Racial and Ethnic Disparities in Preoperative Surgical Wait Time and Renal Cell Carcinoma Tumor Characteristics

Racial/ethnic minority groups have a disproportionate burden of kidney cancer. The objective of this study was to assess if race/ethnicity was associated with a longer surgical wait time (SWT) and upstaging in the pre-COVID-19 pandemic time with a special focus on Hispanic Americans (HAs) and American Indian/Alaska Natives (AIs/ANs). Medical records of renal cell carcinoma (RCC) patients who underwent nephrectomy between 2010 and 2020 were retrospectively reviewed (n = 489). Patients with a prior cancer diagnosis were excluded. SWT was defined as the date of diagnostic imaging examination to date of nephrectomy. Out of a total of 363 patients included, 34.2% were HAs and 8.3% were AIs/ANs. While 49.2% of HA patients experienced a longer SWT (≥90 days), 36.1% of Non-Hispanic White (NHW) patients experienced a longer SWT. Longer SWT had no statistically significant impact on tumor characteristics. Patients with public insurance coverage had increased odds of longer SWT (OR 2.89, 95% CI: 1.53–5.45). Public insurance coverage represented 66.1% HA and 70.0% AIs/ANs compared to 56.7% in NHWs. Compared to NHWs, HAs had higher odds for longer SWT in patients with early-stage RCC (OR, 2.38; 95% CI: 1.25–4.53). HAs (OR 2.24, 95% CI: 1.07–4.66) and AIs/ANs (OR 3.79, 95% CI: 1.32–10.88) had greater odds of upstaging compared to NHWs. While a delay in surgical care for early-stage RCC is safe in a general population, it may negatively impact high-risk populations, such as HAs who have a prolonged SWT or choose active surveillance.

Impact of Surgical Wait Time on Survival in Patients With Upper Urinary Tract Urothelial Carcinoma With Hydronephrosis

Background and ObjectivesDue to the inevitability of waiting time for surgery, this problem seems to have become more pronounced since the outbreak of COVID-19, and due to the high incidence of preoperative hydronephrosis in upper urinary tract urothelial carcinoma (UTUC) patients, it is particularly important to explore the impact of preoperative waiting time and hydronephrosis on upper urinary urothelial carcinoma.Methods316 patients with UTUC who underwent radical surgery at a high-volume center in China between January 2008 and December 2019 were included in this study. We retrospectively collected the clinicopathologic data from the medical records, including age, sex, smoking history, ECOG performance status (ECOG PS), body mass index (BMI), tumor location and size, number of lesions, T stage, N stage, surgical approach and occurrence of hydronephrosis, lymph node invasion, lymph node dissection, surgical margin, tumor necrosis, infiltrative tumor architecture, lymphovascular invasion and concomitant bladder cancer. Surgical wait time was defined as the interval between initial imaging diagnosis and radical surgery of UTUC. Hydronephrosis was defined as abnormal dilation of the renal pelvis and calyces due to obstruction of the urinary system. Firstly, all patients were divided into short-wait (<31 days), intermediate-wait (31-90 days) and long-wait (>90 days) groups according to the surgical wait time. The clinicopathological characteristics of each group were evaluated and the survival was compared. For patients with hydronephrosis, we subsequently divided them into two groups: short-wait (≤60 days) and long-wait (>60 days) groups according to the surgical wait time. Univariate and multivariate COX regression analysis were performed to evaluate the prognostic risk factor for patients with hydronephrosis.ResultsA total of 316 patients with UTUC were included in this study with a median surgical wait time of 22 days (IQR 11-71 days). Of the 316 patients, 173 were classified into the short-wait group (54.7%), 69 into the intermediate-wait group (21.8%) and 74 into the long-wait group (23.5%). The median follow-up time for all patients was 43 months (IQR 28-67months). The median surgical wait times of the short-wait, intermediate-wait and long-wait group were12 days (IQR 8-17days), 42days (IQR 37-65days) and 191days (IQR 129-372days), respectively. The 5-year overall survival (OS) of all patients was 54.3%. The 5-year OS of short-wait, intermediate-wait and long-wait groups were 56.4%, 59.3% and 35.1%, respectively (P=0.045). The 5-year cancer-specific survival (CSS) of short-wait, intermediate-wait and long-wait groups were 65.8%, 70.9% and 39.6%, respectively (P=0.032). In the subgroup analysis, we divided 158 UTUC patients with hydronephrosis into short-wait group (≤60 days) and long-wait group (> 60 days), 120 patients were included in the short-wait group and 38 patients in the long-wait group. The median surgical wait times of the short-wait and long-wait group were 14days (IQR 8-28days) and 174days (IQR 100-369days), respectively. The 5-year OS of long-wait group was significantly lower than the OS of short-wait group (44.2% vs. 55.1%, P =0.023). The 5-year CSS of long-wait and short-wait group were 49.1% and 61.7%, respectively (P=0.041). In multivariate Cox regression analysis of UTUC patients with hydronephrosis, surgical wait time, tumor grade, pathological T stage, and tumor size were independent risk factors for OS and CSS. Lymph node involvement was also a prognostic factor for CSS.ConclusionFor patients with UTUC, the surgical wait time should be limited to less than 3 months. For UTUC patients with hydronephrosis, the OS and CSS of patients with surgical wait time of more than 60 days were relatively shorted than those of patients with surgical wait time of less than 60 days.

