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Underuse of Surgical Therapy of Gastrointestinal Cancer in the United States
Attila Dubecz*1, Norbert Solymosi2, Michael Schweigert1, Rudolf J. Stadlhuber1, Jeffrey H. Peters3, Hubert J. Stein1
1Surgery, Klinikum Nürnberg, Nuremberg, 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
Surgery is the mainstay of curative therapy for most localized gastrointestinal (GI) malignancies. Our objective was to evaluate the utilization of surgery in non-metastatic GI cancer and identify factors predicting failure to undergo surgery.
METHODS
Using the National Cancer Institute's Surveillance Epidemiology and End Results-Database (1998-2008), a total of 331,911 patients (esophagus: 20,475; stomach: 18,585; small bowel: 2,647; colon: 184,675; rectum: 45,599; liver: 24,318; pancreas: 35,612) were identified with non-metastatic cancer. The rate of surgical therapy in each type was calculated. Multivariate logistic regression was employed to identify factors predicting failure to undergo surgical
therapy. Reason for no surgery and the impact of surgery on survival were also assessed.
RESULTS
Surgical resection for locoregional cancer was surprisingly low for cancers of the liver (27%), pancreas (32%), and esophagus (56%). Cancers of the colon (91%) rectum (72%) stomach (78%) and small intestine (74%) had higher rates although as many as one quarter of patients did not undergo surgical resection. The primary reason for not undergoing surgery was classified as "not recommended" in from 1-49% of the patients again highest in pancreas (49%), liver (47%) and esophagus (26%). Men, non-white race, patients >80 yrs, or those undergoing surgical therapy later in the study period and living in areas with high poverty rates were significantly less likely to receive surgical treatment (all p<.0001). Median survival in patients who did not undergo surgical resection was significantly better than those with metastatic disease (9 vs 6, p<0.0001) but far worse than patients who underwent surgery for locoregional disease (96 vs 9, p<0.0001).
CONCLUSIONS
When viewed from a national perspective the rates of surgical resection for locoregional GI cancer vary considerably. These data suggest that operative therapy in esophageal, liver and pancreatic cancer is particularly underutilized.
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