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National Trends in Utilization of Endoscopic Ultrasound for Gastric Cancer: a SEER-Medicare Study

  • 2015 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

Accurate preoperative staging is important for patients with gastric cancer. This study identifies the rate of utilization of endoscopic ultrasound (EUS) and its associated factors in Medicare patients with gastric adenocarcinoma.

Methods

The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare claims database was queried from 1996 to 2009 for patients with gastric cancer who underwent gastric resection. Analysis with univariate, multivariate, and Cochran-Armitage trend tests were performed.

Results

In 5826 patients with gastric cancer with an average age of 76.9 ± 6.62 years, 59.1 % had regionalized spread of cancer. EUS utilization increased significantly during the study period from 2.6 % to 22 % (p < 0.0001). EUS patients were more likely to be male, white, married, have higher education and income quartiles, and live in large metropolitan areas compared to non-EUS patients (p < 0.0001). Even after controlling for confounding factors, patients who underwent EUS were more likely to have >15 lymph nodes examined (odds ratio (OR) 1.26, 95 % confidence interval (CI) 1.04–1.53) and have the administration of both pre- and postoperative chemotherapy (OR 1.27, 95 % CI 1.03–1.57).

Conclusion

EUS is currently under-utilized but increasing. Patients who underwent EUS (12.9 %) were more likely to receive other NCCN-recommended care, including perioperative chemotherapy and adequate nodal retrieval.

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References

  1. American Cancer Society and the International Agency for Research on Cancer (2011) Global Cancer Facts & Figures. 2nd edn. American Cancer Society

  2. American Cancer Society (2014) Stomach Cancer: Detailed Guide. American Cancer Society

  3. Stomach Cancer Factsheet (1975-2014.). SEER Cancer Statistics Review. National Cancer Institute, Bethesda, MD.

  4. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, Haller DG, Ajani JA, Gunderson LL, Jessup JM, Martenson JA (2001) Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10):725-730. doi:10.1056/NEJMoa010187

    Article  PubMed  CAS  Google Scholar 

  5. Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE, Verma M, Weeden S, Chua YJ, Participants MT (2006) Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 355 (1):11-20. doi:10.1056/NEJMoa055531

    Article  PubMed  CAS  Google Scholar 

  6. Fairweather M, Jajoo K, Sainani N, Bertagnolli MM, Wang J (2015) Accuracy of EUS and CT imaging in preoperative gastric cancer staging. J Surg Oncol. doi:10.1002/jso.23919

    Google Scholar 

  7. Lei C, Huang L, Wang Y, Huang Y, Huang Y (2013) Comparison of MRI and endoscope ultrasound detection in preoperative T/N staging of gastric cancer. Mol Clin Oncol 1 (4):699-702. doi:10.3892/mco.2013.103

    PubMed  PubMed Central  Google Scholar 

  8. Mehmedovi A, Mesihovi R, Saray A, Vanis N (2014) Gastric Cancer Staging: EUS And CT. Medical Archives 68 (1):34. doi:10.5455/medarh.2014.68.34-36

    Article  Google Scholar 

  9. Mocellin S, Pasquali S (2015) Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev 2:CD009944. doi:10.1002/14651858.CD009944.pub2

    PubMed  Google Scholar 

  10. Papanikolaou IS, Triantafyllou M, Triantafyllou K, Rösch T (2011) EUS in the management of gastric cancer. Ann Gastroenterol 24 (1):9-15

    PubMed  PubMed Central  Google Scholar 

  11. Schwarz RE (2015) Current status of management of malignant disease: current management of gastric cancer. J Gastrointest Surg 19 (4):782-788. doi:10.1007/s11605-014-2707-x

    Article  PubMed  Google Scholar 

  12. Spolverato G, Ejaz A, Kim Y, Squires MH, Poultsides GA, Fields RC, Schmidt C, Weber SM, Votanopoulos K, Maithel SK, Pawlik TM (2015) Use of endoscopic ultrasound in the preoperative staging of gastric cancer: a multi-institutional study of the US gastric cancer collaborative. J Am Coll Surg 220 (1):48-56. doi:10.1016/j.jamcollsurg.2014.06.023

