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Delays in surgery for advanced esophageal cancer result in significantly worse survival than early surgery

CHICAGO: Delays in surgery for esophageal cancer did not appear to have much impact on patients’ relative survival for early-stage cancer compared with…

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CHICAGO: Delays in surgery for esophageal cancer did not appear to have much impact on patients’ relative survival for early-stage cancer compared with patients who had surgery early, but they did reduce the relative survival rate by almost half for patients with more advanced disease, according to an analysis of the National Cancer Database (NCDB).

Credit: American College of Surgeons

CHICAGO: Delays in surgery for esophageal cancer did not appear to have much impact on patients’ relative survival for early-stage cancer compared with patients who had surgery early, but they did reduce the relative survival rate by almost half for patients with more advanced disease, according to an analysis of the National Cancer Database (NCDB).

The research is published as an “article in press” on the website of the Journal of the American College of Surgeons (JACS) and is one of the earliest studies to examine the impact of an extended three-month delay in esophagectomy for esophageal cancer.

The relative survival rate indicates whether a disease shortens one’s life. It’s a way to compare survival of those who have a specific disease with those who don’t over a given period of time, typically five years from diagnosis date or the start of treatment for those with the disease, according to the National Cancer Institute.

“Timely care should always be the priority for patients,” said senior author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at Massachusetts General Hospital in Boston and an assistant professor of surgery at Harvard Medical School. “However, there were times during the COVID-19 pandemic when delays to cancer care occurred. This study, using pre-pandemic data, helps us understand the impact of the delay to care for patients with different stages of operable esophageal cancer.”

Added lead author Simar Singh Bajaj, a student at Harvard and a researcher in the department of surgery at Mass General, “When we looked at early versus delayed surgery for patients with stage I cancer, patients in both groups had similar five-year survival rates. However, for patients with stage II or III disease, delayed surgery was associated with worse survival when compared with early surgery.” Stage II and III esophageal cancer is more advanced than Stage I.

“This finding is especially important as we’re still working toward reintegrating services during the pandemic,” Mr. Bajaj said. “We’ve seen a lot of delays in care as hospitals have been overwhelmed with COVID patients.”

About the study

The researchers extracted pre-COVID-19 pandemic surgical cases for esophageal cancer from the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons (ACS) and the American Cancer Society. The NCDB is estimated to include more than 75 percent of the newly diagnosed esophageal cancer cases in the United States.

The researchers compared survival of patients with stage I disease who had early surgery—that is, within four weeks after diagnosis—versus delayed surgery at 12 to 16 weeks after diagnosis. For patients with stage II/III esophageal cancer, the analysis compared results, after timely chemoradiation up to four weeks after diagnosis, of early esophagectomy (nine to 17 weeks after diagnosis) versus delayed surgery (21 to 29 weeks afterward). Propensity-score matching was used to create two comparator subgroups for timing of surgery within each staging group: 134 in each Stage I subgroup and 130 in each Stage II/III subgroup.

Study results

  • The five-year relative survival rate was similar for patients with Stage I disease who had early and delayed surgery: 65% (55.2–73.2%) and 65.1% (55.6–73.1%) percent, respectively (p=0.50).
  • The five-year relative survival rate for patients with stage II/III cancer who had delayed surgery was about 45% worse than those who had early surgery: 22.9% (14.9–31.8%) versus 41.6% (32.1–50.8%), respectively (p=0.006).

Prioritize patients without delaying care

At the start of the COVID-19 pandemic in March 2020, the Centers for Medicare and Medicaid Services announced that “all elective surgeries, non-essential medical, surgical, and dental procedures would be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak” to preserve hospital resources to handle the pandemic.1 Some national medical societies issued triage guidelines for dealing with delays for a host of elective procedures. The ACS and the Thoracic Surgery Outcomes Research Network issued early guidance that recommended a three-month delay of surgery for esophageal cancer in hospitals with resources—intensive-care unit beds, ventilators, hospital staff—stretched thin by the pandemic.2,3

When appointments could be scheduled again, cancer clinicians noticed patients were slow or unlikely to schedule regular cancer screenings.4 However, research findings are just starting to emerge to determine the impact that all of these delays may have had on patient outcomes, including survival for a variety of cancers.

