Faculty Bibliography

Introduction: Colonic polyps with carcinoma in situ (Tis) are considered advanced adenomas, appropriately treated by endoscopic resection. However, they represent a risk factor for metachronous neoplasia for which current guidelines recommend shorter interval surveillance as compared with low-risk adenomas. While the worse survival of proximal colon cancers has been established, the prognostic impact of laterality for Tis remains unknown. Additionally, proximal adenomas are more challenging to identify and resect, and possibly associated with higher rates of subsequent pathology; therefore, we hypothesized that Tis polyps in this location would have worse prognosis.
Method(s): Adult patients with TisNxMx tumors managed with endoscopic polypectomy alone were identified in the National Cancer Database, 2004-2017.
Result(s): A total of 3,980 patients were included; 29% had proximal lesions. Endoscopically excised proximal Tis polyps were more common in elderly, Black patients, and those with public insurance and more comorbidities (all p<0.01). There was no difference in median size (10mm) between sides. Unadjusted 5-year overall survival (OS) was 81% vs 89% for proximal and distal polyps, while 10-year OS was 67% vs 78% (p<0.01). In multivariable analysis, proximal location did not demonstrate significant worse prognosis (HR=1.11, 95%CI 0.94-1.31).
Conclusion(s): After adjusting for patient factors, proximal Tis polyps did not have significantly lower OS. However, survival may not be the optimal outcome for high-risk adenomas, particularly when considering the relatively low cancer incidence and effective treatment for early-stage malignancy. Future research should focus on risk of metachronous neoplasia, excluded from most national databases, to determine optimal surveillance protocols

BACKGROUND: Patients who are immigrants, notably those with undocumented status, face challenges to equitable healthcare access. By understanding immigration status as a social determinant of health (SDOH), physicians can begin to address such disparities. However, few undergraduate medical curricula include formal longitudinal instruction addressing immigration. We conducted a needs assessment of a medical school's curricular content in teaching medical students to address immigration as a SDOH.
METHOD(S): MS1-3 students from a school in Bronx, NY where 35% of the patient population are immigrants, received a 13-question email survey via surveymonkey.com. Students were assessed on three primary areas based on a literature review on sanctuary doctoring and SDOH: 1) Knowledge of immigrants' barriers to care (4-point scale, strongly disagree to strongly agree); 2) Confidence in assessing patient immigration status, taking an immigration history, and advocating for patients at risk of deportation (3-point scale, not confident to very confident); and 3) Frequency of assessing patients' immigration status, identifying immigration status when presenting cases, and referring undocumented patients to social/legal resources (4-point scale, never to always). Outcomes were compared between pre-clinical (MS1-2) and clinical (MS3) students.
RESULT(S): Among 539 students, 159 (29.5%) responded, with 104 preclinical and 55 clinical students. 79.2% strongly agreed that undocumented immigration status limits healthcare access. Few students reported being very confident in asking about immigration status (8.8%), taking an immigration history (12.6%), providing legal information (2.5%) and advocating for patients at risk of deportation (6.3%). Compared to the pre-clinical cohort, clinical students were significantly more confident in taking an immigration history (p=0.04) but not in other skills. Few students endorsed frequently or always asking patients about immigration status (3.2%), identifying immigration status when presenting patients (4.5%), and referring undocumented patients to appropriate resources (8.3%). There were no significant differences in frequencies of use of clinical skills pertaining to care of immigrant patients in the pre- and clinical cohorts.
CONCLUSION(S): Students are aware of barriers that immigrant patients face but lack confidence and experience in identifying and supporting undocumented patients. Our results will inform a revision of the longitudinal curriculum, including didactics and practical activities. LEARNING OBJECTIVE #1: 1. Assess students' skills and confidence in identifying and advocating for undocumented immigrant patients in clinical practice LEARNING OBJECTIVE #2: 2. Assess students' knowledge of immigrants' barriers to care