Background Adenosquamous carcinoma of the pancreas is rare. Our understanding of the disease and its prognosis comes mainly from small retrospective studies. Methods Using the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2007), we identified patients with adenosquamous carcinoma (N=415) or adenocarcinoma (N=45,693) of the pancreas. The demographics, tumor characteristics, resection status, and survival were compared between the groups. Results Compared to patients with adenocarcinoma, patients with adenosquamous carcinoma were more likely to have disease located in the pancreatic body and tail (44.6% vs 53.5%, P<0.0001). While the stage distribution was similar between the two groups, adenosquamous carcinomas were more likely to be poorly differentiated (71% vs 45%, P<0.0001), node positive (53% vs. 47%, P<0.0001), and larger (5.7 vs. 4.3 cm, P<0.0001). For locoregional disease, resection increased over time from 26% in 1988 to 56% in 2007. The overall 2-year survival was 11% in both groups. Following resection, patients with adenosquamous carcinoma had worse 2-year survival (29% vs. 36%, P<0.0001). Resection was the strongest independent predictor of survival for patients with locoregional pancreatic adenosquamous carcinoma (HR 2.35, 95% CI=1.47-3.76). Conclusions This is the first population-based study to evaluate outcomes in adenosquamous carcinoma of the pancreas. When compared to pancreatic adenocarcinoma, adenosquamous carcinoma was more likely to occur in the pancreatic tail, be poorly differentiated, larger, and node positive. The long-term survival following surgical resection is significantly worse for adenosquamous cancers; however, patients with adenosquamous carcinoma can still benefit from surgical resection, which is the strongest predictor of survival.

Background Depression has been associated with delayed presentation, inadequate treatment, and poor survival in patients with cancer. Methods Using Surveillance, Epidemiology and End Results and Medicare linked data (1992–2005), we identified patients with pancreatic adenocarcinoma (N = 23,745). International Classification of Diseases, 9th edition, Clinical Modification codes were used to evaluate depression during the 3 to 27 months before the diagnosis of cancer. The effect of depression on receipt of therapy and survival was evaluated in univariate and multivariate models. Results Of patients with pancreatic cancer in our study, 7.9% had a diagnosis of depression (N = 1,868). Depression was associated with increased age, female sex, white race, single or widowed status, and advanced stage disease (P < .0001). In an adjusted model, patients with locoregional disease and depression had 37% lower odds of undergoing surgical resection (odds ratio, 0.63; 95% confidence interval, 0.52–0.76). In patients with locoregional disease, depression was associated with lower 2-year survival (hazard ratio, 1.20; 95% confidence interval, 1.09–1.32). After adjusting for surgical resection, this association was attenuated (hazard ratio, 1.14; 95% confidence interval, 1.04–1.26). In patients who underwent surgical resection, depression was a significant predictor of survival (hazard ratio, 1.34; 95% confidence interval, 1.04–1.73). Patients with distant disease and depression had 21% lower odds of receiving chemotherapy (odds ratio, 0.79; 95% confidence interval, 0.70–0.90). After adjusting for chemotherapy for distant disease, depression was no longer a significant predictor of survival (hazard ratio, 1.03; 95% confidence interval, 0.97–1.09). Conclusion The decreased survival associated with depression appears to be mediated by a lower likelihood of appropriate treatment in depressed patients. Accurate recognition and treatment of pancreatic cancer patients with depression may improve treatment rates and survival.

Background The recommended therapy for mild gallstone pancreatitis is cholecystectomy on initial hospitalization. Methods Using a 5% national Medicare sample (1996–2005) we evaluated adherence to current guidelines (cholecystectomy rates on initial hospitalization and the use of ERCP/sphincterotomy). We evaluated predictors of cholecystectomy, gallstone-related readmissions, and 2-year mortality. Results Adherence to current guidelines was low. Only 57% of 8,452 Medicare beneficiaries presenting to an acute care hospital with a first episode of mild gallstone pancreatitis had cholecystectomy on initial hospitalization. Of the patients who did not receive cholecystectomy, 55% were never evaluated by a surgeon. Likewise, only 28% of patients who did not undergo cholecystectomy had a sphincterotomy. 2-year readmission rates were higher in patients who did not undergo cholecystectomy (44% vs. 4%, P<0.0001), and 33% of these patients required cholecystectomy after discharge. In the no cholecystectomy group, ERCP prevented readmissions (HR=0.53, 95% CI 0.47–0.61) and when readmissions occurred they were less likely to be for gallstone pancreatitis in patients who had an ERCP (27.8% vs. 53.2%, P<0.0001). In a multivariate analysis, patients who were older, black, admitted to a non-surgical service, lived in certain US regions, and had specific comorbidities were less likely to undergo cholecystectomy. Conclusions Adherence to current recommendations for the management of mild gallstone pancreatitis is low in older patients. Our data suggest that over 40% of patients who did not undergo cholecystectomy would have benefited from early definitive therapy. Implementation of policies to increase adherence to guidelines would prevent gallstone-related morbidity and mortality in older patients.

BACKGROUND Our goal was to characterize hospice enrollment and aggressiveness of care for pancreatic cancer patients at the end of life. METHODS We used Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992–2006) to identify patients with pancreatic cancer who had died (n= 22,818). We evaluated hospice use, hospice enrollment ≥4 weeks before death, and aggressiveness of care as measured by receipt of chemotherapy, acute care hospitalization, and intensive care unit (ICU) admission in the last month of life. RESULTS Overall, 56.9% of patients enrolled in hospice, and 35.9% of hospice users enrolled for four weeks or more. Hospice use increased from 36.2% in 1992–1994 to 67.2% in 2004–2006 (P<0.0001). Admission to the ICU and receipt of chemotherapy in the last month of life increased from 15.5% to 19.6% (P<0.0001) and 8.1% to 16.4% (P<0.0001), respectively. Among patients with locoregional disease, those who underwent resection were less likely to enroll in hospice before death and much less likely to enroll early. They were also more likely to receive chemotherapy (14% vs. 9%, P<0.0001), be admitted to an acute care hospital (61% vs. 53%, P<0.0001), and be admitted to an ICU (27% vs. 15%, P<0.0001) in the last month of life. CONCLUSIONS While hospice use increased over time, there was a simultaneous decrease in early enrollment and increase in aggressive care at the end of life for patients with pancreatic cancer. CONDENSED This study examined hospice enrollment and aggressiveness of care for pancreatic cancer patients at the end of life. While hospice use increased over time, there was a simultaneous increase in aggressive care at the end of life for patients with pancreatic cancer.

Objective To determine the frequency and predictors of cardiac stress testing prior to elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation. Background American College of Cardiology/American Heart Association guidelines indicate that patients without class I (AHA high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing prior to elective noncardiac, non-vascular surgery. Methods We used 5% Medicare inpatient claims data (1996–2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urologic, or orthopedic procedures (N=211,202). We examined use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N=74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing. Results Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N= 2,803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (p<0.0001). Multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female gender (OR=1.11, 95% CI=1.02–1.21), presence of other comorbidities (OR=1.22, 95% CI=1.09–1.35), high risk procedure (OR=2.42, 95% CI=2.04–2.89), and larger hospital size (OR=1.17, 95% CI=1.03–1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR=1.24, 95% CI=1.05–1.45) were more likely to receive stress tests. Conclusions In a 5% sample of Medicare claims data, 2,803 patients underwent preoperative stress testing without any indications. When these results are applied to the entire Medicare population, we estimate that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications increased significantly over time.