February 20, 2025 • 23 mins
In this episode, Lillian Erdahl, MD, FACS, is joined by Judy Boughey, MD, FACS, from the Mayo Clinic Rochester Department of Surgery. They discuss Dr Boughey’s recent article, “American College of Surgeons Cancer Programs Annual Report from 2021 Participant User File.” This inaugural annual report from the National Cancer Database describes the 2021 adult participant user files (PUF) as a whole, as well as the PUFs for breast, colon, and pancreatic cancer in more detail. It summarizes new observations and recent trends of cancer diagnoses, patient demographics, and treatment trends.
Disclosure Information: Drs Erdahl has nothing to disclose. Dr Boughey receives funding paid to her institution from Eli Lilly and SymBioSis; sits on the Data Safety Monitoring Committee of CairnsSurgical; and has received honoraria from PER, PeerView, OncLive, EndoMag, and UpToDate.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome back to The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your co-host, Lillian Erdahl,and today I am joined by Dr Judy Boughey,
who is the DivisionChair of Reston Melanoma Surgical Oncology
and the Breast CancerDisease Group Chair at the Mayo Clinic.
(00:50):
She also holdsa number of national titles,
including Chair of the American Collegeof Surgeons Cancer Research program
and President of the American Societyof Breast Surgeons.
And she also is my mentor
and was my fellowship director,or so it's just,
pleasure to be able to have this podcastinterview with you, Dr Boughey.
(01:11):
Welcome.
Well, Dr Erdahl,it's a real pleasure to be doing this
podcast with you and working togetherwith you over the years.
So thank you for this opportunity.
Yeah.
And we are here to talk aboutthe publication, the American College
of Surgeons Cancer Programs Annual Reportfrom the 2021 Participant User File.
(01:32):
So first, I'll ask youif you have any disclosures to share,
related to this work.
Yeah.
I don't have any disclosuresspecifically related to this work.
As the publication notes, I have had money
paid to my institution of researchfrom Eli Lilly and Symbiosis,
and I sit on a data safety monitoringcommittee for Cairns Surgical.
I've had some honoraria in the pastfrom educational opportunities
(01:55):
like PeerView, OncLive,UpToDate and also, EndoMag.
Great.
Thank you for sharing those.
This publication,I think, is of interest to our readers,
not just because of the content, but also,because it's a little bit unique.
So this is the first time,
that we've had a publication of this kind,is that correct?
(02:17):
Yeah.
So this really camethrough the American College of Surgeons
cancer research program, as you mentioned,I'm the chair of that group,
working closelywith the National Cancer Database.
So the cancer research programis really looking at what is the research
and the information that is valuable
to membersof the American College of Surgeons.
And so with that,we felt that the National Cancer
(02:39):
Database is obviously a very well known,strong database
that many researchers will access thePUF file, look up individual,
research projects, and
then make their publications,using the NCDB data.
But there, we never really hada publication essentially
from the NCDB leadership,along with cancer researchers
(03:02):
to really describe thatwhole overview of the data in the NCDB.
And so really this as you mentionedis our first annual report
looking at a high level acrossall of the National Cancer
Database data user,Participant User File from 2021.
And so the paper is structuredvery much to look at that overview
of all of the cancer cases
(03:23):
we focus on and a little bit on the fivemost common adult cancers.
And then in the second part of the reportwe focus on the first three,
specific cancers.
We take a focus on breast
cancer, colon cancer,and pancreatic cancer in this issue.
And then in subsequent annual reports,we plan to cover
different cancers in each report.
(03:44):
And I think there's a lot of information
here, partly because there are millions of
patients diagnosed with
cancerwho are represented in this database.
1500 Commission on Cancer Facilities,you know, it
represents 73.7% of the newly diagnosedcancer cases in the United States.
(04:07):
So what a great repository of data. And,
as I'm sure that the researcherslistening know, this is just represents
so much effort from so many differentindividuals to collect the data.
And it was interesting to meas a breast cancer
doctor to look at, you know, some of the,the details on
(04:30):
breast cancer, but I think also it to me,it provides a way for researchers
who might request NCDB data in the futureto understand a little bit better
what's captured in the database,because I think that's one of the
challenges sometimes, in thinking aboutwho is is putting in requests.
And I know,those requests are reviewed to see whether
(04:51):
it's, you know, meaningful researchand whether it's something that
that the NCDB is the correct database,to provide those details.
So hopefully this helps, you know,not just provide an overview of,
of the cancer data collected,but also, to tell researchers considering
looking at these files, you know,what might be of significance for them?
(05:13):
Yes, it's definitely there are nuances to,
using the data from the NCDB andunderstanding the coding in the language.
