Adherence with operative standards in the treatment of gastric cancer in the United States
Despite multiple clinical trials and practice guidelines for the treatment of gastric cancer, oncologic outcomes have not improved in the United States. One potential reason could be differences in the quality of surgery as performed in a controlled trial versus in practice.
Using the National Cancer Database, rates of adherence with operative standards for gastrectomy for cancer were analyzed. Of the numerous evidence-based operative standards outlined in the manual, two were reliably measured in the NCDB: (1) achieving and R0 resection, and (2) having > 16 lymph nodes examined. Univariable and multivariable Cox proportional hazard modeling and logistic regression were performed.
A total of 28,705 patients with gastric adenocarcinoma who underwent curative-intent gastrectomy during 2004–2014 were identified. Only 36.5% of stage 0/I patients, and 41.8% of stage II/III patients, met minimum standards. Predictors for meeting standards included age < 65, fewer comorbidities, Asian/Pacific Islander race, and treatment at academic and high-volume centers. Patients who met standards had longer OS (stage 0/I: 104.9 versus 66.6 months; stage II/III: 40.6 versus 26.0 months; p < 0.001 for both). Meeting standards was a significant predictor for improved OS for both stage 0/I and II/III patients (HR = 0.665 and HR = 0.747, respectively, p < 0.001 for both).
For standards that are measurable in the NCDB, adherence is poor. Improved adherence with operative standards may improve survival for gastric cancer patients in the U.S. There is a need for better measuring of, and adherence with, operative standards in gastrectomy for cancer.
KeywordsGastric cancer National Cancer Database NCDB Operative standards
Compliance with ethical standards
Conflict of interest
Dr. Beiqun Zhao is supported by the National Library of Medicine Training Grant [NIH Grant: T15LM011271]. The funding source had no role in the design and/or general conduct of this study; had no access to the data or role in data collection, management, analysis, or interpretation; had no role in the preparation, review, or approval of the manuscript; and had no role in the decision to submit the manuscript for publication. The coauthors have no financial or other conflicts of interest to disclose.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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