitted for a repeat fall. Patients at high risk for falls (on the Hester-Davis scale) were significantly more likely to be readmitted (p = 0.005) and expire within six months (p = 0.033) than moderate risk patients. Mortality at 12 months post-admission for all patients was 19.4%.ConclusionThis large study demonstrated that geriatric trauma patients admitted for a fall were already at risk for falling in the 12 months prior to admission. This is a novel finding that presents a substantial prevention opportunity for healthcare systems. Education and implementation of proven techniques to prevent falls as soon as at-risk patients are identified has the potential to change the course for a patient who may not only fall, but also fall again. This proactive approach could significantly impact the fall epidemic in our elderly population.     

Surgical outcomes in children with Trisomy 13: An ACS NSQIP – Pediatric review

BackgroundTrisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls.MethodsUsing the ACS NSQIP Pediatric 2012–2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity.ResultsThe median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87–1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28–8.61, p<0.001).ConclusionsWe conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.     

Obesity is Associated with Worse Outcomes Among Abdominal Trauma Patients Undergoing Laparotomy: A Propensity-Matched Nationwide Cohort Study

Introduction

Obesity is associated with increased morbidity and mortality in abdominal trauma patients. The characteristics of abdominal trauma patients with poor outcomes related to obesity require evaluation. We hypothesize that obesity is related to increased mortality and length of stay (LOS) among abdominal trauma patients undergoing laparotomies.

Methods

Abdominal trauma patients were identified from the National Trauma Data Bank between 2013 and 2015. Patients who received laparotomies were analyzed using propensity score matching (PSM) to evaluate the mortality rate and LOS between obese and non-obese patients. Patients without laparotomies were analyzed as a control group using PSM cohort analysis.

Results

A total of 33,798 abdominal trauma patients were evaluated, 10,987 of them received laparotomies. Of these patients, the proportion of obesity in deceased patients was significantly higher when compared to the survivors (33.1% vs. 26.2%, p < 0.001). Elevation of one kg/m² of body mass index independently resulted in 2.5% increased odds of mortality. After a well-balanced PSM, obese patients undergoing laparotomies had significantly higher mortality rates [3.7% vs. 2.4%, standardized difference (SD) = 0.241], longer hospital LOS (11.1 vs. 9.6 days, SD = 0.135), and longer intensive care unit LOS (3.5 vs. 2.3 days, SD = 0.171) than non-obese patients undergoing laparotomies.

Conclusions

Obesity is associated with increased mortality in abdominal trauma patients who received laparotomies versus those who did not. Obesity requires a careful evaluation of alternatives to laparotomy in injured patients.

     

Competing mortality risk from second primary malignancy in bladder cancer patients following radical cystectomy: Implications for survivorship

IntroductionMuscle-invasive bladder cancer (BC) often occurs in patients with competing mortality risks, while also being associated with the highest rate of second primary nonurothelial cancers (SNUC) of all solid malignancies. We investigated the incidence, risk factors, and timing of SNUC as a competing mortality risk factor in patients with BC who were treated with curative intent radical cystectomy (RC).MethodsWe performed a retrospective cohort study assessing patients who underwent RC for cT2-4 N0M0 BC from January 1, 2005 to December 31, 2018 at a single, high volume tertiary care referral center. The Fine–Gray multivariable regression model was used to evaluate predictive factors for SNUC. Cumulative incidence of mortality (CIM) was estimated with modified Kaplan–Meier analysis.ResultsThe median follow-up time for the 693 patients who underwent RC was 3.7 years (interquartile range [IQR] 1.9–5.9 years). SNUC developed in 85 (12.3%) patients at a median 3.0 years post-RC (IQR 1.2–5.5 years). On multivariable analysis, the only significant predictor for developing SNUC was freedom from BC recurrence or metastasis (HR 1.54, 95% CI 1.12–1.76, P = 0.019). The most common SNUCs were primary lung cancer (24, 3.2% of cohort) and colon cancer (9, 1.3% of cohort). BC surveillance imaging diagnosed SNUC in 35/52 (67.3%) patients with solid-organ visceral primaries. The overall mortality rate for any SNUC was 38.8%, with the 3 most lethal cancer types being pancreatic, lung, and colon (62.5%, 54.2%, and 44.4% mortality, respectively). The incidence of SNUC uniformly increased postoperatively, with a cumulative incidence of 22.1% (95% CI, 16.8–27.9%) at 12-years post-RC. 163 patients (23.5%) died from BC, 33 patients (4.8%) died from SNUC, and 94 patients (13.6%) died from other causes. While the CIM for BC plateaued around 5-years post-RC at 24%, the incidence of other-cause mortality uniformly rose throughout the postoperative period. By post-RC year 9 there was no significant difference in CIM between BC (CIM 27.2%, 95% CI, 23.5–31.1%) and other-causes (CIM 20.0%, 95% CI, 15.8–24.6%).ConclusionsThe cumulative incidence of SNUC at 12-years post-RC was 22%, with the majority identified on BC surveillance imaging. While BC mortality plateaued around 5-years post-RC, mortality related to SNUC or other causes rose steadily in the postoperative period. These data have clinical significance with regards to patient counseling, survivorship and oncologic surveillance in the highly comorbid muscle-invasive BC population.     

