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BACKGROUND: The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcomes data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995-1996) breast cancer data on patients from low income zip codes are described here. METHODS: Since 1989, eight Calls for Data have been issued, yielding a total of 191,714 reports of non-Hispanic white patients with breast cancer for the years analyzed, 1995-1996. A total of 1961 hospital cancer registries have participated in at least one of the Calls for Data. RESULTS: A diverse range of breast cancer cases was reported from a variety of geographic locations and medical care environments. There were general similarities in the treatment of patients from the different income groups; however, some differences were reported. Among patients from lower income zip codes, 60.7% were age 60 years or older, compared with 55.1% from other income zip code groups. The AJCC stage distribution was reported as less favorable for patients from low income zip codes than for other patients. The percentage of patients from low income zip codes diagnosed as Stage 0 or I was 51.2%, compared with 55.9% of patients from the other income zip codes. Of patients from lower income zip codes, 12.1% were reported to have Stage III or IV disease, compared with 10.0% of patients from other income zip codes. Patients from low income zip codes received less tissue-sparing surgery. Of patients from low income zip codes, 14.9% received partial mastectomy with or without radiation or systemic therapy, compared with 18.3% of patients from other income zip codes. The percentage of patients from low income zip codes who received a partial mastectomy with axillary lymph node dissection was 23.3% for patients from other income zip codes, the percentage was 30.5%. Conversely, 49.8% of patients from lower income zip codes received a modified radical mastectomy, compared with 40.5% of patients from other income zip codes. CONCLUSIONS: Further improvements in the early diagnosis and surgical treatment of low income patients can probably be achieved. Programmatic activities that further explain or reduce the apparent nonpreferred treatment of some low income patients should be encouraged.

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BACKGROUND: Male breast cancer is rare, and there are no large comparative studies to guide treatment. We used National Cancer Data Base data on 4755 men and 624,174 women who had breast cancer (1985-1994) to identify equivalent groups of male and female breast cancer patients. METHODS: For each man with breast cancer, the next woman treated at the same hospital was sought who matched the man's age (within 5 years), ethnicity, income category, and stage. We identified 3627 closely matched pairs of male and female patients with breast cancer. RESULTS: Men were more likely to be treated with mastectomy (modified radical, 65% of men versus 55.1% of women; radical, 2.5% of men versus 0.9% of women; simple, 7.6% of men versus 3.4% of women; P <.001), and more likely to receive radiation therapy after mastectomy (men, 29%; women, 11%; P <.001). Men treated with lumpectomy were less likely to receive radiation therapy (men, 54%; women, 68%; P <. 001). Men were also less likely to receive chemotherapy (26.7% of men versus 40.6% of women; P <. 001) after any surgical treatment. CONCLUSIONS: This large comparative study is the first to detail stage-specific differences in contemporary treatment strategies for highly comparable groups of men and women treated for breast cancer. Further studies of male breast cancer should focus on identifying prognostic factors and defining optimal therapy.

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The laparoscopic anatomy of the pelvis is reviewed. Both male and female anatomy are detailed, and special emphasis is placed on avoiding anatomic complications of laparoscopic pelvic surgery.

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BACKGROUND: Breast conservation (partial mastectomy, axillary node dissection or sampling, and radiotherapy) is the current standard of care for eligible patients with Stages I and II breast cancer. Because axillary node dissection (AND) has a low yield, some have argued for its omission. The present study was undertaken to determine factors that correlated with omission of AND, and the impact of the decision to omit AND on 10-year relative survival. STUDY DESIGN: A retrospective review of National Cancer Data Base (NCDB) data for 547,847 women with Stage I and Stage II breast cancer treated in US hospitals from 1985 to 1995 was undertaken. A subset of 47,944 Stage I and 23,283 Stage II women treated with breast-conserving surgery (BCS) was identified. Cross-tab analysis was used to compare patterns of surgical care within this subset. Relative survival was calculated as the ratio of observed survival to the expected survival for women of the same age and racial/ethnic background. RESULTS: The rate of BCS with and without AND increased steadily from 17.6% and 6.4% of patients from 1985-1989, to 36.6% and 10.6% of patients from 1993-1995 respectively. AND was more likely to be omitted in women with Stage I than women with Stage II disease (14.5% versus 5.5%). Similarly, AND was omitted more frequently in women with Grade 1 than women with higher grades (Grade 1, 14.9%; Grade 2, 10.1%; Grade 3, 7.1%; Grade 4, 7%). Although the rate of BCS with AND varied considerably according to location in the breast, the overall rate of BCS without AND appeared independent of site of lesion. Women over the age of 70 years were more than twice as likely to have AND omitted from BCS than their younger counterparts. Women with lower incomes, women treated in the Northeast, or at hospitals with annual caseloads <150 were all less likely to undergo AND than their corresponding counterparts. Ten-year relative survival for Stage I women treated with partial mastectomy and AND was 85% (n = 1242) versus 66% (n = 1684) for comparable women in whom AND was omitted. BCS with AND followed by radiation therapy for Stage I disease resulted in 94% (n = 5469) 10-year relative survival, compared with 85% (n = 1284) without AND. Addition of both radiation and chemotherapy to BCS with AND for Stage I disease resulted in 86% (n = 2800) versus 58% (n = 512) without AND. In contrast, Stage II women treated with BCS with AND followed by radiation and chemotherapy experienced a 72% 10-year relative survival. CONCLUSIONS: A significant number of women with Stage I breast cancer do not undergo AND as part of BCS. The trend is most pronounced for the elderly, but significant fractions of women of all ages are also being undertreated by current standards. Ten-year survival is significantly worse when AND is omitted. This adverse survival effect is not solely from understaging.

