Background: Melanoma is amongst the malignancies with the greatest annual increase in incidence. The prognosis for melanoma is partially dependent on lymph node status. Staging of lymph node basins in patients without clinical evidence of lymphadenopathy is typically by sentinel lymph node (SLN) biopsy. In this study, we sought to determine factors associated with the number of sentinel lymph nodes examined. Methods: The National Cancer Database Participant User File from 2018 to 2020 was queried for clinical node negative patients who underwent sentinel lymph node biopsy. Descriptive statistics were obtained. Stepwise negative binomial regression analysis was performed in addition to ANOVA, chi-squared and Student's t-tests. Results: We identified 32,516 clinically node negative patients with melanoma from 2018 to 2020 who had undergone sentinel lymph node biopsy. Using a stepwise negative binomial model, male patients had a 3.8 % increase in the number of SLNs examined compared to females, while each year of age predicted a 0.3 % decrease in the number of SLNs examined. Breslow thickness > 2 mm was associated with a 6.9 % increase in SLN examined. Primary sites with multiple potential lymphatic drainage basins including ear, lip, scalp & neck, and trunk were associated with a 55.2 %, 29.6 %, 46.6 %, 43.4 % increase in SLNs examined, respectively. The study did not identify a difference in overall survival based on the number of lymph nodes examined (p = 0.25). Conclusion: The number of sentinel lymph nodes examined in melanoma patients is associated positively with younger age, male sex, Breslow thickness, and primary site. Synopsis: A National Cancer Database study of sentinel lymph node biopsy yield in clinically node-negative melanoma patients showed association with age, sex, Breslow thickness, and primary site. Clinicopathologic factors were predictive of sentinel lymph node yield, indicating other influences rather than objective sentinel lymph node criteria on node biopsy.

INTRODUCTION:Gender disparities exist in nonresearch industry payments to U.S. physicians, but detailed analyses specific to surgeons are limited. This study aims to investigate the gender pay gap in industry general nonresearch payments made to U.S. general and fellowship-trained surgeons between 2016 and 2022. METHODS:Data on industry payments to U.S. surgeons were collected from the open payments database. General and fellowship-trained surgeons were included. Gender prediction was conducted using an artificial intelligence tool. Payment type, amount, and company were summarized. Gender differences were compared. RESULTS:Between 2016 and 2022, the medical and device industry made 1,998,110 payments totaling $739,264,940 to U.S. general and fellowship-trained surgeons. The median payment was $31, primarily for food and beverages. Surgeons receiving over $5000 annually accounted for $634,530,579 (86%). Most payments were device-related (92%). Intuitive ($199M), Medtronic ($57M), and Boston Scientific ($46M) were the top-paying companies. California received the highest payments ($90M). Payments peaked in 2019 before falling due to the COVID-19 pandemic. Men were paid significantly more than women, with an average $16,509 annual pay gap favoring men (P < 0.001). In 2019, the industry paid men $44,025 on average, compared to $16,677 for women. CONCLUSIONS:Among U.S. general and fellowship-trained surgeons, there is a gender pay gap in industry general payments, where males receive higher compensation for nonresearch-related reasons. Understanding the factors contributing to this disparity, such as differential access to industry opportunities and potential biases in compensation negotiations, is crucial for promoting equity in industry relationships.

