BACKGROUND Among surgically treated patients with colon cancer, lower long-term mortality has been demonstrated in those with 12 or more lymph nodes evaluated. We examined whether patients receiving adequate lymph node evaluation were also more likely to receive comprehensive postsurgical care, leading to lower mortality. STUDY DESIGN We used the 1992 to 2007 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify surgically treated American Joint Committee on Cancer (AJCC) stage III colon cancer patients. We used chi-square analyses and logistic regression to evaluate the association between adequate (≥12) lymph node evaluation and receipt of postsurgical care (adjuvant chemotherapy, surveillance colonoscopy, CT scans, and CEA testing) and Cox proportional hazards regression to evaluate 10-year all-cause mortality, adjusting for postsurgical care. RESULTS Among 17,906 surgically treated stage III colon cancer patients, adequate (≥12) lymph node evaluation was not associated with receiving comprehensive postsurgical care after adjustment for patient and tumor characteristics (p > 0.05 for all). Initially, adequate lymph node evaluation was associated with lower all-cause mortality (hazard ratio [HR] 0.88; 95% CI [0.85 to 0.91]), but among 3-year survivors, the impact of adequate lymph node evaluation on lower mortality was diminished (HR 0.94; 95% CI [0.88 to 1.01]). However, receiving comprehensive postsurgical care was associated with continued lower mortality in 3-year survivors. CONCLUSIONS Adequate lymph node evaluation for colon cancer was associated with lower mortality among all patients. However, among 3-year survivors, the association between lymph node evaluation and lower hazard of death was no longer significant, while postsurgical care remained strongly associated with lower long-term mortality, indicating that postsurgical care may partially explain the relationship between lymph node evaluation and mortality.

PURPOSE To examine the impact of cancer on work and education in a sample of adolescent and young adult (AYA) patients with cancer. PATIENTS AND METHODS By using the Adolescent and Young Adult Health Outcomes and Patient Experience Study (AYA HOPE)-a cohort of 463 recently diagnosed patients age 15 to 39 years with germ cell cancer, Hodgkin's lymphoma, non-Hodgkin's lymphoma, sarcoma, and acute lymphocytic leukemia from participating Surveillance, Epidemiology, and End Results (SEER) cancer registries-we evaluated factors associated with return to work/school after cancer diagnosis, a belief that cancer had a negative impact on plans for work/school, and reported problems with work/school after diagnosis by using descriptive statistics, χ(2) tests, and multivariate logistic regression. RESULTS More than 72% (282 of 388) of patients working or in school full-time before diagnosis had returned to full-time work or school 15 to 35 months postdiagnosis compared with 34% (14 of 41) of previously part-time workers/students, 7% (one of 14) of homemakers, and 25% (five of 20) of unemployed/disabled patients (P < .001). Among full-time workers/students before diagnosis, patients who were uninsured (odds ratio [OR], 0.21; 95% CI, 0.07 to 0.67; no insurance v employer-/school-sponsored insurance) or quit working directly after diagnosis (OR, 0.15; 95% CI, 0.06 to 0.37; quit v no change) were least likely to return. Very intensive cancer treatment and quitting work/school were associated with a belief that cancer negatively influenced plans for work/school. Finally, more than 50% of full-time workers/students reported problems with work/studies after diagnosis. CONCLUSION Although most AYA patients with cancer return to work after cancer, treatment intensity, not having insurance, and quitting work/school directly after diagnosis can influence work/educational outcomes. Future research should investigate underlying causes for these differences and best practices for effective transition of these cancer survivors to the workplace/school after treatment.

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.

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has become an important surgical quality program in the United States, yet few studies describe their methods for handling missing data. Our study examines the impact of missing data on predictive models for short-term operative outcomes after cancer surgery in the ACS NSQIP database. STUDY DESIGN We identified 97,230 patients who underwent oncologic resections for neoplasms in the 2005–2009 ACS NSQIP. We used multivariable logistic regression to assess the impact of pre-, intra-, and postoperative factors on short-term operative outcomes by type of procedure where missing values were included as a variable category, excluded, and imputed. RESULTS A large proportion (72.8%) of patients had one or more missing pre-, intra-, or postoperative characteristics, particularly preoperative laboratory values. Missing data were more frequent in healthier patients and those undergoing lower-risk procedures. Although data were not missing at random, the impact of preoperative risk factors on adverse operative outcomes after cancer surgery was similar across methods for handling missing data. However, analytic approaches using only patients with complete or imputed information risk basing the analysis on a potentially nonrepresentative sample. CONCLUSIONS Missing data present challenges to interpreting predictors of short-term operative outcomes after cancer surgery at ACS NSQIP hospitals. Similar to best practices for other data sets, this study highlights the importance of using missing values carefully when using ACS NSQIP. Given its potential to introduce bias, the approach to handling missing values should be detailed in future ACS NSQIP studies.

