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Time-Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: a Population-Based Analysis of 342,792 Patients
Attila Dubecz*1, Michael Schweigert1, Rudolf J. Stadlhuber1, Norbert Solymosi2, Jeffrey H. Peters3, Hubert J. Stein1
1Surgery, Klinikum Nurnberg, Nurnberg, Germany; 2Veterinary Medicine, Szent István University, Budapest, Hungary; 3Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
BACKGROUND
The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objective was to evaluate the time-trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample.
METHODS
Using the National Cancer Institute's Surveillance Epidemiology and End Results-Database (1998-2008), a total of 342,792 patients with surgically treated GI malignancy(esophagus: 13,471; stomach: 21,094; small bowel: 10,588; colon: 243,982; rectum: 41,683; pancreas: 11,974) were identified. Adequate lymphadenectomy was defined based on review of pusblished data and was defined as: 23 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum and 12 pancreas. The median number of lymph nodes removed and prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the 10 study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy.
RESULTS
The median number of excised nodes improved over the decade of study in all types of cancer; esophagus: from 7 to 13, stomach 9 - 12, small bowel 3 - 6, colon 9 - 15, rectum 8 - 13 and pancreas 7 - 11. Further the percentage of patients with an adequate lymphadenectomy (median 42.3% for all types) steadily increased and those with zero nodes removed (median 7.1% for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2008, the percentage of patients with adequate lymphadenectomy was 16.4% for esophagus, 37.4% for stomach, 31.4% for small intestine, 72.7% for colon, 58.2% for rectum and 49.9% for pancreas. Men, non-white race, patients >65 yrs, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p<.0001).
CONCLUSIONS
Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the United States although the median number of resected nodes increased over the last ten years. Gender, socioeconomic and racial disparities in receiving adequate lymphadenectomy were observed.
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