Faculty Bibliography

BACKGROUND:Nodal surveillance (NS) has overtaken completion lymphadenectomy as the preferred management for sentinel node-positive (SLN+) melanoma, but requires frequent exams and nodal ultrasound (US). Social determinants of health (SDoH) may affect US adherence in real-world populations, and evaluation of these potential impacts is needed. METHODS:Adults with SLN+ melanoma diagnosed from July 2017 to December 2019 who received NS at nine cancer centers were identified retrospectively. Exposures included insurance status, travel distance, and Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), a validated measure of area-level SDoH, indicated as 0 (low) to 1 (high) vulnerability. The primary outcome was US adherence (≥ 1 study per 6-month follow-up interval). The secondary outcomes were combined-modality adherence [US, computed tomography (CT), or positron emission tomography (PET)] and loss to follow-up (LTFU). Bivariate analyses and mixed-effects multivariable logistic regression were performed. RESULTS:Most of the 519 patients were male (57%), non-Hispanic white (94.4%), and insured privately (45.3%) or by Medicare (43.5%). The median travel distance was 63.3 miles (interquartile range [IQR], 31.2-111.0 miles), and the median SVI was 0.426 (IQR, 0.253-0.610). The surveillance adherence rates were 41.6% for US and 75.1% for combined modalities. No significant differences in US adherence were observed based on sociodemographic covariates in regression analysis. Medicaid (odds ratio [OR], 3.12; p = 0.02) and uninsured (OR 4.48; p = 0.01) patients had increased likelihood of LTFU. CONCLUSIONS:Less than half of the patients in this multicenter cohort achieved US adherence, although the rates improved with combined modalities. Medicaid or non-insurance were social risk factors for LTFU. Optimizing surveillance practices for socially vulnerable groups will be crucial for the ongoing real-world implementation of NS.

BACKGROUND:Existing research exploring predictors of success on American Board of Surgery (ABS) exams focused on either resident or residency program characteristics, but limited studies focus on both. This study examines relationships between both resident and program characteristics and ABS Qualifying (QE) and Certifying Exam (CE) outcomes. STUDY DESIGN/METHODS:Multilevel logistic regression was used to analyze the relationship between resident and program characteristics and ABS QE and CE 1st attempt pass and eventual certification. Resident characteristics were gender, IMG status, and prior performance, measured by 1st attempt USMLE Step 2 CK and Step 3 scaled scores. Program characteristics were size, %female, %International Medical Graduate (IMG), and program type. The sample included surgeons with QE and CE data from 2007-2019 and matched USMLE scores. RESULTS:Controlling for other variables, prior medical performance positively related to all ABS exam outcomes. The relationships between USMLE scores and success on ABS exams varied but were generally strong. Other resident characteristics that predicted ABS exam outcomes were gender and IMG (QE 1st attempt pass). The only program characteristic that significantly predicted ABS outcomes was %IMG (QE and CE 1st attempt pass). Despite statistical significance, gender, IMG, and %IMG translated to small differences in predicted probabilities of ABS exam success. CONCLUSION/CONCLUSIONS:This study highlights resident and program characteristics that predict success on ABS exams. USMLE scores consistently and strongly related to ABS exam success, providing evidence that USMLE scores relate to future high-stakes consequences like board certification. After controlling for prior performance, gender, IMG, and program %IMG significantly related to ABS exam success, but effects were small.

BACKGROUND:The existence of sociodemographic disparities in pancreatic cancer has been well-studied but how these disparities have changed over time is unclear. The purpose of this study was to longitudinally assess patient management in the context of sociodemographic factors to identify persisting disparities in pancreatic cancer care. METHODS:Using the National Cancer Database, patients diagnosed with pancreatic ductal adenocarcinoma from 2010 to 2017 were identified. The primary outcomes were surgical resection and/or receipt of chemotherapy. Outcome measures included changes in associations between sociodemographic factors (i.e., sex, age, race, comorbidity index, SES, and insurance type) and treatment-related factors (i.e., clinical stage at diagnosis, surgical resection, and receipt of chemotherapy). For each year, associations were assessed via univariate and multivariate analyses. RESULTS:Of 75,801 studied patients, the majority were female (51%), White (83%), and had government insurance (65%). Older age (range of OR 2010-2017 [range-OR]:0.19-0.29), Black race (range-OR: 0.61-0.78), lower SES (range-OR: 0.52-0.94), and uninsured status (range-OR: 0.46-0.71) were associated with lower odds of surgical resection (all p < 0.005), with minimal fluctuations over the study period. Older age (range-OR: 0.11-0.84), lower SES (range-OR: 0.41-0.63), and uninsured status (range-OR: 0.38-0.61) were associated with largely stable lower odds of receiving chemotherapy (all p < 0.005). CONCLUSIONS:Throughout the study period, age, SES, and insurance type were associated with stable lower odds for both surgery and chemotherapy. Black patients exhibited stable lower odds of resection underscoring the continued importance of mitigating racial disparities in surgery. Investigation of mechanisms driving sociodemographic disparities are needed to promote equitable care.