And as you pointed out, the limitations,
you know, as you pointed out,
the NCDB data represents about 74%of newly diagnosed cancer nationwide.
So we can't really talk about true
incidence because this does not captureall cancers across the country,
(05:37):
although it does capture,very large significant amount,
although obviously the institutionsparticipating may vary each year.
So it is hard.
To do an exact year by year comparison,
although obviously the trendsI think are of interest.
I think one of the
values of the NCDB is we do capture 30-day
(06:00):
morbidity and mortality and, admissionrates and post-operative outcomes.
So from a surgical standpoint,that's very valuable.
I think one of the biggest limitations is
we don't capture breast cancer recurrenceor any type of cancer recurrence.
So while we do get patientoverall survival,
we don't get specific dataon local recurrence, distant recurrence.
(06:22):
And so that obviously is limitation
that needs to be acknowledgedin any oncological publication.
That comes out from the NCDB.
And I think,
those longer term follow ups, as you know,
from all of your research work,are challenging.
Being able to continue to follow a patient
for five yearsor in, in the case of a lot of these
(06:45):
cancer patients are living for decadesafter their treatment,
you know, to really understandthe incidence of recurrence and
especially ER-positive breast cancer,I think it's challenging.
Yeah, I think definitely,as you point out, for breast cancer, it's
more challenging
because we have a patient populationthat has a relatively good survival.
Pancreatic cancer, it's unfortunatelya little bit less challenging.
(07:08):
The registrars at the sitesdo an excellent job
of trying to, get follow upinformation on the patients.
So we have relativelygood follow-up in terms of,
patient status, in terms of
whether they're alive or have passed away.
But yeah, the recurrence dataat this point is not widely available.
Were there, surprises to youor to the research team
(07:31):
in looking through the,the data, you know, putting all of this
togetherand sort of looking at the numbers?
I wouldn't say there were any surprises.
I mean,I think the subject matter experts,
and we did have subject matter expert
from breast and colon and from pancreasfor each of those aspects.
So I don't think any of uswas specifically surprised
at anything that we, we found,I mean, I think we feel like we understand
(07:55):
the trends, but I think it was niceto kind of highlight some of those trends.
And these obviouslywill change with each report. But,
for me, as a breast cancer physician,as you know,
we're using a lot more neoadjuvanttherapy in breast cancer.
And so looking at where neoadjuvanttherapy has been on the rise,
across cancers,we saw that it did rise in breast cancer.
(08:17):
Interestingly.
It kind of went up in 2020 and dippeda bit in 2021 in the neoadjuvant setting.
But and obviously we also sawa very striking increase
in neoadjuvant managementfor patients with,
pancreatic cancer.
The other tumor,other tumor types, it's a little bit
less, frequentthat neoadjuvant is being used.
(08:40):
And I think we, we anticipate thatthat's probably going to change over time
as oncologic therapyand targeted therapy changes.
So I think that was interesting to see.
Again, somewhat limitedbecause this is only the 2021 PUF.
So it'll
be interesting to see how that looks overthe upcoming years.
I think,
(09:00):
obviously focusing on breast,
which is Dr Erdahl’sand my area of interest,
you know, looking athow the use of neoadjuvant therapy
really increased,specifically in like stage two,
ER-negative breast cancer dramatically
kind of from 2018 through 2021.
I thought those graphswere really descriptive.
(09:22):
And I think that's very helpful,not only for researchers, but
also as you're trying to planyour clinical practice, right.
What proportion of your patientsare going to go into neoadjuvant,
what portion need to see medical oncologyprior to surgery
or have a multidisciplinary, clinicor a tumor board?
And then how do you staff,according to how practice is changing.
So I think that these data can be helpful
(09:43):
both from a research standpoint as wellas from a practice management standpoint.
Similarly,I think we've all seen a lot more kind
of same day surgery or shorter,length of admission.
And we, within this paper kind of describeand, the length of stay and the,
30-day mortality and the readmission rates
(10:04):
within 30 days for the breast cancerpatients, the colon cancer
patients undergoing colectomy,and the pancreatic patients.
And that could be helpful
in terms of planning,kind of how many patients to anticipate
how long they aregoing to stay in the hospital.
So I think that this report has valueto administrators, physicians,
healthcare providerskind of across the spectrum.
(10:26):
Well, as I think aboutnot just those physicians
who are at a cancer center and have allthe multidisciplinary resources.
Hopefully this is helpful informationfor anyone
seeing a patientwith a new cancer diagnosis in in a state,
like Iowa, where I practice, you know, anumber of our patients live several hours
(10:46):
away from the nearest cancer centeror that nearest multidisciplinary clinic.