Context Among patients surgically treated for colon cancer, better survival has been demonstrated in those with more lymph nodes evaluated. The presumed mechanism behind this association suggests that a more extensive lymph node evaluation reduces the risk of understaging, leading to improved survival. Objective To further evaluate the mechanism behind lymph node evaluation and survival by examining the association between more extensive lymph node evaluation, identification of lymph node–positive cancers, and hazard of death. Design Observational cohort study. Setting Surveillance, Epidemiology, and End Results (SEER) program data from 1988 through 2008. Patients 86 394 patients surgically treated for colon cancer. Main Outcome Measure We examined the relationship between lymph node evaluation and node positivity using Cochran-Armitage tests and multivariate logistic regression. The association between lymph node evaluation and hazard of death was evaluated using Cox proportional hazards modeling. Results The number of lymph nodes evaluated increased from 1988 to 2008 but did not result in a significant overall increase in lymph node positivity. During 1988-1990, 34.6% of patients (3875/11 200) had 12 or more lymph nodes evaluated, increasing to 73.6% (9798/13 310) during 2006-2008 (P < .001); however, the proportion of node-positive cancers did not change with time (40% in 1988-1990, 42% in 2006-2008, P = .53). Although patients with high levels of lymph node evaluation were only slightly more likely to be node positive (adjusted odds ratio for 30-39 nodes vs 1-8 nodes, 1.11; 95% CI, 1.02-1.20), these patients experienced significantly lower hazard of death compared with those with fewer nodes evaluated (adjusted hazard ratio for 30-39 nodes vs 1-8 nodes, 0.66; 95% CI, 0.62-0.71; unadjusted 5-year mortality, 35.3%). Conclusion The number of lymph nodes evaluated for colon cancer has markedly increased in the past 2 decades but was not associated with an overall shift toward higher-staged cancers, questioning the upstaging mechanism as the primary basis for improved survival in patients with more lymph nodes evaluated.

PURPOSE Because adolescent and young adult (AYA) patients with cancer have experienced variable improvement in survival over the past two decades, enhancing the quality and timeliness of cancer care in this population has emerged as a priority area. To identify current trends in AYA care, we examined patterns of clinical trial participation, time to treatment, and provider characteristics in a population-based sample of AYA patients with cancer. METHODS Using the National Cancer Institute Patterns of Care Study, we used multivariate logistic regression to evaluate demographic and provider characteristics associated with clinical trial enrollment and time to treatment among 1,358 AYA patients with cancer (age 15 to 39 years) identified through the Surveillance, Epidemiology, and End Results Program. RESULTS In our study, 14% of patients age 15 to 39 years had enrolled onto a clinical trial; participation varied by type of cancer, with the highest participation in those diagnosed with acute lymphoblastic leukemia (37%) and sarcoma (32%). Multivariate analyses demonstrated that uninsured, older patients and those treated by nonpediatric oncologists were less likely to enroll onto clinical trials. Median time from pathologic confirmation to first treatment was 3 days, but this varied by race/ethnicity and cancer site. In multivariate analyses, advanced cancer stage and outpatient treatment alone were associated with longer time from pathologic confirmation to treatment. CONCLUSION Our study identified factors associated with low clinical trial participation in AYA patients with cancer. These findings support the continued need to improve access to clinical trials and innovative treatments for this population, which may ultimately translate into improved survival.

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.

Local public health agencies are challenged to continually improve service delivery, yet they frequently operate with constrained resources. Quality improvement methods and techniques such as statistical process control are commonly used in other industries, and they have recently been proposed as a means of improving service delivery and performance in public health settings. We analyzed a quality improvement project undertaken at a local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to reduce waiting times and improve client satisfaction with a walk-in nutrition education service. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients' satisfaction with the WIC service.