INTRODUCTION:Screening for cancer decreased during the COVID-19 pandemic, leading to fewer cancer cases and less than expected early-stage diagnoses. Due to this decrease, the subsequent literature suggested a tidal wave of increased incidence and a larger proportion of late-stage disease. METHODS:The National Cancer Database (NCDB) was used to identify screenable cancer cases from lung, female breast, and colorectal cancer from 2010 to 2023. These were standardized to calculate annual incidence rates per 100,000. A linear regression model of 2010-2022 incidence rates was used to calculate predicted incidence compared with observed incidence in 2023 (most recent NCDB data). Late-stage disease proportions (III/IV versus I/II) were also compared. Sensitivity analyses were conducted using alternative modeling periods and restricting to stable facility participation in NCDB. RESULTS:A total of 2,235,175 lung, 3,090,471 breast, and 1,448,861 colorectal cancer patients were analyzed. In 2023, the observed incidence was lower for lung 63.282 versus 68.914 (95% predictive interval 62.677-75.151), breast 174.055 versus 193.417 (95% PI 178.613-208.221), and colorectal 43.348 versus 45.517 (95% PI 41.266-49.769), although only breast was significantly lower. Observed and predicted late-stage disease proportions were similar for all three screenable cancers: lung: 56.0% versus 59.0%, breast: 11.6% versus 11.6%, and colorectal: 55.6% versus 56.8%. Findings were similar in sensitivity analyses. CONCLUSIONS:Despite the broadly accepted expectation that the incidence of screenable cancers would increase after the initial wave of the COVID-19 pandemic, the rates decreased, particularly for breast cancer. Furthermore, the expectation that late-stage cancers would rise significantly was not observed.

PURPOSE:The Affordable Care Act's Medicaid Expansion increased insurance coverage nationally; its impact on colorectal cancer surgery access and outcomes remains unclear, particularly in rural regions with structural barriers. This study evaluated whether Medicaid Expansion was associated with changes in colorectal cancer surgery utilization, access to elective surgery, and short-term outcomes within eight Midwestern states. METHODS:A population-based difference-in-difference analysis used State Inpatient Databases from 2010-2022, including four expansion and four late or non-expansion states. Adults aged 18-64 years who underwent colorectal cancer resection were included. Primary outcomes included state-level surgical utilization rates and elective surgery rates per 100,000 population. Secondary outcomes included in-hospital mortality and length of stay. RESULTS:Among 42,634 resections, 69.5% occurred in expansion states. Colorectal cancer surgical utilization rates did not increase following Medicaid expansion in either state group, regardless of rurality or insurance type. Elective surgery rates did not increase among rural patients in either group. Among rural uninsured patients, rates declined significantly more in Medicaid Expansion states, consistent with shifts in payer mix post expansion. Length of stay and in-hospital mortality remained low, with no significant differences by expansion status or rurality. CONCLUSION:Medicaid Expansion was not associated with sustained improvements in colorectal cancer surgical utilization, access to elective surgery, or outcomes in the Midwest, including rural populations. Expanded insurance coverage alone may be insufficient to overcome structural barriers to timely colorectal cancer surgery. Further research is needed to uncover drivers of gaps in rural cancer care.

INTRODUCTION:Timely treatment initiation is critical to clinical outcomes in breast cancer (BC). While social determinants of health are established drivers of disparities in the timeliness of care (ToC), the impact of travel burden remains less defined. This study evaluates associations between travel burden, ToC, and overall survival (OS) in a nationally representative BC cohort. METHODS:We analyzed 283,166 BC patients from the National Cancer Database (2004-2021) with documented great circle distance (GCD), categorized as ≤ 10, 10.1-20.0, and > 20 miles. Associations between GCD and ToC-defined as time from diagnosis to first treatment and categorized as < 8, 8-12, and > 12 weeks-were assessed using negative binomial models, and associations with OS were evaluated using Cox models. RESULTS:Compared to patients with GCD < 10 miles, patients with GCD > 20 miles experienced delays in ToC when diagnosed with early-stage disease, especially when undergoing surgery as first treatment (RR: 1.05, 95% CI: 1.04-1.06). Compared to treatment within 8 weeks of diagnosis, treatment initiation > 12 weeks had 24% higher mortality (HR: 1.24, 95% CI: 1.14-1.35), especially among patients receiving surgery (HR: 1.31, 95% CI: 1.19-1.43) and chemotherapy (HR: 1.30, 95% CI: 1.18-1.43). Even surgery within 8-12 weeks carried an elevated risk (HR: 1.09, 95% CI: 1.02-1.16). Metropolitan patients with GCD > 20 miles had a 12% lower mortality (HR: 0.88, 95% CI: 0.81-0.96) than those ≤ 10 miles away; no such differences were observed in urban or rural groups. CONCLUSION:Travel burden influences BC ToC and OS through geographic, clinical, and facility factors, underscoring the need for tailored interventions that address local care capacity, patient demographics, and disease profiles.