    Article  PubMed  Google Scholar 

  13. Ajani JA, D'Amico, T.A (2015) National Comprehensive Cancer Network Gastric Cancer Guidelines, Version 3.2015. National Comprehensive Cancer Network

  14. Gee D, Rattner, D.W. (2007) Management of Gastroesophageal Tumors. The Oncologist 12 (2):175-185. doi:10.1634/theoncologist.12-2-175

    Article  PubMed  Google Scholar 

  15. DeWitt J, Kesler K, Brooks JA, LeBlanc J, McHenry L, McGreevy K, Sherman S (2005) Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy. Dis Esophagus 18 (1):21-27. doi:10.1111/j.1442-2050.2005.00444.x

    Article  PubMed  CAS  Google Scholar 

  16. Hwang SW, Lee DH, Lee SH, Park YS, Hwang JH, Kim JW, Jung SH, Kim NY, Kim YH, Lee KH, Kim HH, Park do J, Lee HS, Jung HC, Song IS (2010) Preoperative staging of gastric cancer by endoscopic ultrasonography and multidetector-row computed tomography. J Gastroenterol Hepatol 25 (3):512-518. doi:10.1111/j.1440-1746.2009.06106.x

    Article  PubMed  Google Scholar 

  17. Puli SR, Reddy JBK, Bechtold ML, Antillon MR, Ibdah JA (2008) How good is endoscopic ultrasound for TNM staging of gastric cancers? A meta-analysis and systematic review. World Journal of Gastroenterology : WJG 14 (25):4011-4019. doi:10.3748/wjg.14.4011

    Article  PubMed  PubMed Central  Google Scholar 

  18. Institute NC (2015) Healthcare Delivery Research: SEER-Medicare- Description of SEER-Medicare Database. National Institutes of Health (NIH). http://healthcaredelivery.cancer.gov/seermedicare/overview/. Accessed May 2015

  19. Karpeh MS, Leon L, Klimstra D, Brennan MF (2000) Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients. Ann Surg 232 (3):362-371

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  20. Filik M, Kir KM, Aksel B, Soyda C, Ozkan E, Kucuk ON, Ibis E, Akgul H (2015) The Role of 18F-FDG PET/CT in the Primary Staging of Gastric Cancer. Mol Imaging Radionucl Ther 24 (1):15-20. doi:10.4274/mirt.26349

    Article  PubMed  PubMed Central  Google Scholar 

  21. Polkowski M, Palucki J, Wronska E, Szawlowski A, Nasierowska-Guttmejer A, Butruk E (2004) Endosonography versus helical computed tomography for locoregional staging of gastric cancer. Endoscopy 36 (7):617-623. doi:10.1055/s-2004-814522

    Article  PubMed  CAS  Google Scholar 

  22. Botet JF, Lightdale CJ, Zauber AG, Gerdes H, Winawer SJ, Urmacher C, Brennan MF (1991) Preoperative staging of gastric cancer: comparison of endoscopic US and dynamic CT. Radiology 181 (2):426-432. doi:10.1148/radiology.181.2.1924784

    Article  PubMed  CAS  Google Scholar 

  23. Ziegler K, Sanft C, Zimmer T, Zeitz M, Felsenberg D, Stein H, Germer C, Deutschmann C, Riecken EO (1993) Comparison of computed tomography, endosonography, and intraoperative assessment in TN staging of gastric carcinoma. Gut 34 (5):604-610

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  24. Ganpathi IS, So JB, Ho KY (2006) Endoscopic ultrasonography for gastric cancer: does it influence treatment? Surg Endosc 20 (4):559-562. doi:10.1007/s00464-005-0309-0

    Article  PubMed  CAS  Google Scholar 

  25. Bhandari S, Shim CS, Kim JH, Jung IS, Cho JY, Lee JS, Lee MS, Kim BS (2004) Usefulness of three-dimensional, multidetector row CT (virtual gastroscopy and multiplanar reconstruction) in the evaluation of gastric cancer: a comparison with conventional endoscopy, EUS, and histopathology. Gastrointest Endosc 59 (6):619-626

