Objectives: Surgical resection is standard treatment for early-stage non-small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non-small cell lung cancer. Methods: The Surveillance Epidemiology and End-Results-Medicare linked database (2000-2005) identified patients (ages 66-80 years) undergoing lobectomy for stage I non-small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision, diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications. Results: In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals (P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%. Conclusions: Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non-small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients. Copyright © 2012 by The American Association for Thoracic Surgery.

BACKGROUND Previous literature has consistently shown worse operative outcomes at low-volume hospitals (LVH) after complex cancer surgery. Whether patient-related factors impact this association remains unknown. We hypothesize that patient-related factors contribute to receipt of complex cancer surgery at LVH. STUDY DESIGN Using the 2003–2008 National Inpatient Sample, we identified 59,841 patients who underwent cancer operations for lung, esophagus, and pancreas tumors. Logistic regression models were used to examine the impact of sociodemographic factors on receipt of complex cancer surgery at LVH. RESULTS Overall, 38.4% received their cancer surgery at LVH. A higher proportion of esophagectomies were performed at LVH (70.3%), followed by pancreatectomy (38.2%) and lung resection (33.8%). Patients who were non-white, with non-private insurance, and had more comorbidities were all more likely to receive their cancer surgery at LVH (for all, p < 0.05). Multivariate analyses continued to demonstrate that non–white race, insurance status, increased comorbidities, region, and nonelective admission predicted receipt of cancer surgery at LVH across all 3 procedures. CONCLUSIONS In this large national study, non-white race and increased comorbidities contributed to receipt of cancer surgery at LVH. Patient selection and access to high-volume hospitals are likely reasons worthy of additional investigation. This study provides additional insight into the volume–outcomes relationship. Given the demonstrated outcomes disparity between high-volume hospitals and LVH, future policy and research should encourage mechanisms for referral of patients with cancer to high-volume hospitals for their surgical care.

BACKGROUND The adverse effects of blood transfusion after cancer surgery have been recently challenged in older anemic persons or those with substantial intraoperative blood loss. We hypothesized that intraoperative blood transfusions continue to adversely impact short-term cancer surgery outcomes regardless of age or preoperative hematocrit levels. METHODS Using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program, we identified 38,926 patients who underwent cancer surgery. Pre-, intra-, and postoperative factors were compared by units of blood transfusion a patient received. Stratified multivariable analyses, by age and hematocrit level, were performed to assess the impact of blood transfusion on operative outcomes, adjusting for covariates. RESULTS Fourteen percent of patients received an intraoperative blood transfusion. Of those, >60% received only 1 to 2 units of blood. Receipt of intraoperative blood transfusion was associated with higher rates of 30-day operative mortality, major complications, total number of complications, and prolonged length of stay across age groups and in persons with low to normal hematocrit levels. CONCLUSION The present study shows that intraoperative blood transfusion adversely impacts short-term operative cancer surgery outcomes across all age groups and in those with low to normal hematocrit levels. These findings provide insightful implications on the patterns of blood transfusion during cancer surgery that deserve further investigation.

BACKGROUND Inadequate access has contributed to widespread racial disparities in cancer care in the United States. However, the outcomes for racial minorities at quality-seeking hospitals, such as those participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), remain unknown. We hypothesized that operative outcomes for racial and ethnic minority patients after cancer surgery at ACS NSQIP hospitals are comparable with those for white patients. STUDY DESIGN Using the 2005−2008 ACS NSQIP data, we identified 38,926 patients who underwent thoracic, abdominal, or pelvic cancer surgery. We used multivariate logistic regression to examine the association between race and ethnicity and short-term (30-day) operative outcomes after cancer surgery. Sensitivity analyses were performed to ensure the relationship remained consistent after stratification by procedure. RESULTS Nonwhite patients constituted 16.9% of patients treated for cancer surgery in ACS NSQIP hospitals. Although nonwhite patients were more likely to have higher levels of comorbidities and undergo more complex resections (p < 0.05 for all), multivariate analyses demonstrated that these patients were as likely as white patients to have adverse short-term operative outcomes develop after cancer surgery. These results persisted after stratification by extent of surgical procedure. However, black, Hispanic, and American-Indian/Alaskan-Native patients were more likely to experience prolonged length of stay (odds ratio for black vs white patients = 1.33; p < 0.001). CONCLUSIONS Racial and ethnic minority patients who undergo their cancer surgery at ACS NSQIP hospitals have short-term operative outcomes similar to white patients, but they remain hospitalized longer. These findings suggest that access to quality-driven hospitals might ameliorate racial disparities in cancer care and outcomes. Future policies should focus on expanding access to quality-driven surgical facilities as a step toward timely and optimal cancer care.