BACKGROUND:Oncologic care received at more than one institution has been shown to negatively impact patient survival in gastric and rectal cancers. Our study evaluated the effect of multi-institutional care (MC) on time to treatment initiation (TTI) and survival in early-stage HCC. METHODS:The National Cancer Database was queried for patients with Stage I and II HCC (2004-2020). Patients were categorized as single-institution care (SC) or multi-institutional care (MC). A negative binomial regression model was used to identify predictors of increased TTI. Survival analyses were estimated with the Kaplan-Meier method. RESULTS:Of 12,704 patients, 51% (n = 6471) received MC and 49% (n = 6233) SC. MC patients were more often older (p < 0.0001), White (p < 0.0001), privately insured (p < 0.0001), and traveling greater distances (p = 0.0001). Median TTI was longer for MC patients than SC (61 vs. 50 days; p < 0.0001). Black, underinsured (Medicaid/other government insurance), and MC patients were associated with increased TTI by factors of 1.131 (95% CI: 1.093-1.170; p < 0.0001), 1.081 (95% CI: 1.046-1.119; p < 0.0001), and 1.203 (95% CI: 1.176-1.231; p < 0.0001). Survival was similar between MC and SC at 1 year (p = 0.1514) and 5 years (p = 0.1769). CONCLUSIONS:Despite increased treatment time, there was no appreciable survival disadvantage among patients receiving care at multiple sites.

BACKGROUND:Large-database cancer research often defines hospitals servicing a threshold number of Medicaid patients "safety net"; however, counts are generally with the cancer of interest, and because sufficient rare/complex cases such as hepatobiliary/pancreatic (HPB) cancers tend to be managed at larger institutions, "safety net" may be skewed toward academic centers. Recent data show similar survival for "safety net" HPB care. We examine patterns/outcomes of curative intent surgery (CIS) for HPB cancers by a more comprehensive Medicaid-serving (AID) status utilizing all alimentary tract cancers to generate AID quartiles. PATIENTS AND METHODS:We identified all alimentary tract cancers (NCDB: 2004-2021) to determine quartile proportions of Medicaid-insured patients. Stage I-III primary HPB cancers were analyzed by highest quartile of AID facility ("high-AID") versus remaining quartiles ("low-AID"). Logistic regression identified predictors for undergoing CIS. Cox proportional regression modeled survival. P < 0.01 was significant. RESULTS:HPB cancer cases totaled 286,873. High-AID patients were more likely to be non-white and have low income/education. Patients were less likely to undergo CIS at high-AID programs (hepatic [H]: OR 0.83, 95% CI 0.80-0.86; pancreas [P]: OR 0.81, 95% CI 0.78-0.84; biliary [B]: OR 0.83, 95% CI 0.79-0.87). Multivariable analyses showed similar survival at 1 and 5 years for hepatic resection at high-AID facilities (1 year: HR 1.01 [0.89-1.14]; 5 years: HR 1.01 [0.95-1.07]). High-AID for pancreatic/biliary patients had greater mortality risk at 1 and 5 years. CONCLUSIONS:Including more hospitals to define AID status revealed worse survival at high-Medicaid-serving facilities for pancreatic/biliary, but not hepatic cancer surgery patients. Our "safety net hospital" proxy (high-AID) allows for better care disparity identification for complex underserved patients with cancer.

INTRODUCTION:Despite guidelines recommending oncologic colectomy (hemicolectomy with adequate lymphadenectomy) for high-risk appendiceal adenocarcinoma, some patients undergo nononcologic resection (NOR; appendectomy or ileocecectomy only). Our study examines patients with high-risk appendiceal cancer who received NOR and examines the association with survival compared to oncologic colectomy. MATERIALS AND METHODS:Patients with appendiceal adenocarcinoma who underwent surgical resection from 2010 to 2019 were identified from the National Cancer Database. Patients with any high-risk features (lymphovascular invasion, high grade, positive surgical margins, pathologic T stage 2 or greater, or American Joint Commission on Cancer stage 1, 2, or 3) were selected. The primary outcome was NOR for high-risk patients; the secondary outcome was long-term survival. Multivariable logistic regression was used to identify patient- and disease-specific variables associated with NOR. Patients were propensity score matched 1:1, and 5-y survival was compared. RESULTS:We identified 4510 patients, of whom 1696 (37.6%) received NOR. NOR was associated with elderly patients, nonprivate insurance, community centers, documented stage 1-2 disease, no lymphovascular invasion, low-grade disease, positive margins, mucinous histology, and no documented chemotherapy. After multivariable regression, NOR was associated with age ≥70 y, Black race, community centers, stage 1 or stage 2 disease, positive margins, and no documented adjuvant chemotherapy. Patients who underwent oncologic colectomy had higher rates of 5-y overall survival compared to NOR before (67.7% versus 60.7%, P < 0.0001) and after (67.5% versus 60.7%, P < 0.0001) propensity score matching. CONCLUSIONS:Despite established guidelines for high-risk appendiceal adenocarcinoma, some patients undergo NOR and demonstrate worse survival. Older patients and patients with early-stage disease have higher odds of NOR.