Safety of Prolonged Wait Time for Nephrectomy for Clinically Localized Renal Cell Carcinoma

BackgroundThere is usually a surgical wait time before nephrectomy for patients with clinically localized renal cell carcinoma, and many factors can influence this preoperative wait time. A relatively prolonged wait time may cause tumor progression. Therefore, we assessed the effect of preoperative wait time on the prognosis of patients with clinically localized renal cell carcinoma.MethodsThe outcomes of 561 patients with clinically localized renal cell carcinoma who underwent nephrectomy between July 2011 and March 2017 were retrospectively evaluated. According to the wait time before surgery, we divided the patients into three groups: short-wait group (≤ 30 days), intermediate-wait group (> 30 and ≤ 90 days), and long-wait group (>90 days). The clinicopathological characteristics were evaluated, and the survival rates of the three groups were compared.ResultsThis study included 370 male (66%) and 191(34%) female patients, with a median age of 64 years. There were 520 patients with stage T1 and 41 patients with stage T2 tumors. The median interval between diagnosis and surgery was 21 days. There were no significant differences in age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, body mass index, tumor size, surgical approach, surgical procedure, pathological subtype, tumor stage, tumor grade, and residual tumor among the three groups. Overall survival(OS) and cancer-specific survival (CSS) were comparable; the 5-year OS of the short-, intermediate-, and long-wait time groups were 84.2%, 82.0%, and 89.8%, respectively (P=0.732). The 5-year CSS rates of the short-, intermediate-, and long-wait time groups were 87.1%, 88.9%, and 90.4%, respectively (P=0.896). Multivariate analysis revealed that wait time was not an independent prognostic factor for OS or CSS.ConclusionProlonged surgical wait time (> 90 days) does not influence survival in patients with clinically localized renal cell carcinoma.

The burden of waiting: wait times for pediatric surgical procedures in Quebec and compliance with national benchmarks

Background: Wait time information and compliance with national guidelines are limited to a few adult conditions in the province of Quebec. We aimed to assess compliance with Paediatric Canadian Access Targets for Surgery (P-CATS) guidelines and determine the burden incurred due to waiting for 3 common elective surgical conditions (inguinal hernia, cryptorchidism and hypospadias) in a pediatric population. Methods: We carried out a population-based retrospective cohort study of randomly selected children residing in Quebec without complex chronic medical conditions, using administrative databases belonging to the Régie de l’assurance maladie du Québec for the period 2010–2013. Disability-adjusted life years (DALYs) were calculated to measure the burden due to waiting. Multivariate forward regression identified risk factors for compliance with national guidelines. Results: Surgical wait time information was assessed for 1515 patients, and specialist referral wait time was assessed for 1389 patients. Compliance with P-CATS benchmarks was 76.6% for seeing a specialist and 60.7% for receiving surgery. Regression analysis identified older age (p < 0.0001) and referring physician specialty (p = 0.001) as risk factors affecting specialist referral wait time target compliance, whereas older age (p = 0.040), referring physician specialty (p = 0.043) and surgeon specialty (p = 0.002) were significant determinants in surgical wait time compliance. The total burden accrued due to waiting beyond benchmarks was 35 DALYs. Conclusion: Our results show that provincial compliance rates with wait time benchmarks are still inadequate and need improvement. Patient age and physician specialty were both found to have significant effects on wait time target compliance.

