Under-Utilization of Surgical Resection for Gastric Cancer in the Era of Multi-Modality Therapy
Lee J. Mcghan*1, Barbara a. Pockaj1, Richard J. Gray1, Sanjay P. Bagaria2, Nabil Wasif1
1General Surgery, Mayo Clinic Arizona, Scottsdale, AZ; 2General Surgery, Mayo Clinic Florida, Jacksonville, FL
Introduction: Surgical resection of gastric adenocarcinoma is the cornerstone of potentially curative therapy. We studied the recent utilization of surgical resection for patients diagnosed with gastric adenocarcinoma in the United States in the era of multi-modality therapy.Methods: A retrospective review of all patients with gastric adenocarcinoma diagnosed between 2004-2007 in the Surveillance, Epidemiology and End Results (SEER) cancer registry was conducted. Utilization and extent of surgery was reviewed according to stage at presentation, and factors associated with receipt of surgery were identified. Results: A total of 18,815 patients diagnosed with gastric adenocarcinoma were identified, of whom 47% underwent a surgical resection (defined as any procedure more extensive than a simple local excision). Excluding stage IV patients, 6651/8848 patients (75%) underwent a cancer-directed surgical resection (SR group). Table 1 shows the distribution of SR by AJCC stage at presentation for all patients. Patients in the SR group were younger than those not undergoing surgical resection (NSR group): mean age 68 ± 0.16 vs. 74 ± 0.29, respectively (p<0.001). Patients in the SR group had a higher distribution of distal tumors vs. proximal tumors compared to the NSR group (84% vs. 69%, p<0.001) and were less likely to have T4 tumors (2% vs. 11%, p<0.001). The majority of the 2197 patients in the NSR group (65%) were not recommended any surgical resection and surgery was contra-indicated due to other co-morbid conditions in only 9%. The overall disease-specific survival (DSS) at three years (excluding stage IV patients) was 39% in the NSR group compared with 62% in the SR group (p<0.001). For stage IA patients only, the three-year DSS for the NSR group was 68% compared with 94% in the SR group (p<0.001). Conclusions: In the modern era of cancer care a significant proportion of patients in the United States with early-stage gastric adenocarcinoma are not being offered surgical resection (37% of stage IA patients in our study), despite a clear survival advantage demonstrated following surgery. Further study is required to explain this discrepancy. Patient and physician education, national guidelines and perhaps regionalization of care may be needed to improve patient outcomes.
TABLE 1: Distribution of extent of surgical resection by tumor stage
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