And understanding which patients,
would,
wouldbe most likely to benefit from referral,
you know, looking at
how do you get themto see medical oncology before surgery
if they would benefit from neoadjuvantchemotherapy?
I think this is very informativearound the practice trends.
(11:09):
When I think about the practicein our state and those general surgeons
in rural communities trying to figure out,you know, which patients, can,
can be helped with their local resourcesand which patients need, more resources.
Or again, for administrators, you know, dowe need to look at bringing
more medical oncologists to a community,
vs, you know, having to ask patientsto travel those long distances,
(11:33):
particularly when they're undergoingtreatments like chemotherapy?
So I, I really enjoyed kind of thinkingabout that from a health system
standpoint.
I was interested to see that lobularcarcinoma in situ
was reported as an,you know, a small proportion, but,
as breast cancer,which is not how the NCCN looks at it.
(11:55):
So, so, you know, the contributing usersare, providing information
and, that might be differentfrom how I would look at it.
Yeah.
So as you mentioned, looking at lobularcarcinoma in situ made up about 5%
of those reported in the NCDBand 11% of the total in situ cancers.
But we did exclude them from the numberson the rest of the tables on the graphs.
(12:16):
So we kind of as you eloquently say,you know, we don't really consider
LCIS, cancer consideredas more as a precursor.
And so they're excluded from all of theanalysis that we performed.
I do think the
other thing that came out,and I'll be interested to see the trends
with the other cancers
and subsequent reports, was,as you mentioned, the lack of progress in,
(12:41):
improving mortality and morbidityfor pancreatic cancer
or the ongoing challengesin treating pancreatic cancer.
And I don't know
if you have anything to share about that,but it is disheartening to see that even
with all of our resources and research,we haven't made progress in some areas.
Yeah.
So I think, I think breast and pancreaticare strikingly different,
(13:02):
which is part of why we put both of themin the same report.
And so obviously from, from our lens,
dealing with breast cancerpatients day in and day out.
It's obviously a very different practiceto the survival for pancreatic cancer.
I do think that the trend towards
more neoadjuvant therapy for that patientpopulation is encouraging.
(13:23):
And so, you know, itmay be, you have to remember in breast,
we shifted neoadjuvant kind of in the midtwo tens if we look at the graph.
So I would be really interested to lookagain at the pancreatic data in the model.
Updated Participant User File.
I think in all cancers typeswe are constantly shifting
to try to improve the survivalfor each of our patients.
(13:45):
So I think we will continuallybe working on that.
And the other, things that I think about,and we've seen some national shifts
in recommendations, are the stageat which the colon cancer is diagnosed.
So it looked like colon cancer is stilloften diagnosed at stage two and three.
And I know the age for screening forthe population has shifted younger.
(14:08):
I wonder if we'll see a changein that, stage
at diagnosis 10 years down the road.
Yes. Having, just reached those guidelinesright at the point that they changed.
I personallydid have my first colonoscopy at 45.
So yes, I definitely thinkas the screening guidelines change,
(14:28):
hopefully the goal will be earlierdetection at an earlier stage.
You know, a report like thishopefully will be able to capture that.
So I think this report is so exciting.
It's like I'm anxiousto have even more updated data.
And almost from this report again,as soon as we have kind of the 2022
and hopefully soon after the 2023Participant User File
(14:51):
and I think it gives us actionableinformation.
I know it's a lot to read throughand some of it's very large numbers.
But I think about our efforts again.
One of the things that we did in breast
cancer was sort of return to screeninginitiatives when, we were coming
out of the pandemic, when many patientsdidn't have access, to their screening.
(15:14):
And of course, we've had another changeto the breast cancer screening guidelines.
As well, from the national standpoint,
there's been a lot of controversyaround those screening guidelines as well.
But starting mammograms at age40 for average risk women
and then hopefullydoing a better job of identifying risk.
And I think that's the other piecethat I would wonder how that's going
(15:34):
to change the trends over timeas we're identifying patients at risk for,
you know, several different cancerswith genetic testing, with better
risk stratification based on familyhistory, that the screening tests
for pancreatic cancer and ovarian cancer,for example, are still challenging.
But I think, as we do more
(15:56):
individualized cancer screening,I hope that that will make an impact.
And I don't know what your thoughts are onkind of how we individualize
our cancer screening and treatment,but I know that's a big part of, of,
you know, your practiceand the efforts that you've made.
Yeah.
I mean, I think the future for cancercare is going to be much more kind
of individualized screening.
(16:16):
And then also even in individualizedsurvivorship.
Right.
Why do we follow patientsthat are at high risk of recurrence
the same way as those patientsthat are at low risk of recurrence?