BACKGROUND OBJECTIVES/OBJECTIVE:The aim of this study was to determine the role of site-specific metastatic patterns over time and assess factors associated with extended survival in metastatic PDAC. Half of all patients with pancreatic ductal adenocarcinoma (PDAC) present with metastatic disease. The site of metastasis plays a crucial role in clinical decision making due to its prognostic value. METHODS:We examined 56,757 stage-IV PDAC patients from the National Cancer Database (2016-2019), categorizing them by metastatic site: multiple, liver, lung, brain, bone, carcinomatosis, or other. The site-specific prognostic value was assessed using log-rank tests while time-varying effects were assessed by Aalen's linear hazards model. Factors associated with extended survival (>3years) were assessed with logistic regression. RESULTS:Median overall survival (mOS) in patients with distant lymph node-only metastases (9.0 months) and lung-only metastases (8.1 months) was significantly longer than in patients with liver-only metastases (4.6 months, p < 0.001). However, after six months, the metastatic site lost prognostic value. Logistic regression identified extended survivors (3.6 %) as more likely to be younger, Hispanic, privately insured, Charlson-index <2, having received chemotherapy, or having undergone primary or distant site surgery (all p < 0.001). CONCLUSION/CONCLUSIONS:While synchronous liver metastases are associated with worse outcomes than lung-only and lymph node-only metastases, this predictive value is diminished after six months. Therefore, treatment decisions beyond this time should not primarily depend on the metastatic site. Extended survival is possible in a small subset of patients with favorable tumor biology and good conditional status, who are more likely to undergo aggressive therapies.

OBJECTIVE:To analyze postrecurrence progression in the context of recurrence sites and assess implications for postrecurrence treatment. BACKGROUND:Most patients with resected pancreatic ductal adenocarcinoma (PDAC) recur within 2 years. Different survival outcomes for location-specific patterns of recurrence are reported, highlighting their prognostic value. However, a lack of understanding of postrecurrence progression and survival remains. METHODS:This retrospective analysis included surgically treated patients with PDAC at NYU Langone Health (2010-2021). Sites of recurrence were identified at the time of diagnosis and further follow-up. Kaplan-Meier curves, log-rank test, and Cox regression analyses were applied to assess survival outcomes. RESULTS:Recurrence occurred in 57.3% (196/342) patients with a median time to recurrence of 11.3 months (95% CI: 12.6-16.5). The first site of recurrence was local in 43.9% of patients, liver in 23.5%, peritoneal in 8.7%, lung in 3.6%, whereas 20.4% had multiple sites of recurrence. Progression to secondary sites was observed in 11.7%. Only lung involvement was associated with significantly longer survival after recurrence compared with other sites (16.9 vs 8.49 months, P = 0.003). In local recurrence, 21 (33.3%) patients were alive after 1 year without progression to secondary sites. This was associated with a CA19-9 of <100 U/mL at the time of primary diagnosis ( P = 0.039), nodal negative disease ( P = 0.023), and well-moderate differentiation ( P = 0.042) compared with patients with progression. CONCLUSION/CONCLUSIONS:Except for lung recurrence, postrecurrence survival after PDAC resection is associated with poor survival. A subset of patients with local-only recurrence do not quickly succumb to systemic spread. This is associated with markers for favorable tumor biology, making them candidates for potential curative re-resections when feasible.