INTRODUCTION:International medical graduates (IMGs) make up a small but important percentage of the U.S. surgical workforce. Detailed and contemporary studies on IMGs matching into U.S. general surgery residency positions are lacking. Our objective was to study these trends over a 30-y period. METHODS:We utilized the National Resident Matching Program reports from 1994 to 2023 to analyze the trends of U.S. M.D. seniors, D.O. seniors, and U.S. citizen and non-U.S. citizen IMGs matching into first-year categorical and preliminary general surgery residency positions. The percent of positions filled were calculated and trended over time using linear regression, where β coefficient estimated the percentage of annual change in matched positions, and the R2 coefficient measured the amount of variance explained (perfect regression R2 = 1.0). RESULTS:Over the last 30 y, IMG match percentages have increased for both categorical (β = 0.218%, R2 = 0.49, P < 0.001) and preliminary (β = 0.705%, R2 = 0.76, P < 0.001) general surgery positions, with a greater increase in preliminary positions (β = 0.705%). The percentage of positions filled by M.D. U.S. seniors in categorical positions has steadily decreased over the 30-y period (β = -0.625%, R2 = 0.79, P < 0.001), and this decrease has largely occurred with a concurrent greater increase in U.S. D.O. seniors match percentage rates (β = 0.430%, R2 = 0.64, P < 0.001), rather than IMGs (β = 0.218%). Allopathic M.D. U.S. seniors preliminary match percentages have steadily decreased at the steepest rate (β = -0.927%, R2 = 0.80, P < 0.001). In categorical positions, non-U.S. citizen IMGs' match percentages (β = 0.069%, R2 = 0.204, P = 0.012) increased at a slightly slower rate than U.S. citizen IMGs (β = 0.149%, R2 = 0.607, P < 0.001). In preliminary positions, non-U.S. citizen IMGs' match percentages (β = 0.33%, R2 = 0.478, P < 0.001) increased at a similar rate as U.S. citizen IMGs (β = 0.375%, R2 = 0.823, P < 0.0.001). In the 2023 National Resident Matching Program match, U.S. citizen and non-U.S. citizen IMGs together made up 10.3% of the categorical and 44.5% of the preliminary general surgery positions that were filled. For categorical positions in 2023, there was no major difference between positions matched by U.S. citizen IMGs (4.62%) and non-U.S. citizen IMGs (5.72%); on the other hand, for preliminary positions in 2023, non-U.S. citizen IMGs (31.96%) filled 2.5× times the number of positions as U.S. citizen IMGs (12.54%). CONCLUSIONS:Over the last 30 y, U.S. allopathic M.D. seniors matching into categorical general surgery positions have steadily decreased, while both U.S. osteopathic D.O. seniors and IMGs matching have increased. These data have important implications for the future U.S. surgical workforce.

Introduction The management of many patients with early-stage melanoma includes sentinel lymph node (SLN) biopsy for prognostic and treatment planning purposes. While the minimum necessary number of SLNs to examine has been determined for patients with other malignancies, it has not been delineated in melanoma. The current study evaluates risk factors for SLN positivity and the associated number of SLNs that are necessary to examine for appropriate staging. Materials and methods The National Cancer Database participant user file from 2018 to 2020 was queried for clinically node-negative patients who underwent SLN biopsy. Descriptive statistics were obtained. Analysis of variance statistical analyses were performed. Results Eight thousand forty eight melanoma patients out of 48,748 were identified from 2018 to 2020 that had lymph node positivity on SLN biopsy. The median age of patients was 64. The male-to-female ratio was 1.47. Chi-squared analysis revealed that there was a statistically significant difference in positivity rate between at least two groups (P = 0.006) for primary melanoma site, male sex (P < 0.01), race, age, histologic type, Breslow thickness, and lymphovascular invasion (P < 0.001). SLN positivity rate increased with the number of SLNs examined until plateauing at 4 SLNs. There was no statistical difference between positivity for 3 SLNs and larger numbers of SLNs examined. Propensity matching revealed no statistically significant difference in positive rate when more than 2 SLNs were biopsied. Conclusions SLN positivity is proportionally related to the number of SLNs examined, suggesting that surgeons should attempt to remove a minimum of 2 SLNs for the optimal staging of patients with melanoma.

Objective: To characterize industry non-research payments made to general and fellowship-trained surgeons between 2016-2020. Background: The Centers for Medicare & Medicaid Services Open Payments Data (OPD) reports industry payments made to physicians related to drugs and medical devices. General payments are those not associated with research. Methods: OPD data were queried for general and fellowship-trained surgeons who received general payments from 2016 to 2020. Payments’ nature, amount, company, covered product, and location were collected. Surgeons’ demographics, subspecialty, and leadership roles in hospitals, societies, and editorial boards were evaluated. Results: From 2016 to 2020, 44,700 general and fellowship-trained surgeons were paid $535,425,543 in 1,440,850 general payments. The median payment was $29.18. The most frequent payments were for food and beverage (76.6%) and travel and lodging (15.6%); however, the highest dollar payments were for consulting fees ($93,128,401; 17.4%), education ($88,404,531; 16.5%), royalty or license ($87,471,238; 16.3%), and travel and lodging ($66,333,149; 12.4%). Five companies made half of all payments ($265,654,522; 49.6%): Intuitive Surgical ($128,517,411; 24%), Boston Scientific ($48,094,570; 9%), Edwards Lifesciences ($41,835,544, 7.8%), Medtronic Vascular ($33,607,136; 6.3%), and W. L. Gore & Associates ($16,626,371; 3.1%). Medical devices comprised 74.7% of payments ($399,897,217), followed by drugs and biologicals ($33,945,300; 6.3%). TX, CA, FL, NY, and PA received the most payments; however, the top dollar payments were in CA ($65,702,579; 12.3%), MI ($52,990,904, 9.9%), TX ($39,362,131; 7.4%), MD ($37,611,959; 7%), and FL ($33,417,093, 6.2%). General surgery received the highest total payments ($245,031,174; 45.8%), followed by thoracic surgery ($167,806,514; 31.3%) and vascular surgery ($60,781,266; 11.4%). A total of 10,361 surgeons were paid >$5,000, of which 1,614 were women (15.6%); in this group, men received higher payments than women (means, $53,446 vs. $22,571; P<0.001) and thoracic surgeons received the highest payments (mean, $76,381; NS, P=0.14). A total of 120 surgeons were paid >$500,000 ($203,011,672; 38%) – 5 non-Hispanic white (NHW) women (4.2%) and 82 NHW (68.3%), 24 Asian (20%), 7 Hispanic (5.8%), and 2 Black (1.7%) men; in this group, men received higher payments than women (means, $1,735,570 vs. $684,224), and NHW men received payments double those of other men (means, $2,049,554 vs. $955,368; NS, P=0.087). Among these 120 highly paid surgeons (>$500,000), 55 held hospital and departmental leadership roles, 30 were leaders in surgical societies, 27 authored clinical guidelines, and 16 served on journal editorial boards. During COVID-19, 2020 experienced half the number of payments than the preceding 3 years. Conclusions: General and fellowship-trained surgeons received substantial industry non-research payments. Highest paid recipients were men. Further work is warranted in assessing how race, gender, and leadership roles influence the nature of industry payments and surgical practice. A significant decline in payments was observed early during the COVID-19 pandemic.