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Laparoscopic biliary bypass provides an attractive alternative to endoscopic stenting for nonresectable pancreatic carcinoma. Laparoscopic gastroenterostomy may be added if duodenal obstruction is present. These simple palliative procedures achieve long-term relief of jaundice and duodenal obstruction. The laparoscopic approach allows early discharge from the hospital with minimal incisional pain, both of which are highly beneficial to patients with limited lifespan.

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BACKGROUND: The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcome data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995) data are described herein. METHODS: Since 1989, seven calls for data have been issued, yielding reports on a total of 240,031 breast carcinoma patients for the years included in this analysis. A total of 1849 hospital cancer registries responded to at least 1 of the calls for data. RESULTS: A continuous improvement in care was reported. By 1995, 45.8% (nearly one-half) of breast carcinoma patients were diagnosed early as Stage 0 or I, and early stage patients (Stage 0 or I) were most often treated with partial mastectomy (in 58% of cases). Favorable 10-year relative survival rates for Stage 0 (95%) and Stage I (88%) breast carcinoma patients were reported. Patients who were presumed to be Stage I and were not selected for axillary dissection had poorer survival. Survival differences were reported for different treatment groups within individual stage strata. Over the 10-year observation period, fewer patients from lower-income neighborhoods were diagnosed with early stage breast carcinoma. In general, the annual relative survival rate remained constant over the 10-year observation period (with no plateau after 5 years) within each stage and for all stages combined. CONCLUSIONS: Improvements in diagnosis and treatment during the period 1985-1995 were demonstrated by these data. The NCDB breast carcinoma data are appropriate norms for formal quality assurance purposes, such as those specified by the Standards of the Commission on Cancer published by the American College of Surgeons Commission on Cancer. Cancer committees and other clinicians working within the hospital setting should assess and compare stage distribution, stage specific treatment patterns, and the correlations between the outcomes of patients and both disease stage and treatment.

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Cancer complicating pregnancy is uncommon, with an incidence of approximately 1 in 1000 pregnancies. The obstetrician attending 250 deliveries per year would need to accumulate 40 years of clinical experience to encounter two to three cases of PABC. The increases in the size, weight, vascularity, and density of the breasts associated with pregnancy make the detection of mass lesions difficult both clinically and mammographically. Most of the benign lesions seen in pregnancy are the same ones seen in the nongravid state. Most cases of PABC present as painless masses, and as many as 90% of these masses are detected by breast self-examination. Women with PABC generally have more advanced disease with larger tumors, a higher percentage of inoperable lesions, and a higher percentage of nodal involvement. Because most PABC presents with a palpable mass, the role of imaging modalities in the evaluation of these patients remains limited. Fine-needle aspiration cytology is the initial procedure of choice for evaluating breast masses during pregnancy and lactation. Therapeutic abortion does not improve survival. The general principle is to treat the cancer and to allow the pregnancy to proceed. No studies have shown an adverse effect of a subsequent pregnancy even in patients with positive axillary nodes and patients in whom pregnancy occurs earlier than 2 years after treatment.

