DISPARITIES IN RECEIPT OF NEOADJUVANT THERAPY FOR GASTRIC AND PANCREATIC CANCERS: THE SELECTION BIAS IS REAL
Amanda Arrington*, Catherine OGrady, Mohammad Khreiss, Taylor S. Riall
University of Arizona, Tucson, AZ
BACKGROUND:
Current studies support the use of neoadjuvant chemotherapy in stage II/III gastric cancer and resectable/borderline resectable pancreatic cancer. The advantages of neoadjuvant therapy (NAC) in operable gastric and pancreatic cancers include higher rates of down-staged disease and N0 disease at time of surgical resection. Despite recommendations, not all patients get stage-appropriate NAC. We hypothesize that there are significant socioeconomic and racial disparities in patients who undergo NAC compare to upfront surgery.
METHODS:
Patients who underwent surgery with/without NAC for gastric (stage II/III) or pancreatic (stage I/II/III) adenocarcinomas diagnosed between 2010-2015 were identified using the National Cancer Database (NCDB). We evaluated clinical and demographic differences between the NAC and upfront surgery groups and then used regression models to examine the association of socioeconomic status with the receipt of NAC.
RESULTS:
A total of 23,842 patients (7934 stomach and 15,908 pancreatic) were included of which 61.1% and 21.2% received NAC, respectively. On multivariable analysis, gastric cancer patients who were male (OR 1.81, 95% CI 1.64-2.04, p<0.0001), younger (OR 0.95, 95% CI 0.94-0.95 p<0.0001), Caucasian (vs. black, OR 2.78, 95% CI 2.38-3.23 p<0.0001), with private insurance (vs Medicaid) (OR 1.52, 95% CI 1.25-1.85), and higher incomes (>$48,000 vs <$38,000; OR 1.55, 95% CI 1.31-1.81) were more likely to receive NAC. Similarly, pancreatic cancer patients who were younger patients (pancreatic OR 0.97, 95% CI 0.96-0.9) who were Caucasian (OR 1.30, 95% CI 1.14-1.49 p=0.002), with private insurance (OR 1.25, 95% CI 1.04-1.52), and who had higher incomes pancreatic OR 1.23 95%CI 1.08-1.40) were more likely to receive NAC. This was true even after controlling for resection at academic medical centers, where patients were also more likely to receive NAC (gastric OR 1.92, 95% CI 1.72-2.13 p<0.0001, pancreatic OR 1.69, 95% CI 1.54-1.85). Patients with more comorbidities were less likely to receive NAC (Charlson score 3 vs 0: gastric OR 0.53, 95% CI 0.41-0.83 p=0.003, pancreatic OR 0.58, 95% CI 0.41-0.83 p=0.003).
CONCLUSIONS
In gastric and pancreatic cancers, there are significant disparities in age, race, insurance status and socioeconomic status between patients who receive neoadjuvant therapy and those that undergo upfront surgery. Though those with more comorbidities were less likely to receive NAC, NAC may be a better approach in these patients to understand tumor biology. In patients with lower socioeconomic status, this overall pattern has the potential to propagate ongoing cancer outcome disparities as well.
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