“As we continue to move out of the COVID pandemic, surgeons are trying to address the backlog of patients with esophageal cancer. The point of this study is to consider how we should reintegrate services in such a way that it prioritizes patients that are most at risk,” Mr. Bajaj said.

That prioritization means patients with stage II/III esophageal cancer should get surgery “as soon as possible,” he said. Although the researchers found no difference in survival for early versus delayed surgery for patients with stage I esophageal cancer, he warned that’s not a valid reason to delay their care. “This study should not be used to recommend delays in any circumstance, just because for stage I disease we didn’t see that there was an adverse impact to survival when you delayed surgery,” he said. “Esophageal cancer surgery should always be performed as promptly as possible.”

Guidance for future response

The findings provide esophageal cancer guidance for responding to future pandemics or COVID surges, Mr. Bajaj said. “Triage is all about prioritizing patients and trying to treat the most vulnerable first in order to give them the best chance of survival,” he said.

“This study highlights the differences in early-stage and advanced-stage esophageal cancer and helps us to realize how important timely treatment is,” said Shanda H. Blackmon, MD, MPH, FACS, a thoracic surgeon at Mayo Clinic in Rochester, Minn., who was not involved with the study.

Being mindful of treatment delays for esophageal cancer patients is critical at any time, she said. “Many esophageal patients have significant delays in diagnosis as the majority of these patients don’t present until they’re symptomatic, and, frequently, by the time they do present, they have advanced disease,” Dr. Blackmon said.

The study also provides important information in the event of another COVID-19 variant surge or pandemic, she said. “We would need to prepare in such a way that we could minimize delays by creating lists that allow us to prioritize patients according to the severity of disease.”

Study coauthors are Kavya M. Shah, Alexandra L. Potter, and Uma Sachdeva, MD, PhD of the department of surgery at Massachusetts General Hospital; Nicholas R. Mayne, MD, of the department of medicine at Duke University in Durham, N.C.; and Mong-Wei Lin, MD, PhD, of the department of thoracic surgery at the National Taiwan University in Taipei.

None of the study authors have any disclosures. Dr. Blackmon also has no disclosures.

Citation: Early Versus Delayed Surgery for Esophageal Cancer During the COVID-19 Pandemic. Journal of American College of Surgeons. DOI: 10.1097/XCS.0000000000000133

___

1 CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures During COVID-19 Response. Centers for Medicare and Medicaid Services; 2020. Available at https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental. Accessed May 9, 2022.

2 COVID-19 Guidelines for Triage of Thoracic Patients. American College of Surgeons; 2020. Accessed May 3,4, 2022. http://www.facs.org/covid-19/clinical-guidance/elective-case/thoracic-cancer

3Antonoff M, Backhus L, Boffa DJ, et al. COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement from Thoracic Surgery Outcomes Research Network. Ann Thorac Surg. 2020;110(2):692-696.

4 Juong RH, Nelson H, Mullet TW, et al. A national quality improvement study identifying and addressing cancer screening deficits due to the COVID- 19 pandemic. Cancer. 2022 Jun 1;128(11):2119-2125.

# # #

About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates a surgeon is a Fellow of the American College of Surgeons.

The Journal of the American College of Surgeons (JACS) is the official scientific journal of ACS. Each month, JACS publishes peer-reviewed original contributions on all aspects of surgery, with the goal of providing its readership the highest quality rapid retrieval of information relevant to surgeons.


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Are Voters Recoiling Against Disorder?

Are Voters Recoiling Against Disorder?

Authored by Michael Barone via The Epoch Times (emphasis ours),

The headlines coming out of the Super…

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Are Voters Recoiling Against Disorder?