OBJECTIVE:To characterize industry nonresearch payments made to general and fellowship-trained surgeons between 2016 and 2020. BACKGROUND:The Centers for Medicare & Medicaid Services Open Payments Data (OPD) reports industry payments made to physicians related to drugs and medical devices. General payments are those not associated with research. METHODS:OPD data were queried for general and fellowship-trained surgeons who received general payments from 2016 to 2020. Payments' nature, amount, company, covered product, and location were collected. Surgeons' demographics, subspecialty, and leadership roles in hospitals, societies, and editorial boards were evaluated. RESULTS:From 2016 to 2020, 44,700 general and fellowship-trained surgeons were paid $535,425,543 in 1,440,850 general payments. The median payment was $29.18. The most frequent payments were for food and beverage (76.6%) and travel and lodging (15.6%); however, the highest dollar payments were for consulting fees ($93,128,401; 17.4%), education ($88,404,531; 16.5%), royalty or license ($87,471,238; 16.3%), and travel and lodging ($66,333,149; 12.4%). Five companies made half of all payments ($265,654,522; 49.6%): Intuitive Surgical ($128,517,411; 24%), Boston Scientific ($48,094,570; 9%), Edwards Lifesciences ($41,835,544, 7.8%), Medtronic Vascular ($33,607,136; 6.3%), and W. L. Gore & Associates ($16,626,371; 3.1%). Medical devices comprised 74.7% of payments ($399,897,217), followed by drugs and biologicals ($33,945,300; 6.3%). Texas, California, Florida, New York, and Pennsylvania received the most payments; however, the top dollar payments were in California ($65,702,579; 12.3%), Michigan ($52,990,904, 9.9%), Texas ($39,362,131; 7.4%), Maryland ($37,611,959; 7%), and Florida ($33,417,093, 6.2%). General surgery received the highest total payments ($245,031,174; 45.8%), followed by thoracic surgery ($167,806,514; 31.3%) and vascular surgery ($60,781,266; 11.4%). A total of 10,361 surgeons were paid >$5000, of which 1614 were women (15.6%); in this group, men received higher payments than women (means, $53,446 vs $22,571; P <0.001) and thoracic surgeons received highest payments (mean, $76,381; NS, P =0.14). A total of 120 surgeons were paid >$500,000 ($203,011,672; 38%)-5 non-Hispanic White (NHW) women (4.2%) and 82 NHW (68.3%), 24 Asian (20%), 7 Hispanic (5.8%), and 2 Black (1.7%) men; in this group, men received higher payments than women (means, $1,735,570 vs $684,224), and NHW men received payments double those of other men (means, $2,049,554 vs $955,368; NS, P =0.087). Among these 120 highly paid surgeons (>$500,000), 55 held hospital and departmental leadership roles, 30 were leaders in surgical societies, 27 authored clinical guidelines, and 16 served on journal editorial boards. During COVID-19, 2020 experienced half the number of payments than the preceding 3 years. CONCLUSIONS:General and fellowship-trained surgeons received substantial industry nonresearch payments. The highest-paid recipients were men. Further work is warranted in assessing how race, gender, and leadership roles influence the nature of industry payments and surgical practice. A significant decline in payments was observed early during the COVID-19 pandemic.