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EQUIVALENT TREATMENT AND SURVIVAL AFTER RESECTION OF PANCREATIC CANCER AT SAFETY-NET HOSPITALS
Vikrom K. Dhar*, Richard S. Hoehn, Young Kim, Brent Xia, Andrew Jung, Dennis J. Hanseman, Syed Ahmad, Shimul A. Shah
Surgery, University of Cincinnati, Cincinnati, OH
Background: Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. We now hypothesize that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation therapy, resulting in inferior long-term outcomes.
Methods: The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n=32,296) from 1998-2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival.
Results: Patients at safety-net hospitals were less often white, had less income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p=0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days. vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived >30 days (HR 1.02, p=0.63).
Conclusion: Despite previous reports suggesting worse short-term surgical outcomes at safety-net hospitals, these centers have equivalent long-term survival following pancreatic cancer surgery potentially due to equivalent delivery of multimodal therapy as at non-safety net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.
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