Authored by Michael Barone via The Epoch Times (emphasis ours),

The headlines coming out of the Super Tuesday primaries have got it right. Barring cataclysmic changes, Donald Trump and Joe Biden will be the Republican and Democratic nominees for president in 2024.

(Left) President Joe Biden delivers remarks on canceling student debt at Culver City Julian Dixon Library in Culver City, Calif., on Feb. 21, 2024. (Right) Republican presidential candidate and former U.S. President Donald Trump stands on stage during a campaign event at Big League Dreams Las Vegas in Las Vegas, Nev., on Jan. 27, 2024. (Mario Tama/Getty Images; David Becker/Getty Images)

With Nikki Haley’s withdrawal, there will be no more significantly contested primaries or caucuses—the earliest both parties’ races have been over since something like the current primary-dominated system was put in place in 1972.

The primary results have spotlighted some of both nominees’ weaknesses.

Donald Trump lost high-income, high-educated constituencies, including the entire metro area—aka the Swamp. Many but by no means all Haley votes there were cast by Biden Democrats. Mr. Trump can’t afford to lose too many of the others in target states like Pennsylvania and Michigan.

Majorities and large minorities of voters in overwhelmingly Latino counties in Texas’s Rio Grande Valley and some in Houston voted against Joe Biden, and even more against Senate nominee Rep. Colin Allred (D-Texas).

Returns from Hispanic precincts in New Hampshire and Massachusetts show the same thing. Mr. Biden can’t afford to lose too many Latino votes in target states like Arizona and Georgia.

When Mr. Trump rode down that escalator in 2015, commentators assumed he’d repel Latinos. Instead, Latino voters nationally, and especially the closest eyewitnesses of Biden’s open-border policy, have been trending heavily Republican.

High-income liberal Democrats may sport lawn signs proclaiming, “In this house, we believe ... no human is illegal.” The logical consequence of that belief is an open border. But modest-income folks in border counties know that flows of illegal immigrants result in disorder, disease, and crime.

There is plenty of impatience with increased disorder in election returns below the presidential level. Consider Los Angeles County, America’s largest county, with nearly 10 million people, more people than 40 of the 50 states. It voted 71 percent for Mr. Biden in 2020.

Current returns show county District Attorney George Gascon winning only 21 percent of the vote in the nonpartisan primary. He’ll apparently face Republican Nathan Hochman, a critic of his liberal policies, in November.

Gascon, elected after the May 2020 death of counterfeit-passing suspect George Floyd in Minneapolis, is one of many county prosecutors supported by billionaire George Soros. His policies include not charging juveniles as adults, not seeking higher penalties for gang membership or use of firearms, and bringing fewer misdemeanor cases.

The predictable result has been increased car thefts, burglaries, and personal robberies. Some 120 assistant district attorneys have left the office, and there’s a backlog of 10,000 unprosecuted cases.

More than a dozen other Soros-backed and similarly liberal prosecutors have faced strong opposition or have left office.

St. Louis prosecutor Kim Gardner resigned last May amid lawsuits seeking her removal, Milwaukee’s John Chisholm retired in January, and Baltimore’s Marilyn Mosby was defeated in July 2022 and convicted of perjury in September 2023. Last November, Loudoun County, Virginia, voters (62 percent Biden) ousted liberal Buta Biberaj, who declined to prosecute a transgender student for assault, and in June 2022 voters in San Francisco (85 percent Biden) recalled famed radical Chesa Boudin.

Similarly, this Tuesday, voters in San Francisco passed ballot measures strengthening police powers and requiring treatment of drug-addicted welfare recipients.

In retrospect, it appears the Floyd video, appearing after three months of COVID-19 confinement, sparked a frenzied, even crazed reaction, especially among the highly educated and articulate. One fatal incident was seen as proof that America’s “systemic racism” was worse than ever and that police forces should be defunded and perhaps abolished.