Why do we follow a stage one cancer thesame way as we follow stage three cancer?
Right.
We follow those that respondedwell to chemo at the same way we follow
those that had a complete,you know, had a lot of residual disease.
(16:37):
So I think, you know,individualization of care is,
I think, going to be the biggest themeover the next decade now in cancer,
both in screening, in treatmentand then in surveillance.
And I think, you know, obviouslyin breast, in the dense
breast, aspect,and how we best screened those patients.
I think genetic testing is becomingfar more widespread.
(16:59):
We will identify patientsthat are at increased risk,
and hopefully have appropriatescreening programs for pancreatic cancer,
ovarian cancer, colon cancer,for all of those individuals.
So I think we will start seeing a shiftin all of these numbers.
Yeah.
And again, I'm putting on my health systemhat, as you talk about
individualizing the survivorshipand the screening,
(17:20):
because the other challengesare workforce,
and our ability to see patients
every three months for fiveor 10 or 20 years after their treatments.
And so figuring out,
from the standpoint of the health system,but also the individual patient
when those visits are excessiveand not serving benefits.
Sounds really exciting to me.
(17:42):
And the individualization of survivorship,
definitely,
touches my practicebecause we have everything from stage
zero in situ, not life-threatening cancer
to, you know, advanced stage cancer with,metastatic disease, where we're trying
to, manage those patientsand they don't have the same needs,
(18:04):
both in the acute managementand in the long term follow up.
Yeah, I would agree.
And I think, hopefully in the futureAI will have some ability to kind of
help us with, you know, flagsin the electronic medical record
and questionnaires for the patients.
And maybe we can do a little bit moreremote and minimize the time
for the patient away from their work,coming into our practice for visits.
(18:25):
So, I think it's a lot of moving partsright now in the healthcare system.
And that's it's scary, but it's exciting.
Yeah. Do you,
do you see other large databases
reporting sort of all of their datain this way?
Because again, the, the historicallythe NCDB has really worked
as a repositoryfor more individualized projects.
(18:50):
Is this a trend that we are seeingnationally
where we're going to have more sortreporting out of large databases?
Or do you think thatthis is unique to NCDB?
I think SEER has done its reportfor many years, and there's often
a very highly cited report.
And obviously they can talkmore clearly about incidence.
And so we were very promisingwhen we put this report together.
(19:11):
This is distinctly differentto the SEER annual report.
And so trying to focuson the areas of data that the NCDB has
that does not overlap with SEER,because there's no point having
overlapping reports.
And so we're, we're very much more focusedon kind of,
the specificsof how the patient was treated.
(19:31):
And along with the outcomes
and I think I've been really pleasedto hear
how well this paper has been receivedand the interest in this paper.
And really, I think that's what speaks towhether this would continue.
I think that the leadershipof the American College of Surgeons
cancer research program and the NCDB been
would like to make this an annual reportas long as there is value,
(19:53):
in the readershipfrom having this information.
And so our goal is
probably to, to keep this going.
I’m actuallyhopeful that we'll get the 2022
PUF File reportpublished in the first half of this year.
So it may actually be quickerthan one year by the time
that this was released,and we're actually ideally
(20:14):
would like to have the data from the NCDBbe a little bit more real time.
So my goal maybe for 2026 or 2027that we may actually be able
to report just on the previous year,as opposed to, 3 to 4 years earlier data.
So that's kind of our goalsmoving forward.
But it's very much dependenton the readership, but based on what
we've seen of the interest in this report,this podcast, the media,
(20:38):
picking this report up, it seems thatpeople are definitely interested in that.
And if there's an interest
the American College of Surgeons cancerprogram leadership definitely wants to
invest to make the information availableto the people that are interested in it.
Well, I think that that is a
great summary statementfor our podcast discussion.
(21:00):
And I again,I was excited to read these data
and learn more about the trends in cancer
care, particularly breast cancer care,but all of cancer care.
And I hope that
all of our readers and,
you know, the hospital systemsand cancer programs
can use these data to guide what they doand what they're seeing.
(21:24):
And even more real time data, hopefullyin the future would be excellent.
But I think looking at these trends overtime,
as subsequent reportscome out is very interesting to me
to see how we're changingand where to focus our efforts
to make more improvementsin cancer care and cancer outcomes.
And I know,
you know, my,
(21:46):
chair, Dr Weigel as well,from the American College of Surgeons
cancer programs, reallyis dedicated to figuring out
how do we improve cancer care acrossall of our institutions, everywhere
that our patients are being treated,particularly by surgeons?
But, we know that cancer careis multidisciplinary.
So thank you to you and your team.
(22:07):
I know this, represents a lot of effort
from so many peopleto put a report like this together.