OBJECTIVE Surgical morbidity may influence long-term cancer survival. Because resection of early stage nonsmall cell lung cancer (NSCLC) is primary therapy, we sought to determine the survival impact of surgical complications for elderly patients undergoing resection of stage I NSCLC. METHODS Using the linked Surveillance Epidemiology and End Results-Medicare database (2000-2005), we identified elderly patients who underwent lobectomy for stage I NSCLC. We then assessed the unadjusted association between in-hospital, postoperative complications, and long-term survival for patients who survived more than 30 days after resection using the Kaplan-Meier method. Finally, we used Cox proportional hazards regression to evaluate the relationship between postoperative complications and 5-year cancer-specific (CSS) and overall survival (OS) after adjusting for patient, tumor, and treatment characteristics. RESULTS We identified 3996 eligible patients. The overall in-hospital, postoperative complication rate was 54.2%. Pulmonary complications were the most common (n = 1464) followed by cardiac (n = 916). Unadjusted 5-year CSS was significantly worse for those who had an in-hospital, postoperative complication (70.9%) compared to those who did not (78.9%, P < 0.001). OS was also significantly worse (P < 0.001) for patients who developed a complication. Complications continued to predict worse 5-year CSS and OS after adjusting for patient, tumor, and treatment characteristics (HR: 1.38, 95% CI, 1.17-1.64). CONCLUSIONS The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year CSS after resection of stage I NSCLC. Importantly, the impact of surgical complications extends well after the initial perioperative period. These findings may help identify important targets for best practice guidelines and quality-of-care measures.

A B S T R A C T Purpose After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006. Patients and Methods Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospec-tive cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods. Results We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P Ͻ .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P Ͻ .0001), after adjusting for patient and tumor factors. Conclusion In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.

Background: Community socioeconomic deprivation (CSD) may be related to higher oil and natural gas development (OGD) exposure. We tested for distributive and benefit-sharing environmental injustice in Pennsylvania's Marcellus Shale by examining (1) whether OGD and waste disposal occurred disproportionately in more deprived communities and (2) discordance between the location of land leased for OGD and where oil and gas rights owners resided. Materials and Methods: Analyses took place at the county subdivision level and considered OGD wells, waste disposal, and land lease agreement locations from 2005 to 2019. Using 2005-2009 American Community Survey data, we created a CSD index relevant to community vulnerability in suburban/rural areas. Results: In adjusted regression models accounting for spatial dependence, we observed no association between the CSD index and conventional or unconventional drilled well presence. However, a higher CSD index was linearly associated with odds of a subdivision having an OGD waste disposal site and receiving a larger volume of waste. A higher percentage of oil and gas rights owners lived in the same county subdivision as leased land when the community was least versus most deprived (66% vs. 56% in same county subdivision), suggesting that individuals in more deprived communities were less likely to financially benefit from OGD exposure. Discussion and Conclusions: We observed distributive environmental injustice with respect to well waste disposal and benefit-sharing environmental injustice related to oil and rights owner's residential locations across Pennsylvania's Marcellus Shale. These results add evidence of a disparity between exposure and benefits resulting from OGD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a heterogeneous pulmonary disease affecting 16 million Americans. Individuals with COPD are susceptible to environmental disturbances including heat and cold waves that can exacerbate disease symptoms. OBJECTIVE: Our objective was to estimate heat and cold wave-associated mortality risks within a population diagnosed with a chronic respiratory disease. METHODS: We collected individual level data with geocoded residential addresses from the Veterans Health Administration on 377,545 deceased patients with COPD (2016 to 2021). A time stratified case-crossover study was designed to estimate the incidence rate ratios (IRR) of heat and cold wave mortality risks using conditional logistic regression models examining lagged effects up to 7 d. Attributable risks (AR) were calculated for the lag day with the strongest association for heat and cold waves, respectively. Effect modification by age, gender, race, and ethnicity was also explored. RESULTS: Heat waves had the strongest effect on all-cause mortality at lag day 0 [IRR: 1.04; 95% confidence interval (CI): 1.02, 1.06] with attenuated effects by lag day 1. The AR at lag day 0 was 651 (95% CI: 326, 975) per 100,000 veterans. The effect of cold waves steadily increased from lag day 2 and plateaued at lag day 4 (IRR: 1.04; 95% CI: 1.02, 1.07) with declining but still elevated effects over the remaining 7-d lag period. The AR at lag day 4 was 687 (95% CI: 344, 1,200) per 100,000 veterans. Differences in risk were also detected upon stratification by gender and race. DISCUSSION: Our study demonstrated harmful associations between heat and cold waves among a high-risk population of veterans with COPD using individual level health data. Future research should emphasize using individual level data to better estimate the associations between extreme weather events and health outcomes for high-risk populations with chronic medical conditions. https://doi.