2020 was “the year America went crazy,” I wrote in January 2021, a year in which police funding was actually cut by Democrats in New York, Los Angeles, San Francisco, Seattle, and Denver. A year in which young New York Times (NYT) staffers claimed they were endangered by the publication of Sen. Tom Cotton’s (R-Ark.) opinion article advocating calling in military forces if necessary to stop rioting, as had been done in Detroit in 1967 and Los Angeles in 1992. A craven NYT publisher even fired the editorial page editor for running the article.

Evidence of visible and tangible discontent with increasing violence and its consequences—barren and locked shelves in Manhattan chain drugstores, skyrocketing carjackings in Washington, D.C.—is as unmistakable in polls and election results as it is in daily life in large metropolitan areas. Maybe 2024 will turn out to be the year even liberal America stopped acting crazy.

Chaos and disorder work against incumbents, as they did in 1968 when Democrats saw their party’s popular vote fall from 61 percent to 43 percent.

Views expressed in this article are opinions of the author and do not necessarily reflect the views of The Epoch Times or ZeroHedge.

Tyler Durden Sat, 03/09/2024 - 23:20

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Veterans Affairs Kept COVID-19 Vaccine Mandate In Place Without Evidence

Veterans Affairs Kept COVID-19 Vaccine Mandate In Place Without Evidence

Authored by Zachary Stieber via The Epoch Times (emphasis ours),

The…

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Veterans Affairs Kept COVID-19 Vaccine Mandate In Place Without Evidence

Authored by Zachary Stieber via The Epoch Times (emphasis ours),

The U.S. Department of Veterans Affairs (VA) reviewed no data when deciding in 2023 to keep its COVID-19 vaccine mandate in place.

Doses of a COVID-19 vaccine in Washington in a file image. (Jacquelyn Martin/Pool/AFP via Getty Images)

VA Secretary Denis McDonough said on May 1, 2023, that the end of many other federal mandates “will not impact current policies at the Department of Veterans Affairs.”

He said the mandate was remaining for VA health care personnel “to ensure the safety of veterans and our colleagues.”

Mr. McDonough did not cite any studies or other data. A VA spokesperson declined to provide any data that was reviewed when deciding not to rescind the mandate. The Epoch Times submitted a Freedom of Information Act for “all documents outlining which data was relied upon when establishing the mandate when deciding to keep the mandate in place.”

The agency searched for such data and did not find any.

The VA does not even attempt to justify its policies with science, because it can’t,” Leslie Manookian, president and founder of the Health Freedom Defense Fund, told The Epoch Times.

“The VA just trusts that the process and cost of challenging its unfounded policies is so onerous, most people are dissuaded from even trying,” she added.

The VA’s mandate remains in place to this day.

The VA’s website claims that vaccines “help protect you from getting severe illness” and “offer good protection against most COVID-19 variants,” pointing in part to observational data from the U.S. Centers for Disease Control and Prevention (CDC) that estimate the vaccines provide poor protection against symptomatic infection and transient shielding against hospitalization.

There have also been increasing concerns among outside scientists about confirmed side effects like heart inflammation—the VA hid a safety signal it detected for the inflammation—and possible side effects such as tinnitus, which shift the benefit-risk calculus.

President Joe Biden imposed a slate of COVID-19 vaccine mandates in 2021. The VA was the first federal agency to implement a mandate.

President Biden rescinded the mandates in May 2023, citing a drop in COVID-19 cases and hospitalizations. His administration maintains the choice to require vaccines was the right one and saved lives.

“Our administration’s vaccination requirements helped ensure the safety of workers in critical workforces including those in the healthcare and education sectors, protecting themselves and the populations they serve, and strengthening their ability to provide services without disruptions to operations,” the White House said.

Some experts said requiring vaccination meant many younger people were forced to get a vaccine despite the risks potentially outweighing the benefits, leaving fewer doses for older adults.

By mandating the vaccines to younger people and those with natural immunity from having had COVID, older people in the U.S. and other countries did not have access to them, and many people might have died because of that,” Martin Kulldorff, a professor of medicine on leave from Harvard Medical School, told The Epoch Times previously.