Well,thank you, Dr Erdahl, for the opportunity
to discuss this with you today.
And if anyone does have any particularadditional aspects, I'd like to see and
reports like this, please don't hesitateto reach out to me and to Dr Weigel.
We want to make this as usefulto our readership as possible,
(22:28):
and we really appreciate everyone'sinterest.
Great talking to you, too.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available
(22:50):
or listen on the American Collegeof Surgeons website at FACS.org/podcasts.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome back to The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your co-host, Lillian Erdahl,and today I am joined by Dr Judy Boughey,
who is the DivisionChair of Reston Melanoma Surgical Oncology
and the Breast CancerDisease Group Chair at the Mayo Clinic.
(00:50):
She also holdsa number of national titles,
including Chair of the American Collegeof Surgeons Cancer Research program
and President of the American Societyof Breast Surgeons.
And she also is my mentor
and was my fellowship director,or so it's just,
pleasure to be able to have this podcastinterview with you, Dr Boughey.
(01:11):
Welcome.
Well, Dr Erdahl,it's a real pleasure to be doing this
podcast with you and working togetherwith you over the years.
So thank you for this opportunity.
Yeah.
And we are here to talk aboutthe publication, the American College
of Surgeons Cancer Programs Annual Reportfrom the 2021 Participant User File.
(01:32):
So first, I'll ask youif you have any disclosures to share,
related to this work.
Yeah.
I don't have any disclosuresspecifically related to this work.
As the publication notes, I have had money
paid to my institution of researchfrom Eli Lilly and Symbiosis,
and I sit on a data safety monitoringcommittee for Cairns Surgical.
I've had some honoraria in the pastfrom educational opportunities
(01:55):
like PeerView, OncLive,UpToDate and also, EndoMag.
Great.
Thank you for sharing those.
This publication,I think, is of interest to our readers,
not just because of the content, but also,because it's a little bit unique.
So this is the first time,
that we've had a publication of this kind,is that correct?
(02:17):
Yeah.
So this really camethrough the American College of Surgeons
cancer research program, as you mentioned,I'm the chair of that group,
working closelywith the National Cancer Database.
So the cancer research programis really looking at what is the research
and the information that is valuable
to membersof the American College of Surgeons.
And so with that,we felt that the National Cancer
(02:39):
Database is obviously a very well known,strong database
that many researchers will access thePUF file, look up individual,
research projects, and
then make their publications,using the NCDB data.
But there, we never really hada publication essentially
from the NCDB leadership,along with cancer researchers
(03:02):
to really describe thatwhole overview of the data in the NCDB.
And so really this as you mentionedis our first annual report
looking at a high level acrossall of the National Cancer
Database data user,Participant User File from 2021.
And so the paper is structuredvery much to look at that overview
of all of the cancer cases
(03:23):
we focus on and a little bit on the fivemost common adult cancers.
And then in the second part of the reportwe focus on the first three,
specific cancers.
We take a focus on breast
cancer, colon cancer,and pancreatic cancer in this issue.
And then in subsequent annual reports,we plan to cover
different cancers in each report.
(03:44):
And I think there's a lot of information
here, partly because there are millions of
patients diagnosed with
cancerwho are represented in this database.
1500 Commission on Cancer Facilities,you know, it
represents 73.7% of the newly diagnosedcancer cases in the United States.
(04:07):
So what a great repository of data. And,
as I'm sure that the researcherslistening know, this is just represents
so much effort from so many differentindividuals to collect the data.
And it was interesting to meas a breast cancer
doctor to look at, you know, some of the,the details on
(04:30):
breast cancer, but I think also it to me,it provides a way for researchers
who might request NCDB data in the futureto understand a little bit better
what's captured in the database,because I think that's one of the
challenges sometimes, in thinking aboutwho is is putting in requests.
And I know,those requests are reviewed to see whether
(04:51):
it's, you know, meaningful researchand whether it's something that
that the NCDB is the correct database,to provide those details.
So hopefully this helps, you know,not just provide an overview of,
of the cancer data collected,but also, to tell researchers considering
looking at these files, you know,what might be of significance for them?
(05:13):
Yes, it's definitely there are nuances to,
using the data from the NCDB andunderstanding the coding in the language.
And as you pointed out, the limitations,
you know, as you pointed out,
the NCDB data represents about 74%of newly diagnosed cancer nationwide.
So we can't really talk about true
incidence because this does not captureall cancers across the country,
(05:37):
although it does capture,very large significant amount,
although obviously the institutionsparticipating may vary each year.
So it is hard.
To do an exact year by year comparison,
although obviously the trendsI think are of interest.