INTRODUCTION:Timely treatment for patients with melanoma is critical. This study evaluated associations between the COVID-19 pandemic and time to treatment for patients with melanoma and delineated factors associated with delayed treatment. METHODS:Using the National Cancer Database, patients with cutaneous melanoma were categorized using year of diagnosis: COVID era (2020) versus pre-COVID era (2018-2019). Multivariable logistic regression was used to estimate the odds of delayed time to surgery (DTS) and/or chemoimmunotherapy (DTC), defined as >30 d. RESULTS:Among 72,590 patients with melanoma, 71.2% were diagnosed in the pre-COVID era (25,210 in 2018; 26,471 in 2019) compared to 28.8% diagnosed in the 2020 COVID era. Of the COVID era patients, 40.4% received COVID-19 testing, with 5.7% having a positive result. COVID era patients were diagnosed at a later stage (3 and 4), 7.4% versus 6.6%. While overall DTS decreased for COVID era patients, a higher proportion of patients tested for COVID experienced longer DTS. In multivariable logistic analysis, male sex, Black race, Hispanic ethnicity, uninsured or underinsured status, less education, stage > 1, and treatment locations in the Northeast, West, and South were associated with DTS. COVID era diagnosis was not associated with DTC; however, uninsured or underinsured status and treatment in the South were associated with DTC. CONCLUSIONS:The pandemic was not associated with overall delays in treatment for melanoma; however, vulnerable populations and certain geographic areas experienced disproportionate differences in treatment timing. The potential long-term associations between delayed treatment and outcomes warrant further investigation, especially for marginalized populations.

BACKGROUND:Gastrointestinal (GI) and abdominal wall surgical procedures are core components of general surgery. Increasingly, residents are pursuing fellowship after completing general surgery residency for reasons, including desired subspecialty and/or perceived readiness for practice. This study aimed to determine what proportion of graduating general surgery residents pursue fellowships related to the GI tract and abdominal wall. METHODS:Publicly available data from the American Board of Surgery (ABS) were used to quantify the rates of ABS-certified surgeons with fellowship training. Data were categorized by the degree of fellowship-level GI-specific training: (i) no fellowship, (ii) all GI (advanced GI, bariatric, colon and rectal, endoscopy, hepatobiliary, and minimally invasive), (iii) most GI (acute care, complex general surgical oncology, and oncology), (iv) some GI (pediatric, thoracic, and transplantation), and (v) non-GI (breast, critical care, endocrine, hand, other, plastic, trauma burns, and vascular). Trends were statistically analyzed using Mann-Kendall tests and 2-sample proportion t tests. RESULTS:In 1980, 5.8% of applicants for initial ABS fellowship certification were made up of GI-related surgeons (ie, all GI + most GI + some GI), whereas 84.5% of surgeons did not pursue any fellowship training. By 2023, the number of surgeons applying for initial ABS fellowship certification had substantially increased to 39.6%, whereas the number of surgeons pursuing no fellowship had fallen to a mere 18.2%. There were statistically significant increasing trends over time for each fellowship, and a significant decreasing trend for no fellowship (P <.0001). When comparing all, most, and some GI training, all GI training demonstrated the largest increase of fellowships between 1980-1980 (3.2%) and 2014-2023 (20.3%) (P <.0001). The largest increases in enrollment in individual GI fellowships between 1980-1989 and 2014-2023 were in colon and rectal surgery (CRS: 1.7% in 1980-1989 vs 7.5% in 2014-2023; P <.0001) and minimally invasive surgery (MIS: 0.3% in 1980-1989 vs 7.4% in 2014-2023; P <.0001) fellowships. CONCLUSION:Over time, there has been a significant increase in surgeons pursuing additional training in GI-related fields, especially CRS and MIS. Additional investigation is necessary to determine whether this is secondary to exposure in residency and/or increasing complexity of operations. However, our data suggest that even with the increase in fellowships, general surgery residents continue to seek careers focused on the GI tract, which remains at the core of the surgical field.