The VA was one of just a handful of agencies to keep its mandate in place following the removal of many federal mandates.

“At this time, the vaccine requirement will remain in effect for VA health care personnel, including VA psychologists, pharmacists, social workers, nursing assistants, physical therapists, respiratory therapists, peer specialists, medical support assistants, engineers, housekeepers, and other clinical, administrative, and infrastructure support employees,” Mr. McDonough wrote to VA employees at the time.

This also includes VA volunteers and contractors. Effectively, this means that any Veterans Health Administration (VHA) employee, volunteer, or contractor who works in VHA facilities, visits VHA facilities, or provides direct care to those we serve will still be subject to the vaccine requirement at this time,” he said. “We continue to monitor and discuss this requirement, and we will provide more information about the vaccination requirements for VA health care employees soon. As always, we will process requests for vaccination exceptions in accordance with applicable laws, regulations, and policies.”

The version of the shots cleared in the fall of 2022, and available through the fall of 2023, did not have any clinical trial data supporting them.

A new version was approved in the fall of 2023 because there were indications that the shots not only offered temporary protection but also that the level of protection was lower than what was observed during earlier stages of the pandemic.

Ms. Manookian, whose group has challenged several of the federal mandates, said that the mandate “illustrates the dangers of the administrative state and how these federal agencies have become a law unto themselves.”

Tyler Durden Sat, 03/09/2024 - 22:10

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The Coming Of The Police State In America

The Coming Of The Police State In America

Authored by Jeffrey Tucker via The Epoch Times,

The National Guard and the State Police are now…

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The Coming Of The Police State In America

Authored by Jeffrey Tucker via The Epoch Times,

The National Guard and the State Police are now patrolling the New York City subway system in an attempt to do something about the explosion of crime. As part of this, there are bag checks and new surveillance of all passengers. No legislation, no debate, just an edict from the mayor.

Many citizens who rely on this system for transportation might welcome this. It’s a city of strict gun control, and no one knows for sure if they have the right to defend themselves. Merchants have been harassed and even arrested for trying to stop looting and pillaging in their own shops.

The message has been sent: Only the police can do this job. Whether they do it or not is another matter.

Things on the subway system have gotten crazy. If you know it well, you can manage to travel safely, but visitors to the city who take the wrong train at the wrong time are taking grave risks.

In actual fact, it’s guaranteed that this will only end in confiscating knives and other things that people carry in order to protect themselves while leaving the actual criminals even more free to prey on citizens.

The law-abiding will suffer and the criminals will grow more numerous. It will not end well.

When you step back from the details, what we have is the dawning of a genuine police state in the United States. It only starts in New York City. Where is the Guard going to be deployed next? Anywhere is possible.

If the crime is bad enough, citizens will welcome it. It must have been this way in most times and places that when the police state arrives, the people cheer.

We will all have our own stories of how this came to be. Some might begin with the passage of the Patriot Act and the establishment of the Department of Homeland Security in 2001. Some will focus on gun control and the taking away of citizens’ rights to defend themselves.

My own version of events is closer in time. It began four years ago this month with lockdowns. That’s what shattered the capacity of civil society to function in the United States. Everything that has happened since follows like one domino tumbling after another.

It goes like this:

1) lockdown,

2) loss of moral compass and spreading of loneliness and nihilism,

3) rioting resulting from citizen frustration, 4) police absent because of ideological hectoring,

5) a rise in uncontrolled immigration/refugees,

6) an epidemic of ill health from substance abuse and otherwise,

7) businesses flee the city

8) cities fall into decay, and that results in

9) more surveillance and police state.

The 10th stage is the sacking of liberty and civilization itself.

It doesn’t fall out this way at every point in history, but this seems like a solid outline of what happened in this case. Four years is a very short period of time to see all of this unfold. But it is a fact that New York City was more-or-less civilized only four years ago. No one could have predicted that it would come to this so quickly.