I think one of the
values of the NCDB is we do capture 30-day
(06:00):
morbidity and mortality and, admissionrates and post-operative outcomes.
So from a surgical standpoint,that's very valuable.
I think one of the biggest limitations is
we don't capture breast cancer recurrenceor any type of cancer recurrence.
So while we do get patientoverall survival,
we don't get specific dataon local recurrence, distant recurrence.
(06:22):
And so that obviously is limitation
that needs to be acknowledgedin any oncological publication.
That comes out from the NCDB.
And I think,
those longer term follow ups, as you know,
from all of your research work,are challenging.
Being able to continue to follow a patient
for five yearsor in, in the case of a lot of these
(06:45):
cancer patients are living for decadesafter their treatment,
you know, to really understandthe incidence of recurrence and
especially ER-positive breast cancer,I think it's challenging.
Yeah, I think definitely,as you point out, for breast cancer, it's
more challenging
because we have a patient populationthat has a relatively good survival.
Pancreatic cancer, it's unfortunatelya little bit less challenging.
(07:08):
The registrars at the sitesdo an excellent job
of trying to, get follow upinformation on the patients.
So we have relativelygood follow-up in terms of,
patient status, in terms of
whether they're alive or have passed away.
But yeah, the recurrence dataat this point is not widely available.
Were there, surprises to youor to the research team
(07:31):
in looking through the,the data, you know, putting all of this
togetherand sort of looking at the numbers?
I wouldn't say there were any surprises.
I mean,I think the subject matter experts,
and we did have subject matter expert
from breast and colon and from pancreasfor each of those aspects.
So I don't think any of uswas specifically surprised
at anything that we, we found,I mean, I think we feel like we understand
(07:55):
the trends, but I think it was niceto kind of highlight some of those trends.
And these obviouslywill change with each report. But,
for me, as a breast cancer physician,as you know,
we're using a lot more neoadjuvanttherapy in breast cancer.
And so looking at where neoadjuvanttherapy has been on the rise,
across cancers,we saw that it did rise in breast cancer.
(08:17):
Interestingly.
It kind of went up in 2020 and dippeda bit in 2021 in the neoadjuvant setting.
But and obviously we also sawa very striking increase
in neoadjuvant managementfor patients with,
pancreatic cancer.
The other tumor,other tumor types, it's a little bit
less, frequentthat neoadjuvant is being used.
(08:40):
And I think we, we anticipate thatthat's probably going to change over time
as oncologic therapyand targeted therapy changes.
So I think that was interesting to see.
Again, somewhat limitedbecause this is only the 2021 PUF.
So it'll
be interesting to see how that looks overthe upcoming years.
I think,
(09:00):
obviously focusing on breast,
which is Dr Erdahl’sand my area of interest,
you know, looking athow the use of neoadjuvant therapy
really increased,specifically in like stage two,
ER-negative breast cancer dramatically
kind of from 2018 through 2021.
I thought those graphswere really descriptive.
(09:22):
And I think that's very helpful,not only for researchers, but
also as you're trying to planyour clinical practice, right.
What proportion of your patientsare going to go into neoadjuvant,
what portion need to see medical oncologyprior to surgery
or have a multidisciplinary, clinicor a tumor board?
And then how do you staff,according to how practice is changing.
So I think that these data can be helpful
(09:43):
both from a research standpoint as wellas from a practice management standpoint.
Similarly,I think we've all seen a lot more kind
of same day surgery or shorter,length of admission.
And we, within this paper kind of describeand, the length of stay and the,
30-day mortality and the readmission rates
(10:04):
within 30 days for the breast cancerpatients, the colon cancer
patients undergoing colectomy,and the pancreatic patients.
And that could be helpful
in terms of planning,kind of how many patients to anticipate
how long they aregoing to stay in the hospital.
So I think that this report has valueto administrators, physicians,
healthcare providerskind of across the spectrum.
(10:26):
Well, as I think aboutnot just those physicians
who are at a cancer center and have allthe multidisciplinary resources.
Hopefully this is helpful informationfor anyone
seeing a patientwith a new cancer diagnosis in in a state,
like Iowa, where I practice, you know, anumber of our patients live several hours
(10:46):
away from the nearest cancer centeror that nearest multidisciplinary clinic.
And understanding which patients,
would,
wouldbe most likely to benefit from referral,
you know, looking at
how do you get themto see medical oncology before surgery
if they would benefit from neoadjuvantchemotherapy?
I think this is very informativearound the practice trends.
(11:09):
When I think about the practicein our state and those general surgeons
in rural communities trying to figure out,you know, which patients, can,
can be helped with their local resourcesand which patients need, more resources.