Surgical therapy for epidermoid carcinoma of the anal canal: An NSQIP assessment of short-term outcomes

BackgroundAlthough modern therapy for anal canal cancer typically consists of combined chemoradiation therapy (CRT), surgery remains an option for patients with small lesions, for palliative purposes, and for failure of nonoperative management. This study assesses the short-term outcomes of surgical management for epidermoid carcinoma of the anal canal using a large nationwide database.MethodsWe performed a retrospective review of 30-d outcomes using American College of Surgeons National Surgical Quality Improvement Program database (2005–2009) for all patients with the primary diagnosis of anal canal cancer undergoing oncologic or palliative surgery. We defined preoperative CRT using standard National Surgical Quality Improvement Program time frames of 30 and 90 d, respectively, before surgery.ResultsWe identified 295 patients (mean age, 58.6 y; 54% female; 77% white). A total of 34 patients received prior CRT and had age, body mass index, American Society of Anesthesiologists class, and preoperative laboratory values similar to those without CRT; the only significant differences was a lower hematocrit and platelet count in the CRT group. For the entire cohort, 30% (N = 89) underwent local excision (LE), 24% (N = 71) diversion, and 46% (N = 135) abdominoperineal resection (APR). Complications occurred in 23.7% of the entire cohort, and overall complication rates significantly differed based on the type of procedure [3.4% for LE and 18.3% for diversion, versus 40% for APR (P < 0.001)]. Only operative approach significantly affected morbidity, as patients receiving APR had a 1.67-fold (range, 1.14–2.45; P = 0.008) increased risk of complications. The 30-d mortality for the entire cohort was 2.7%, and was highest in the diversion group (7%) compared with the APR (1.5%) and local excision groups (1.1%; P = 0.036). However, by multivariate analysis, the only factors associated with death were preoperative sepsis (hazard ratio [HR] = 27.5; P = 0.005), lack of functional independence (HR = 26.3; P = 0.001), hypertension (HR = 14.4; P = 0.028), and prior alcohol use (HR = 21.4; P = 0.026). Chemoradiation therapy use did not have a significant effect on complication (36.0% versus 40.9%; P = 0.651) or mortality rates (0% versus 1.8%; P = 0.497).ConclusionsSurgical intervention for anal canal cancer remains a necessary option for select patients. Morbidity rates vary significantly based on the type of treatment; operative approach is the primary factor associated with postoperative short-term complications. When surgery is required, recent CRT is not associated with a higher complication rate. With proper perioperative care and surgical technique, mortality rates remain low, and the increased death rate with diversion, even in the short term, likely represents advanced disease.     

Surgery as a Bridge to Palliative Chemotherapy in Patients with Malignant Bowel Obstruction from Colorectal Cancer

Background Malignant bowel obstruction (MBO) is a feature of the clinical course of 10–28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. Methods Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. Results Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). Conclusion Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival. Dr. Calvin Law is a Career Scientist of the Ontario Ministry of Health and Long Term Care and is supported through a Health Research Personnel Development—Career Scientist Award.