But once the lockdowns happened, all bets were off. Here we had a policy that most directly trampled on all freedoms that we had taken for granted. Schools, businesses, and churches were slammed shut, with various levels of enforcement. The entire workforce was divided between essential and nonessential, and there was widespread confusion about who precisely was in charge of designating and enforcing this.

It felt like martial law at the time, as if all normal civilian law had been displaced by something else. That something had to do with public health, but there was clearly more going on, because suddenly our social media posts were censored and we were being asked to do things that made no sense, such as mask up for a virus that evaded mask protection and walk in only one direction in grocery aisles.

Vast amounts of the white-collar workforce stayed home—and their kids, too—until it became too much to bear. The city became a ghost town. Most U.S. cities were the same.

As the months of disaster rolled on, the captives were let out of their houses for the summer in order to protest racism but no other reason. As a way of excusing this, the same public health authorities said that racism was a virus as bad as COVID-19, so therefore it was permitted.

The protests had turned to riots in many cities, and the police were being defunded and discouraged to do anything about the problem. Citizens watched in horror as downtowns burned and drug-crazed freaks took over whole sections of cities. It was like every standard of decency had been zapped out of an entire swath of the population.

Meanwhile, large checks were arriving in people’s bank accounts, defying every normal economic expectation. How could people not be working and get their bank accounts more flush with cash than ever? There was a new law that didn’t even require that people pay rent. How weird was that? Even student loans didn’t need to be paid.

By the fall, recess from lockdown was over and everyone was told to go home again. But this time they had a job to do: They were supposed to vote. Not at the polling places, because going there would only spread germs, or so the media said. When the voting results finally came in, it was the absentee ballots that swung the election in favor of the opposition party that actually wanted more lockdowns and eventually pushed vaccine mandates on the whole population.

The new party in control took note of the large population movements out of cities and states that they controlled. This would have a large effect on voting patterns in the future. But they had a plan. They would open the borders to millions of people in the guise of caring for refugees. These new warm bodies would become voters in time and certainly count on the census when it came time to reapportion political power.

Meanwhile, the native population had begun to swim in ill health from substance abuse, widespread depression, and demoralization, plus vaccine injury. This increased dependency on the very institutions that had caused the problem in the first place: the medical/scientific establishment.

The rise of crime drove the small businesses out of the city. They had barely survived the lockdowns, but they certainly could not survive the crime epidemic. This undermined the tax base of the city and allowed the criminals to take further control.

The same cities became sanctuaries for the waves of migrants sacking the country, and partisan mayors actually used tax dollars to house these invaders in high-end hotels in the name of having compassion for the stranger. Citizens were pushed out to make way for rampaging migrant hordes, as incredible as this seems.

But with that, of course, crime rose ever further, inciting citizen anger and providing a pretext to bring in the police state in the form of the National Guard, now tasked with cracking down on crime in the transportation system.

What’s the next step? It’s probably already here: mass surveillance and censorship, plus ever-expanding police power. This will be accompanied by further population movements, as those with the means to do so flee the city and even the country and leave it for everyone else to suffer.

As I tell the story, all of this seems inevitable. It is not. It could have been stopped at any point. A wise and prudent political leadership could have admitted the error from the beginning and called on the country to rediscover freedom, decency, and the difference between right and wrong. But ego and pride stopped that from happening, and we are left with the consequences.

The government grows ever bigger and civil society ever less capable of managing itself in large urban centers. Disaster is unfolding in real time, mitigated only by a rising stock market and a financial system that has yet to fall apart completely.

Are we at the middle stages of total collapse, or at the point where the population and people in leadership positions wise up and decide to put an end to the downward slide? It’s hard to know. But this much we do know: There is a growing pocket of resistance out there that is fed up and refuses to sit by and watch this great country be sacked and taken over by everything it was set up to prevent.

Tyler Durden Sat, 03/09/2024 - 16:20

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