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Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC. Patients diagnosed with metastatic CRC within NCDB from 2006-2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively. 128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy. Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

BackgroundPrior literature has demonstrated that bariatric surgery is a safe approach for patients with morbid obesity. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the relationship between BMI and risk of mortality using data obtained from a national database, with a special focus on patients with BMI ≥ 70.0 kg/m2. MethodsA retrospective cohort study of patients with morbid obesity (BMI ≥ 40 kg/m2) undergoing first-time bariatric surgery between 2015 and 2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome was intra-operative death or death within 30 days post-operatively. Patients were categorized into quartiles according to BMI. Multivariable analysis was performed to evaluate the association of BMI with risk of mortality. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively.ResultsA total of 463, 436 patients were included with a 30-day mortality rate of 0.11%. Mean BMI (SD) was 48.2 (7.3) kg/m2; 1.5% of patients had BMI ≥ 70.0 kg/m2. On multivariable analysis, highest quartile patients had a significantly higher risk of mortality than lowest quartile patients. For patients with BMI ≥ 70.0 kg/m2, the risk of mortality was more pronounced with an eightfold increase compared to the lowest quartile. In patients with BMI ≥ 70.0 kg/m2, although sleeve gastrectomy (SG) was the most common procedure, the risk of mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB).ConclusionsBMI is associated with increased risk of 30-day mortality. The effect of BMI is more pronounced in patients with BMI ≥ 70.0 kg/m2. In these patients, RYGB is associated with increased risk of mortality compared to SG.

Background An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. Materials and Methods We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. Results Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10 mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1 mg/dL and 14.9 mg/dL. Biliary decompression in patients with bilirubin ≥15 mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7 days vs. 17.2 days, P = .01). Discussion All patients presenting with bilirubin ≥15 mg/dL should undergo PBD, while those with bilirubin ≤10 mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9 mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

Serum carbohydrate antigen (CA19-9) is known to correlate with stage, resectability, and prognosis of pancreatic cancer. The goal of pancreaticoduodenectomy is to achieve an R0 resection because worse outcomes are reported in the presence of positive margins. The purpose of this study was to evaluate the predictive utility of CA19-9 for pancreaticoduodenectomy margin status. A retrospective review of patients with pancreatic adenocarcinoma undergoing pancreaticoduodenectomy between October 2007 and November 2018 at our institution was performed. Patient demographics, preoperative CA19-9, and tumor characteristics were analyzed. Univariate and mul-tivariate logistic regression was performed to determine factors associated with positive margins. A total of 184 patients were included. The mean age was 65 years; most patients were male and white. Majority had a positive preoperative CA19-9 (69%). There were nearly twice as many patients with negative as positive margins. Groups had similar demographics and preoperative CA19-9. A greater proportion of patients with negative margins had smaller tumors and early disease. On univariate and multivariate analysis, larger and higher stage tumors had greater odds of positive margins (P < 0.05). There was no significant association between margin status and preoperative CA19-9. Preoperative CA19-9 is not predictive of margin status. These results suggest that although preoperative CA19-9 values are associated with both resectability and prognosis, positive margins may not be a contributing mechanism.

BackgroundBlack patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC.Materials and methodsPatients diagnosed with metastatic CRC within NCDB from 2006-2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively.Results128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy.ConclusionBlack patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Background Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. Methods Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. Results Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black ( n  = 46), 48.2% rural ( n  = 54), 4.5% uninsured ( n  = 5), and 6.3% Medicaid-insured ( n  = 7) patients. Median visit time was 97 min (95% CI 70–107 min) before and 100 min after implementation (95% CI 75–119 min; p  = 0.95). In total, 95.5% ( n  = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. Conclusions Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.

Background Squamous cell carcinoma of the prostate (SCCP) is a neoplasm that comprises fewer than 1% of all primary prostate cancer diagnoses. Given its rarity, there is a paucity of data regarding the treatment of this disease. The limited literature points to the potential of local therapy in conjunction with chemotherapy to improve patient mortality. Methods Using the National Cancer Initiative's Surveillance, Epidemiology, and End Results (SEER) database, a retrospective review of patients diagnosed with primary SCCP between 2000 and 2018 was performed. Patient demographics, tumor characteristics, and patient outcomes based on treatment modality were analyzed. Univariate and survival analyses were conducted with p < 0.05 indicating statistical significance. Results A total of 66 patients were identified. Five‐year overall survival (5y OS) was 24%; mean and median survival were 2.2 years (1.8, 2.7) and 1.2 years (0.3, 2.1), respectively. Patients with Grade I or Grade II disease had an increased 5y OS of 55% (27%, 83%). In comparison, 5y OS was 13% (−2%, 29%) for patients with Grade III and Grade IV disease (p = 0.017). Analysis of 5y OS based on disease histology revealed patients with papillary SCC had a 5y OS of 50% [9.2%, 91%], compared to 21% [9%, 34%] for patients with SCC, not otherwise specified and 0% for those with lymphoepithelial carcinoma (p = 0.048). Analysis of 5y OS stratified by treatment modality revealed no statistically significant change with any treatment (surgery, radiotherapy, and chemotherapy). No difference in 5y OS was seen between those treated with radical prostatectomy versus external beam radiation therapy. Conclusions The literature on SCCP remains sparse; the rarity of this disease limits analysis. While the investigation undertaken in this paper does not find any change in 5y OS regardless of treatment modality, the variation in 5y OS based on histologic classification of SCCP points to a potential route for the future treatment of this disease.