Mortality Increases When Radical Nephrectomy is Delayed More Than 60 Days for T3 Renal Cell Carcinoma

Background: Radical nephrectomy is widely accepted as the default management option for patients with T3 renal cell carcinoma (RCC). However, it may require a certain time before surgery for various reasons. There are concerns that the delay in surgery may affect postoperative outcomes. The present study aimed to evaluate the impact of surgical wait time on survival in patients with T3 RCC. Methods: We retrospectively selected 138 patients with T3 RCC who underwent radical surgery between July 2009 and December 2019. Surgical wait time was defined as the period from initial imaging diagnosis to surgery. Patients were divided into the following 2 groups according to wait time: short-wait group(≤60 days), and long-wait group (>60 days). The clinical and pathological characteristics were evaluated. The overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) of each group were calculated and compared. Age, gender, interval, tumor size, pathological grade, Eastern Cooperative Oncology Group performance status (ECOG PS), surgical approach, year of surgery, and pathological type were included in the multivariable model. Results: This study included 91 male (65.9%) and 47 female (34.1%) patients. The median age of all patients was 60 years (interquartile range [IQR] 52-68 years). The median body mass index is 22.2 kg/m2 (IQR 18.9-24.7 kg/m2). There were 128 patients (92.8%) with pT3a disease and 10 patients (7.3%) with pT3b disease. The median surgical wait time for all patients was 16 days (IQR 10-77 days). The median surgical wait time of the short- and long-wait groups was 12 days (IQR 8-16 days) and 92 days (IQR 79-115 days), respectively. Until the last follow-up, 54 patients died. Among them, 49 patients (90.7%) died of tumor-related causes, and 5 patients (9.3%) died of other causes. There are 1 and 4 cases in the short-wait and long-wait groups, respectively. There were no significant differences in gender, ECOG PS, American society of anesthesiologists score, Charlson comorbidity index, clinical T stage, clinical N stage, and body mass index. And there were no significant differences in tumor size, surgical approach, year of surgery, pathological type, tumor grade, pathological T stage, pathological N stage, and venous involvement between the 2 groups. OS, CSS, and RFS were compared. The 5-year OS of the short- and long-wait time groups were 65.0% and 40.9%, respectively ( P = .030). The 5-year CSS rates of the short- and long-wait time groups were 68.7% and 51.5%, respectively ( P = .012). The 5-year RFS rates of the short- and long-wait time groups were 61.5% and 46.8%, respectively ( P = .119). Multivariable analysis revealed that surgical wait time interval and tumor size were independent risk factors for OS and that wait time was also an independent risk factor for CCS. Conclusion: Delay in radical surgery beyond 60 days can negatively affect OS in patients with T3 RCC.

Abstract 15673: Racial Disparities in Referral for Pre-operative Cardiovascular Evaluation, Surgical Wait Time, and Weight Loss in Patients Undergoing Bariatric Surgery

Introduction: White patients undergo bariatric surgery more frequently and with fewer complications compared to non-white patients. Yet, racial disparities in referral pattern for preoperative cardiovascular evaluation (CVE) are unexplored. We hypothesized that racial disparities exist in preoperative CVE in white vs. non-white patients undergoing bariatric surgery. Methods: We identified consecutive patients undergoing bariatric surgery at our institution from 2014-2018. The association of white vs. non-white race with referral for CVE, cardiac testing, surgical wait time, and postoperative weight loss was determined in a multivariate model adjusting for baseline demographic comorbidities and income. Additional adjustment for insurance provider was made for surgical wait time. Results: Of the 797 patients undergoing bariatric surgery during the study period, 86% (n=682) were non-white. White vs. non-white patients had similar age, gender distribution, and prevalence of hypertension, hyperlipidemia, Type 2 diabetes, and heart failure. A similar proportion of whites vs. non-whites were referred to cardiology for pre-operative evaluation (65% vs. 68%, p=0.52), while whites were more likely to undergo further preoperative cardiac testing after adjustment (68% vs. 55%, p=0.04; adjusted, OR 0.6, 95%CI 0.35-1.0, p=0.05). Despite less cardiac testing, non-white patients referred to cardiology waited longer for surgery (9.9 months vs. 12.1 months, p=0.008), including after adjustment (HR 0.7, 95%CI 0.53-0.91, p= 0.008. Weight loss at 6 months was higher in whites (12.9 kg/m 2 vs. 11.95 kg/m 2 , p=0.03), but equivalent at 1 year (whites 14.9 kg/m 2 vs. non-whites 14.3 kg/m 2 , p=0.33). Conclusions: In a bariatric surgery population, white vs. non-white patients were referred for CVE in similar proportion. However, white patients underwent more subsequent cardiac testing pre-operatively when compared to non-whites yet had a shorter wait time for surgery. Early weight loss was greater in whites, but equivalent between groups at 1 year.