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COMPARISON OF PERIOPERATIVE CHEMOTHERAPY VS. POSTOPERATIVE CHEMORADIATION THERAPY FOR ADENOCARCINOMA OF THE GASTRIC CARDIA: AN ANALYSIS OF THE NATIONAL CANCER DATABASE
Mihir M. Shah*1, Rachel E. NeMoyer2, Stephanie H. Greco1, Yong Lin5, Miral S. Grandhi1, Darren Carpizo1, Parisa Javidian3, Salma K. Jabbour4, David A. August1, H. Richard Alexander1, Steven K. Libutti1, Timothy J. Kennedy1
1Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; 2General Surgery, Rutgers Robertwood Johnson University Hospital, New Brunswick, NJ; 3Pathology, Rutgers Robertwood Johnson University Hospital, New Brunswick, NJ; 4Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; 5Biostatistics, Rutgers School of Public Health, New Brunswick, NJ

Introduction
Perioperative chemotherapy (PEC) and postoperative chemoradiation therapy (POCR) are considered standard of care for patients with resectable gastric adenocarcinoma (GC) based on level 1 evidence. However, no significant evidence exists directly comparing PEC and POCR for gastric cardia adenocarcinoma. The purpose of this study was to compare these treatment modalities in patients with surgically resectable gastric cardia adenocarcinoma to determine the impact on overall survival (OS).

Methods
A retrospective review of patients undergoing definitive surgery for GC was performed using the National Cancer Database (2004-2014). Only patients with gastric cardia as the primary tumor site were included. The difference in OS in patients who received PEC or POCR was compared. A second analysis identified patients who received optimal therapy, defined as - negative surgical margins, radiation doses between 4500-5040cGy, radiation to the esophagus and stomach only, and chemotherapy started within 90 days of surgery. We utilized Cox proportional hazard model for our multivariable analysis.

Results
We identified 62,931 patients who underwent definitive surgery for GC. 1,932 patients with gastric cardia adenocarcinoma underwent PEC or POCR. No difference in OS was noted between the patients receiving PEC and POCR (p=0.486; HR 1.069) [Table 1]. The median OS was 35.2 months for all patients (PEC 38.47 months, POCR 34.04 months). No difference in OS was maintained, after selecting patients who received optimal therapy (n = 862) (p=0.7658; HR 1.035) [Table 2]. The median OS was 39.9 months for all patients (PEC 45.01 months, POCR 38.83 months). Age, grade, Charlson score and lymph node positive ratio were statistically significant predictors of OS.

Conclusion
After adjusting for covariates in patients who underwent definitive surgery for adenocarcinoma of the gastric cardia, there is no difference in OS in patients receiving PEC and POCR. Even after selecting patients who received optimal therapy, there is no difference in OS between PEC and POCR. The median OS is superior in patients receiving optimal therapy, regardless of the treatment type.

Table 1. Hazard Ratio for Each Factor
PARAMETER p-valueHazard Ratio95% Hazard Ratio Confidence Limits
PEC10.48601.0690.8861.289
SEX10.89610.9890.8321.175
RACE10.85840.9600.6141.501
RACE20.25740.7370.4351.249
GRADE10.01800.5210.3040.894
GRADE20.02390.6280.4190.940
GRADE30.08510.7070.4761.049
CHARLSON SCORE00.07770.7800.5921.028
CHARLSON SCORE10.23320.8340.6191.124
AGE < 0.00011.0191.0121.025
TUMOR SIZE 0.32791.0010.9991.002
LYMPH NODE POSITIVE RATIO < 0.00015.6554.5067.095


Table 2. Hazard Ratio for Each Factor
PARAMETER p-valueHazard Ratio95% Hazard Ratio Confidence Limits
PEC10.76581.0350.8231.303
SEX10.70551.0600.7831.436
RACE10.50560.7870.3881.594
RACE20.17690.5580.2391.301
GRADE10.06110.4360.1831.039
GRADE20.07590.5380.2721.067
GRADE30.16320.6190.3161.215
CHARLSON SCORE00.94710.9850.6221.559
CHARLSON SCORE10.97111.0090.6171.652
AGE 0.00501.0151.0041.025
TUMOR SIZE 0.54731.0010.9981.004
LYMPH NODE POSITIVE RATIO < 0.00015.8223.9948.485


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