H. A. Frohman1, J. T. Martin2, A. H. Le1, S. P. Dineen1, C. D. Tzeng1 1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 2Southern Ohio Medical Center,Department Of Cardiothoracic Surgery,Portsmouth, OH, USA
Introduction: Surgical resection is the main component of multimodality therapy for resectable gastric cancer (GC). However, a significant proportion of patients never receive curative-intent surgery. The primary aims of this study were to evaluate national trends of surgical rates for resectable GC and to identify disparities and targetable risk factors associated with failure to operate.
Methods: The National Cancer Database was used to identify patients with resectable GC (defined as adenocarcinoma, pre-treatment clinical stage IA-IIIC), diagnosed 2004-2013. Curative-intent surgery included any gastrectomy for stage IA-IIIC and endoscopic mucosal resection for stage IA. Multivariate modeling was used to identify predictors of resection and to analyze the impact of surgery on overall survival (OS).
Results: Of 46,970 total patients, 18,085 (39%) with resectable GC did not receive a potentially curative operation. While rate of resection increased from 2004 to 2013 (52% vs. 62%, p<0.001), 69% of unresected patients had no listed co-morbidities. Variables independently associated with no surgery included: insurance other than private or Medicare (odds ratio, OR 1.60, 1.54), non-academic/research hospital (OR 1.16), non-Asian race (OR 1.72), male gender (OR 1.19), older age (OR 1.04), Charlson/Deyo score >1 (OR 1.17), residing in areas with median income <$48,000 (OR 1.23), areas with <13% high school degrees (OR 1.25), small urban populations <20,000 (OR 1.41), and increasing stage (reference IA; OR range 1.36-3.79 from stage IB-IIIC) (all p<0.001). Among all stages, failure to resect was independently associated with reduced median OS (44.4 vs. 11.8mo, hazard ratio, HR 2.09, p<0.001) (Figure). In the multivariate OS analysis, the most critical factors affecting OS were resection (HR 2.09) and stage (reference IA; HR range 1.16-3.50 from stage IB-IIIC). Other independently associated socioeconomic factors, clinical predictors, and demographic variables had HRs ≤1.51.
Conclusions: Over one-third of patients with resectable GC fail to receive surgery, which is the greatest determinant of OS besides clinical stage. Patients without access to academic/research hospitals, without adequate insurance, and living in areas with lower socioeconomic status, are most vulnerable to insufficient GC treatment. Suitable insurance coverage and treatment facility are the most salient (and only modifiable) risk factors for omitting surgery. To mitigate these national disparities in surgical care, policymakers should consider improving insurance coverage in underserved areas and regionalization of GC care. Only by improving these patients’ odds for resection will meaningful improvement in national outcomes be possible.