Or again, for administrators, you know, dowe need to look at bringing
more medical oncologists to a community,
vs, you know, having to ask patientsto travel those long distances,
(11:33):
particularly when they're undergoingtreatments like chemotherapy?
So I, I really enjoyed kind of thinkingabout that from a health system
standpoint.
I was interested to see that lobularcarcinoma in situ
was reported as an,you know, a small proportion, but,
as breast cancer,which is not how the NCCN looks at it.
(11:55):
So, so, you know, the contributing usersare, providing information
and, that might be differentfrom how I would look at it.
Yeah.
So as you mentioned, looking at lobularcarcinoma in situ made up about 5%
of those reported in the NCDBand 11% of the total in situ cancers.
But we did exclude them from the numberson the rest of the tables on the graphs.
(12:16):
So we kind of as you eloquently say,you know, we don't really consider
LCIS, cancer consideredas more as a precursor.
And so they're excluded from all of theanalysis that we performed.
I do think the
other thing that came out,and I'll be interested to see the trends
with the other cancers
and subsequent reports, was,as you mentioned, the lack of progress in,
(12:41):
improving mortality and morbidityfor pancreatic cancer
or the ongoing challengesin treating pancreatic cancer.
And I don't know
if you have anything to share about that,but it is disheartening to see that even
with all of our resources and research,we haven't made progress in some areas.
Yeah.
So I think, I think breast and pancreaticare strikingly different,
(13:02):
which is part of why we put both of themin the same report.
And so obviously from, from our lens,
dealing with breast cancerpatients day in and day out.
It's obviously a very different practiceto the survival for pancreatic cancer.
I do think that the trend towards
more neoadjuvant therapy for that patientpopulation is encouraging.
(13:23):
And so, you know, itmay be, you have to remember in breast,
we shifted neoadjuvant kind of in the midtwo tens if we look at the graph.
So I would be really interested to lookagain at the pancreatic data in the model.
Updated Participant User File.
I think in all cancers typeswe are constantly shifting
to try to improve the survivalfor each of our patients.
(13:45):
So I think we will continuallybe working on that.
And the other, things that I think about,and we've seen some national shifts
in recommendations, are the stageat which the colon cancer is diagnosed.
So it looked like colon cancer is stilloften diagnosed at stage two and three.
And I know the age for screening forthe population has shifted younger.
(14:08):
I wonder if we'll see a changein that, stage
at diagnosis 10 years down the road.
Yes. Having, just reached those guidelinesright at the point that they changed.
I personallydid have my first colonoscopy at 45.
So yes, I definitely thinkas the screening guidelines change,
(14:28):
hopefully the goal will be earlierdetection at an earlier stage.
You know, a report like thishopefully will be able to capture that.
So I think this report is so exciting.
It's like I'm anxiousto have even more updated data.
And almost from this report again,as soon as we have kind of the 2022
and hopefully soon after the 2023Participant User File
(14:51):
and I think it gives us actionableinformation.
I know it's a lot to read throughand some of it's very large numbers.
But I think about our efforts again.
One of the things that we did in breast
cancer was sort of return to screeninginitiatives when, we were coming
out of the pandemic, when many patientsdidn't have access, to their screening.
(15:14):
And of course, we've had another changeto the breast cancer screening guidelines.
As well, from the national standpoint,
there's been a lot of controversyaround those screening guidelines as well.
But starting mammograms at age40 for average risk women
and then hopefullydoing a better job of identifying risk.
And I think that's the other piecethat I would wonder how that's going
(15:34):
to change the trends over timeas we're identifying patients at risk for,
you know, several different cancerswith genetic testing, with better
risk stratification based on familyhistory, that the screening tests
for pancreatic cancer and ovarian cancer,for example, are still challenging.
But I think, as we do more
(15:56):
individualized cancer screening,I hope that that will make an impact.
And I don't know what your thoughts are onkind of how we individualize
our cancer screening and treatment,but I know that's a big part of, of,
you know, your practiceand the efforts that you've made.
Yeah.
I mean, I think the future for cancercare is going to be much more kind
of individualized screening.
(16:16):
And then also even in individualizedsurvivorship.
Right.
Why do we follow patientsthat are at high risk of recurrence
the same way as those patientsthat are at low risk of recurrence?
Why do we follow a stage one cancer thesame way as we follow stage three cancer?
Right.
We follow those that respondedwell to chemo at the same way we follow
those that had a complete,you know, had a lot of residual disease.
(16:37):
So I think, you know,individualization of care is,
I think, going to be the biggest themeover the next decade now in cancer,
both in screening, in treatmentand then in surveillance.
And I think, you know, obviouslyin breast, in the dense
breast, aspect,and how we best screened those patients.