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BACKGROUND: The National Cancer Data Base (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, is a cancer management and outcomes data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. This article describes the most current (1995) data. METHODS: Since 1989, 7 calls for data have been issued, yielding a total of 5,558,389 cancer patient reports for the years 1985-1995. A total of 1849 hospital cancer registries have participated in at least 1 of the calls for data. RESULTS: One thousand one hundred and fourteen hospitals from 50 states and the District of Columbia reported 655,627 cases for the diagnosis year 1995. The hospitals represented a wide range of sizes (187 [16.8%] with 1000+ cases annually, 405 [36.4%] with 500-999 cases annually, 255 [22.9%] with 300-499 cases annually, 211 [18.9%] with 100-299 cases annually, and 56 [5%] with < 100 cases annually) and types (21 [1.9%] National Cancer Institute [NCI]-recognized cancer centers, 119 [10.7%] government hospitals, 102 [9.2%] teaching hospitals, 256 [23.0%] large community hospitals, 297 [26.7%] medium/small community hospitals, and 257 [23.1%] nongovernmental hospitals without approval status from the Commission on Cancer or NCI recognition). Remarkably similar distributions of cases by primary site and age were reported from each of six U.S. geographic regions. In addition, within each of these six regions, the cases were reported from a wide range of income strata and ethnicities. For several states, relatively few cancer cases were reported. For several examples of relatively rare patient and tumor groups, all reported cases between 1985-1995 included potentially useful quantities of patients in whom further study of such special groups was warranted. CONCLUSIONS: The authors conclude that the reported cases most likely are representative at the regional (but not state) level of cancer patients diagnosed and treated at U.S. hospitals with regard to types of cancer and ages of the patients. They conclude further that cancer reporting may be quite diverse within each region with regard to other known patient and reporting institution characteristics.

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BACKGROUND: The National Cancer Data Base (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, is a cancer management and outcomes data base for health care organizations. It provides a comparative summary of patient care that is used by communities and participating hospitals for self-assessment. The most current (1994) data are described here. METHODS: Six calls for data have yielded a total of 4,580,000 cases for the years 1985-1994. A total of 1735 hospital cancer registries have each participated in at least one of the calls for data. RESULTS: Summing the last year's report from each of the 1227 hospitals that participated in 1994, the cases represent the equivalent of 57% of the estimated 1994 U.S. cancer cases. These data were received from all six regions of the country, including all 50 states. Ninety-seven percent of patients received all or part of their treatment at the reporting hospital. The four most common cancers are carcinomas of the breast (15.7%), lung (14.3%), prostate (13.1%), and colon (7.7%), and collectively they comprise a majority of new cases. CONCLUSIONS: The NCDB is a cancer management and outcomes data base for health care organizations that currently provides data on 57% of the estimated new cases in the U.S. Past data have been used extensively to assess patterns of care and outcomes.

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The Mississippi Breast and Cervical Cancer Control Coalition conducted a survey of health care professionals to assess current practices in the areas of breast and cervical cancer screening. A 22% response rate was obtained, with family practitioners having the highest response rate. Cost was cited as a major barrier to access to screening mammography. Some discrepancies between provider perceptions and currently accepted guidelines were identified.

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As the immunocompromised patient population grows, the gastrointestinal surgeon is increasingly called upon to make complex diagnostic and therapeutic decisions. The surgeon should first identify the patient as immunocompromised and then categorize the probable degree of immunocompromise as mild, moderate, or severe. Mildly immunocompromised patients tend to present late and with minimal symptoms, but the disease entities are the same ones seen in the general population. Moderately and severely immunocompromised patients may also develop the usual surgical problems, but the differential diagnosis is expanded to include complications of the immunocompromised state or complications of the underlying problem which caused the immune compromise. The expanded differential diagnosis includes infections with atypical organisms, opportunistic neoplasms, neutropenic enterocolitis, complications of medications, and forms of biliary tract disease not seen in the general population. Advances in oncology, transplantation, and the treatment of AIDS, have extended the life expectancy of these patients and increased the immunocompromised population. Prompt appropriate operative therapy may be lifesaving when surgical complications develop.

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The finite time span and the nonrepetitive nature of the project distinguish it from the routine activities characteristic of the management of a surgical department or division. Defined goals, specific (finite) resource allocation, and identifiable sequential phases also characterize the project. This paper reviews project management techniques that may be useful in the Department of Surgery.

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A laparoscopic approach to patients with possible appendicitis has increased in popularity. In this article it is compared to the traditional open appendectomy, and the management of frequently found gynecologic pathology masquerading as appendicitis is described.

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The use of laparoscopy in the treatment of malignant diseases is one of the great advances of surgery in the last few decades. Its roles as a diagnostic modality, a staging tool, and a therapeutic avenue for the various malignancies of the abdominal cavity continue to expand. The benefits to cancer patients with regard to reduced morbidity and shorter hospitalizations are well established. As video, optical, insufflation, and instrumentation technologies advance further, laparoscopic techniques for the treatment of cancer can only multiply in depth and breadth.