BACKGROUND:There is an ongoing debate on surgical training and its evolution to meet the demands of a complex and changing healthcare environment. METHODS:A GI Surgery Summit was held in January 2024 that included prominent leaders and rising talents from the Society for Surgery of the Alimentary Tract, Society of Surgical Oncology, Association for Academic Surgery, and Society of University Surgeons. This meeting was held to address the multifaceted current and future challenges of surgery. RESULTS:This paper addresses the topic of recruitment and training of the next generation of surgeons in the United States and abroad and reflects a collective focus on surgical education to ensure the delivery of high-quality care in an increasingly sophisticated medical and surgical landscape. CONCLUSION:The discussions and recommendations from the 2024 GI Surgery Summit underscore the crucial need to support diversity, embrace innovative educational frameworks, build a robust global surgical workforce, and foster a culture of wellness and support. Focusing on these key areas ensures that the future leaders of surgery are not only skilled and knowledgeable but also resilient and compassionate, ready to meet the evolving challenges of the healthcare landscape.

INTRODUCTION:Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients.METHODS:We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days.RESULTS:A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039).CONCLUSION:At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer.

Background: Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear. Methods: The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD. Results: Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774). Conclusion: SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.

Background: Undifferentiated pleomorphic sarcoma (UPS) is a relatively rare but aggressive neoplasm. We sought to utilize a multi-institutional US cohort of sarcoma patients to examine predictors of survival and recurrence patterns after resection of UPS. Methods: From 2000 to 2016, patients with primary UPS undergoing curative-intent surgical resection at seven academic institutions were retrospectively reviewed. Epidemiologic and clinicopathologic factors were reviewed by site of origin. Overall survival (OS), recurrence-free survival (RFS), time-to-locoregional (TTLR), time-to-distant recurrence (TTDR), and patterns of recurrence were analyzed. Results: Of the 534 UPS patients identified, 53% were female, with a median age of 60 and median tumor size of 8.5 cm. The median OS, RFS, TTLR, and TTDR for the entire cohort were 109, 49, 86, and 46 months, respectively. There were no differences in these survival outcomes between extremity and truncal UPS. Compared with truncal, extremity UPS were more commonly amenable to R0 resection (87% vs. 75%, p = 0.017) and less commonly associated with lymph node metastasis (1% vs. 6%, p = 0.031). R0 resection and radiation treatment, but not site of origin (extremity vs. trunk) were independent predictors of OS and RFS. TTLR recurrence was shorter for UPS resected with a positive margin and for tumors not treated with radiation. Conclusion: For patients with resected extremity and truncal UPS, tumor size >5 cm and positive resection margin are associated with worse survival OS and RFS, irrespectively the site of origin. R0 surgical resection and radiation treatment may help improve these survival outcomes.

Background: Timely treatment for patients with colorectal cancer may have been disrupted by the COVID-19 pandemic. We evaluated the impact of the pandemic on delays to treatment with surgery or systemic therapy for patients with colorectal cancer and delineated factors predictive of delayed treatment. Methods: Using the National Cancer Database, patients diagnosed with colorectal cancer were categorized by year of diagnosis as COVID-19 era (2020) versus pre-COVID-19 (2018-2019). Categorical variables were compared by X-2 analysis. Multivariate logistic regression was used to assess odds ratios for delayed time to surgery or chemoimmunotherapy, defined as >60 days. Results: In total, 50,689 patients colorectal cancer were diagnosed patients who were pre-COVID-19 vs 21,331 within the COVID-19-era. Patients diagnosed with COVID-19 had a higher stage at diagnosis. There were no differences in the proportion of delayed time to surgery for patients diagnosed in 2020, but patients who were tested for COVID-19 had increased proportions of delayed time to surgery (P < .0001). In multivariate analysis, Black race (P = .0026) and uninsured/underinsured status (P = .0017) were associated with delayed time to surgery. Diagnosis during COVID-19 did not increase delayed time to chemoimmunotherapy, regardless of COVID-19 testing or positivity; however, delays were seen for Black (P < .0001), Hispanic (P < .0001), and uninsured/underinsured patients (P < .0001). Conclusion: Although the pandemic did not delay treatment for colorectal cancer overall, vulnerable and underserved populations were disproportionately affected by delays to all forms of therapy. The difference in colorectal cancer outcomes in the coming years as a result of delays in treatment may be significant for these patients.