    Article  PubMed  Google Scholar 

  26. Lee HH, Lim CH, Park JM, Cho YK, Song KY, Jeon HM, Park CH (2012) Low accuracy of endoscopic ultrasonography for detailed T staging in gastric cancer. World J Surg Oncol 10:190. doi:10.1186/1477-7819-10-190

    Article  PubMed  PubMed Central  Google Scholar 

  27. Cardoso R, Coburn NG, Seevaratnam R, Mahar A, Helyer L, Law C, Singh S (2012) A systematic review of patient surveillance after curative gastrectomy for gastric cancer: a brief review. Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association 15 Suppl 1:S164-167. doi:10.1007/s10120-012-0142-9

    Article  Google Scholar 

  28. Ishigami S, Uenosono Y, Arigami T, Yanagita S, Okumura H, Uchikado Y, Kita Y, Kurahara H, Kijima Y, Nakajo A, Maemura K, Natsugoe S (2014) Clinical utility of perioperative staging laparoscopy for advanced gastric cancer. World J Surg Oncol 12:350. doi:10.1186/1477-7819-12-350

    Article  PubMed  PubMed Central  Google Scholar 

  29. Sarela AI, Lefkowitz R, Brennan MF, Karpeh MS (2006) Selection of patients with gastric adenocarcinoma for laparoscopic staging. Am J Surg 191 (1):134-138. doi:10.1016/j.amjsurg.2005.10.015

    Article  PubMed  Google Scholar 

  30. Nieveen van Dijkum EJ, de Wit LT, van Delden OM, Kruyt PM, van Lanschot JJ, Rauws EA, Obertop H, Gouma DJ (1999) Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma. J Am Coll Surg 189 (5):459-465

    Article  PubMed  CAS  Google Scholar 

  31. Reddy NK, Markowitz AB, Abbruzzese JL, Bhutani MS (2008) Knowledge of indications and utilization of EUS: a survey of oncologists in the United States. J Clin Gastroenterol 42 (8):892-896. doi:10.1097/MCG.0b013e3180cab11a

    Article  PubMed  Google Scholar 

  32. Cronin-Fenton DP, Mooney MM, Clegg LX, Harlan LC (2008) Treatment and survival in a population-based sample of patients diagnosed with gastroesophageal adenocarcinoma. World J Gastroenterol 14 (20):3165-3173

    Article  PubMed  PubMed Central  Google Scholar 

  33. Le A, Berger D, Lau M, El-Serag HB (2007) Secular trends in the use, quality, and outcomes of gastrectomy for noncardia gastric cancer in the United States. Ann Surg Oncol 14 (9):2519-2527

    Article  PubMed  Google Scholar 

  34. Higashi T, Nakamura F, Shimada Y, Shinkai T, Muranaka T, Kamiike W, Mekata E, Kondo K, Wada Y, Sakai H, Ohtani M, Yamaguchi T, Sugiura N, Higashide S, Haga Y, Kinoshita A, Yamamoto T, Ezaki T, Hanada S, Makita F, Sobue T, Okamura T (2013) Quality of gastric cancer care in designated cancer care hospitals in Japan. Int J Qual Health Care 25 (4):418-428

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC, 28204, USA

    Ciara R. Huntington

  2. Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, 1021 Morehead Medical Drive #6100, Charlotte, NC, 28204, USA

    Kendall Walsh, Yimei Han, Jonathan Salo & Joshua Hill

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  1. Ciara R. Huntington
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  2. Kendall Walsh
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  3. Yimei Han
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  4. Jonathan Salo
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  5. Joshua Hill
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Corresponding author

Correspondence to Joshua Hill.

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Disclosure Statement

The authors declare no conflict of interest with any persons, companies, or organizations that could bias this work or its conclusions.