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BACKGROUND: Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS: We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these women's charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS: Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS: Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

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BACKGROUND: The peer review process used in most hospitals is largely anecdotal, leading to criticisms about the objectivity of the methods employed. METHODS: The results of 1,500 consecutive abdominal operations performed by general surgeons working at three hospitals in a single community were reviewed. The outcome profile of each surgeon was compared statistically to the cumulative profile of the surgical community with adjustments for physiologic status of the patient, difficulty of the operation, and indications for surgery. RESULTS: A problem surgeon was thus identified whose poor results were significantly different from the rest of the surgical community and could not be explained on the basis of unfavorable patient mix or complexity of the procedures undertaken. CONCLUSIONS: Statistical comparison of a surgeon's outcome profile with those of his colleagues working in the same practice environment is suggested as an approach to the task of peer review that might prove preferable to the usual retrospective review of problem cases.

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Prior studies regarding immune function in bile-duct ligated rats have illustrated blunted immune function. The present study measures natural killer (NK) cell activity. Rats underwent bile duct ligation (BDL) or sham celiotomy (SC) and were sacrificed at 1, 2, and 3 weeks after surgery. Ficoll-Hypaque density centrifugation was used to obtain a purified preparation of splenocytes. NK cell activity was determined by incubating varying concentrations of splenocytes with chromium-labelled YAC-1 tumor cells for 4 hours. Chromium release was measured by a gamma counter and expressed as per cent activity (compared with 100 per cent activity obtained by complete lysis with detergent). The experiments were repeated after preincubation in tissue culture flasks to remove an adherent cell population. NK cell activity was decreased at all spleen cell:target cell ratios studies at 1 week after BDL. At 2 weeks after BDL, NK cell activity was decreased at all but the lowest two concentrations; and 3 weeks after BDL, NK cell activity was decreased only at the highest concentrations used. Separation of an adherent cell fraction restored NK cell activity. This suppression in NK cell activity one week after BDL may account, in part, for the poor response of BDL animals to bacterial and immune challenge. Restoration of activity after removal of an adherent cell fraction suggests that macrophages may be at least partly responsible for this inhibition.

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BACKGROUND: Familial juvenile polyposis predisposes to the development of carcinoma of the colon. Optimum surgical management and recommended surveillance of affected individuals are still being defined. STUDY DESIGN: A retrospective review of experience with a kindred identified in 1988 was carried out. RESULTS: Of 34 living members, 15 have been investigated, and histologically typical juvenile polyps were found in 11. In each instance, polyps were most numerous in the right colon, with few polyps in the descending colon and none in the rectum. Eight patients have had subtotal colectomies with ileorectal anastomoses; the remaining patients were managed by polypectomy (with one recurrence after ten years). In addition to juvenile polyps, polyps with adenomatous or villous elements were identified in three patients. One of these patients had invasive adenocarcinoma in a large mixed polyp of the cecum. Two patients with polyps had coexisting carcinoma of the stomach. All patients have been followed up with periodic upper and lower gastrointestinal endoscopy. Polyps have recurred in the rectal remnants of three patients at a mean of 36 months after subtotal colectomy. Two patients have undergone conversion to total proctocolectomy with ileoanal anastomosis and J pouch; one patient was found to have juvenile polyps in the pouch 40 months after surgery. CONCLUSIONS: Despite the preponderance of right-sided polyps at initial diagnosis, the rapid recurrence of polyps after subtotal colectomy argues in favor of performing proctocolectomy with preservation of anal sphincter function (restorative proctocolectomy) at the time of initial surgery. Patients with a small number of polyps may choose instead to undergo periodic colonoscopy with colonoscopic polypectomy. An algorithm for surveillance and follow-up is proposed.

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BACKGROUND: In addition to mastitis, lactational breast abscesses, and several other benign conditions unique to the puerperium, pregnant women may develop any of the other breast problems seen in the nonpregnant female population. This review deals with the diagnosis and management of breast problems during pregnancy and lactation. DATA SOURCES: A literature review of the evaluation, technique of biopsy, and treatment of cancer in pregnant women was conducted. CONCLUSIONS: The most common problems fall into a spectrum of infectious complications from milk stasis or mastitis to frank abscess formation. Galactoceles, noninfected milk-filled cysts, present as tender masses; aspiration is both diagnostic and curative. Benign fibroadenomas occasionally enlarge significantly or infarct during pregnancy. A physiologic nipple discharge is common during pregnancy, and may be bloody. Rare cases of massive breast hypertrophy during pregnancy have been reported. The mortality of breast cancer during pregnancy is related to delay: compared stage-for-stage with nonpregnant controls, the prognosis is similar. As a general rule, the cancer should be treated surgically and the pregnancy may be allowed to progress.

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