I think genetic testing is becomingfar more widespread.
(16:59):
We will identify patientsthat are at increased risk,
and hopefully have appropriatescreening programs for pancreatic cancer,
ovarian cancer, colon cancer,for all of those individuals.
So I think we will start seeing a shiftin all of these numbers.
Yeah.
And again, I'm putting on my health systemhat, as you talk about
individualizing the survivorshipand the screening,
(17:20):
because the other challengesare workforce,
and our ability to see patients
every three months for fiveor 10 or 20 years after their treatments.
And so figuring out,
from the standpoint of the health system,but also the individual patient
when those visits are excessiveand not serving benefits.
Sounds really exciting to me.
(17:42):
And the individualization of survivorship,
definitely,
touches my practicebecause we have everything from stage
zero in situ, not life-threatening cancer
to, you know, advanced stage cancer with,metastatic disease, where we're trying
to, manage those patientsand they don't have the same needs,
(18:04):
both in the acute managementand in the long term follow up.
Yeah, I would agree.
And I think, hopefully in the futureAI will have some ability to kind of
help us with, you know, flagsin the electronic medical record
and questionnaires for the patients.
And maybe we can do a little bit moreremote and minimize the time
for the patient away from their work,coming into our practice for visits.
(18:25):
So, I think it's a lot of moving partsright now in the healthcare system.
And that's it's scary, but it's exciting.
Yeah. Do you,
do you see other large databases
reporting sort of all of their datain this way?
Because again, the, the historicallythe NCDB has really worked
as a repositoryfor more individualized projects.
(18:50):
Is this a trend that we are seeingnationally
where we're going to have more sortreporting out of large databases?
Or do you think thatthis is unique to NCDB?
I think SEER has done its reportfor many years, and there's often
a very highly cited report.
And obviously they can talkmore clearly about incidence.
And so we were very promisingwhen we put this report together.
(19:11):
This is distinctly differentto the SEER annual report.
And so trying to focuson the areas of data that the NCDB has
that does not overlap with SEER,because there's no point having
overlapping reports.
And so we're, we're very much more focusedon kind of,
the specificsof how the patient was treated.
(19:31):
And along with the outcomes
and I think I've been really pleasedto hear
how well this paper has been receivedand the interest in this paper.
And really, I think that's what speaks towhether this would continue.
I think that the leadershipof the American College of Surgeons
cancer research program and the NCDB been
would like to make this an annual reportas long as there is value,
(19:53):
in the readershipfrom having this information.
And so our goal is
probably to, to keep this going.
I’m actuallyhopeful that we'll get the 2022
PUF File reportpublished in the first half of this year.
So it may actually be quickerthan one year by the time
that this was released,and we're actually ideally
(20:14):
would like to have the data from the NCDBbe a little bit more real time.
So my goal maybe for 2026 or 2027that we may actually be able
to report just on the previous year,as opposed to, 3 to 4 years earlier data.
So that's kind of our goalsmoving forward.
But it's very much dependenton the readership, but based on what
we've seen of the interest in this report,this podcast, the media,
(20:38):
picking this report up, it seems thatpeople are definitely interested in that.
And if there's an interest
the American College of Surgeons cancerprogram leadership definitely wants to
invest to make the information availableto the people that are interested in it.
Well, I think that that is a
great summary statementfor our podcast discussion.
(21:00):
And I again,I was excited to read these data
and learn more about the trends in cancer
care, particularly breast cancer care,but all of cancer care.
And I hope that
all of our readers and,
you know, the hospital systemsand cancer programs
can use these data to guide what they doand what they're seeing.
(21:24):
And even more real time data, hopefullyin the future would be excellent.
But I think looking at these trends overtime,
as subsequent reportscome out is very interesting to me
to see how we're changingand where to focus our efforts
to make more improvementsin cancer care and cancer outcomes.
And I know,
you know, my,
(21:46):
chair, Dr Weigel as well,from the American College of Surgeons
cancer programs, reallyis dedicated to figuring out
how do we improve cancer care acrossall of our institutions, everywhere
that our patients are being treated,particularly by surgeons?
But, we know that cancer careis multidisciplinary.
So thank you to you and your team.
(22:07):
I know this, represents a lot of effort
from so many peopleto put a report like this together.
Well,thank you, Dr Erdahl, for the opportunity
to discuss this with you today.
And if anyone does have any particularadditional aspects, I'd like to see and
reports like this, please don't hesitateto reach out to me and to Dr Weigel.
We want to make this as usefulto our readership as possible,
(22:28):
and we really appreciate everyone'sinterest.
Great talking to you, too.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available
(22:50):
or listen on the American Collegeof Surgeons website at FACS.org/podcasts.
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