BACKGROUND:The appropriate surgical approach for pancreatic ductal adenocarcinoma (PDAC) is determined by the tumor's relation to the porto-mesenteric axis. Although the extent and location of lymphadenectomy is dependent on the type of resection, a pancreatoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) are considered equivalent oncologic operations for pancreatic neck tumors. Therefore, we aimed to assess differences in histopathological and oncological outcomes for surgical approaches in the treatment of pancreatic neck tumors. METHODS:Patients with resected PDAC located in the pancreatic neck were identified from the National Cancer Database (2004-2020). Patients with metastatic disease were excluded. Furthermore, patients with 90-day mortality and R2-resections were excluded from the multivariable Cox-regression analysis. RESULTS:Among 846 patients, 58% underwent PD, 25% DP, and 17% TP with similar R0-resection rates (p = 0.722). Significant differences were observed in nodal positivity (PD:44%, DP:34%, TP:57%, p < 0.001) and mean-number of examined lymph nodes (PD:17.2 ± 10.4, DP:14.7 ± 10.5, TP:21.2 ± 11.0, p < 0.001). Furthermore, inadequate lymphadenectomy (< 12 nodes) was observed in 30%, 44%, and 19% of patients undergoing PD, DP, and TP, respectively (p < 0.001). Multivariable analysis yielded similar overall survival after DP (HR:0.83, 95%CI:0.63-1.11), while TP was associated with worse survival (HR:1.43, 95%CI:1.08-1.89) compared to PD. CONCLUSION/CONCLUSIONS:While R0-rates are similar amongst all approaches, DP is associated with inadequate lymphadenectomy which may result in understaging disease. However, this had no negative influence on survival. In the premise that an oncological resection of the pancreatic neck tumor is feasible with a partial pancreatectomy, no benefit is observed by performing a TP.

BACKGROUND:Surgical subspecialty training aims to meet the needs of practicing surgeons and their communities. This study investigates career preparedness of Complex General Surgical Oncology (CGSO) fellowship graduates, identifies factors associated with practice readiness, and explores potential opportunities to improve the current training model. METHODS:The Society of Surgical Oncology partnered with the National Cancer Institute to conduct a 36-question survey of CGSO fellowship graduates from 2012 to 2022. RESULTS:The overall survey response rate was 38% (221/582) with a slight male predominance (63%). Forty-six percent of respondents completed their fellowship after 2019. Factors influencing fellowship program selection include breadth of cancer case exposure (82%), mentor influence (66%), and research opportunities (38%). Overall, graduates reported preparedness for practice; however, some reported unpreparedness in research (18%) and in specific clinical areas: thoracic (43%), hyperthermic intraperitoneal chemotherapy (HIPEC) (15%), and hepato-pancreato-biliary (15%) surgery. Regarding technical preparedness, 70% reported being "very prepared". Respondents indicated lack of preparedness in robotic (63%) and laparoscopic (33%) surgery approaches. Suggestions for training improvement included increased autonomy and case volumes, program development, and research infrastructure. Current practice patterns by graduates demonstrated discrepancies between ideal contracts and actual practice breakdowns, particularly related to the practice of general surgery. CONCLUSIONS:This study of CGSO fellowship graduates demonstrates potential gaps between trainee expectations and the realities of surgical oncology practice. Although CGSO fellowship appears to prepare surgeons for careers in surgical oncology, there may be opportunities to refine the training model to better align with the needs of practicing surgical oncologists.

OBJECTIVE:To evaluate long-term oncologic outcomes of patients with stage IV pancreatic ductal adenocarcinoma (PDAC) and identify survival benchmarks for comparison when considering resection in these patients. SUMMARY BACKGROUND DATA/BACKGROUND:Highly selected cohorts of patients with liver-oligometastatic pancreas cancer have reported prolonged survival following resection. The long-term impact of surgery in this setting remains undefined due to a lack of appropriate control groups. METHODS:We identified patients with clinical stage IV PDAC with synchronous liver metastases within our cancer registry. We estimated overall survival (OS) among various patient subgroups using the Kaplan-Meier method. To mitigate immortal time bias, we analyzed long-term outcomes of patients who survived beyond 12 months (landmark time) from diagnosis. RESULTS:We identified 241 patients. Median OS was 7 months (95%CI 5-9), both overall and for patients with liver-only metastasis (n=144). Ninety patients (38% of liver-only; 40% of whole cohort) survived at least 12 months; those who received chemotherapy in this subgroup had a median OS of 26 months (95%CI 17-39). Of these patients, those with resectable or borderline resectable primary tumors and resectable liver-only metastasis (n=9, 4%) had a median OS of 39 months (95%CI 13-NR). CONCLUSIONS:The 4% of our cohort that were potentially eligible for surgery experienced a prolonged survival compared to all-comers with stage IV disease. Oncologic outcomes of patients undergoing resection of metastatic pancreas cancer should be assessed in the context of the expected survival of patients potentially eligible for surgery and not relative to all patients with stage IV disease.