Additional information

Primary Discussant

David W. Rattner, M.D. (Boston, MA)

Huntington and coauthors examined 12 years of data from the SEER and Medicare claims databases with the intent to examine the nationwide utilization of EUS and what patient or disease characteristics predicted its use. Even when controlling for confounding factors, the utilization of EUS was significantly associated with the retrieval of >15 lymph nodes at gastric resection (OR 1.26) and with pre- and postoperative chemotherapy administration – both felt to be indicator of quality in the care of gastric cancer patients. The finding that only 31 % of patients undergoing gastric resection had 15 nodes or more removed or examined should be concerning to us as members of the SSAT. My questions to you are:

1) One of the differences in care of gastric cancer patients in Korea, Japan and the USA is a different philosophy about use of neoadjuvant chemoradiation vs a good D2 lymphadenectomy. Given the relatively poor specificity of EUS for both T and N staging, is it possible that we are overtreating some patients with neoadjuvant therapy based on EUS results? Or do you think we are just covering up for an inadequate lymphadenectomy by liberal use of neoadjuvant chemoradiation?

2) EUS is highly operator dependent. Do you have any sense of quality control or improved accuracy over the course of time of your study?

3) What you have really shown in this paper is that relatively few patients with gastric cancer seem to be getting evaluated and treated in a truly multidisciplinary setting that can provide comprehensive cancer care. Given the relative rarity of gastric cancer in the USA - shouldn’t these cases viewed like pancreatic and esophageal neoplasms and be cared for at tertiary care facilities with established multidisciplinary cancer care teams?

Closing Discussant

Dr. Huntington

We would like to thank Dr. Rattner for taking the time to discuss our work and to the SSAT for the opportunity to present our research. The care of gastric cancer patients varies by geographic region, but universally, there is an increasing role for neoadjuvant therapy in locally advanced disease since the MAGIC trial and the French FNLCC/FFCD trial demonstrated an overall survival benefit for patients with preoperative chemotherapy, as well as improved success of surgical resections due to tumor downstaging. Currently, the NCCN recommends that neoadjuvant chemotherapy be considered for patients with stage II disease or any lymph node involvement (N1 or greater). Though EUS has a pooled T classification accuracy of 75 % and an 80 % pooled specificity for N classification in a meta-analysis by Dr. Cardosa and colleagues, EUS may still allow for better identification of patients who would benefit from neoadjuvant therapy prior to surgical resection. Our results actually suggest that we may be under-treating patients since less than 5 % of the patients in our study had chemotherapy prior to major gastric resection, despite the fact more than 60 % had regionalized spread of disease. Though EUS was more strongly associated with patients who had pre- and postoperative chemotherapy, these patients were also more likely to have a “good” lymphadenectomy, as defined by adequate lymph node harvest.

To your second point, our research demonstrates that the utilization of EUS has increased steadily throughout the study period. Though we cannot evaluate the variation in operator experience and interpretation through our study of this linked national dataset, a 2012 systematic review in Gastric Cancer found no significant difference in EUS accuracy in cancer staging based on the annual EUS volume.

Finally, many patients with gastric cancer in the United States could benefit from multimodal therapies to treat their disease, but our research demonstrates that the majority of older patients do not receive this. We believe that patients with gastric cancer benefit from a process of comprehensive care that includes presentation at a multidisciplinary planning conference or tumor board where medical oncologists, radiation oncologists, and surgeons can tailor individual patient care plans based on the consensus opinion of a multidisciplinary cancer care team, expert guidelines, and existing research. Community surgeons who wish to care for patients with gastric cancer should consider participating in these forums, either in person or via teleconference if this resource is not available at their facility. Referral to centers that provide comprehensive cancer care should be considered when optimal management cannot be provided at a local level.

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Huntington, C.R., Walsh, K., Han, Y. et al. National Trends in Utilization of Endoscopic Ultrasound for Gastric Cancer: a SEER-Medicare Study. J Gastrointest Surg 20, 154–164 (2016). https://doi.org/10.1007/s11605-015-2988-8

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  • DOI: https://doi.org/10.1007/s11605-015-2988-8

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