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Time Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: A Population-Based Analysis of 326,243 Patients

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objectives were to evaluate the time trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample.

Methods

Using the National Cancer Institute’s Surveillance Epidemiology and End Results Database (1998–2009), a total of 326,243 patients with surgically treated GI malignancy (esophagus, 13,165; stomach, 18,858; small bowel, 7,666; colon, 232,345; rectum, 42,338; pancreas, 12,141) were identified. Adequate lymphadenectomy was defined based on the National Cancer Center Network’s recommendations as more than 15 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum, and 15 pancreas. The median number of lymph nodes removed and the prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the ten study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy.

Results

The median number of excised nodes improved over the decade of study in all types of cancer: esophagus, from 7 to 13; stomach, 8–12; small bowel, 2–7; colon, 9–16; rectum, 8–13; and pancreas, 7–13. Furthermore, the percentage of patients with an adequate lymphadenectomy (49 % for all types) steadily increased, and those with zero nodes removed (6 % for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2009, the percentages of patients with adequate lymphadenectomy were 43 % for esophagus, 42 % for stomach, 35 % for small intestine, 77 % for colon, 61 % for rectum, and 42 % for pancreas. Men, patients >65 years old, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < 0.0001).

Conclusions

Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the USA, although the median number of resected nodes increased over the last 10 years. Gender and socioeconomic disparities in receiving adequate lymphadenectomy were observed.

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Acknowledgments

This project was partly supported by project TÁMOP 4.2.1.B-11/2/KMR-2011-0003.

Nothing to disclose.

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Authors and Affiliations

  1. Department of Surgery, Klinikum Nürnberg, Prof. Ernst-Nathan Str. 1, 90419, Nuremberg, Germany

    A. Dubecz, M. Schweigert, R. J. Stadlhuber & H. J. Stein

  2. Faculty of Veterinary Science, Szent István University Budapest, Budapest, Hungary

    N. Solymosi

  3. Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    J. H. Peters

  4. Department of Surgery, Paracelsus Medical Private University, Salzburg, Austria

    D. Ofner

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  1. A. Dubecz
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Discussant

Dr. Thomas A. Aloia (New York, NY): Time-Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: A Population-Based Analysis of 342,792 Patients

In this study the authors present data regarding temporal trends in nodal recovery for several gastrointestinal cancers. The data source is the SEER database and the cohort is recent. The majority of procedures examined were colorectal resections. The analysis determined that although progress in appropriate nodal recovery has been made, large numbers of patients may still be subject to undersampling of regional lymph nodes at the time of primary GI tumor resection.

In an additional analysis, the authors note that demographic and socioeconomic factors were statistically associated with adequate node sampling. However, the absolute differences are very small and may not be clinically or socially relevant.

These data are timely. As improved surgical techniques and more effective systemic therapies emerge, the number of patients with metastatic disease who are eligible for attempts at curative resection is on the rise. As we have seen frequently with colorectal liver metastases, these attempts are often thwarted by inadequate oncologic surgery for the primary tumor.

In order to better understand these data and to learn the possible clinical impact of these data the following questions are posed:

1. Large numbers of patients are recorded in the analysis as having no lymph nodes removed. This calls into question either the dataset or the curative intent of the operation. How were missing data handled in your analysis? Were the patients coded as having no lymph nodes removed listed as 0 nodes recovered in the dataset or was the data missing?

2. You dismiss differences in node removal rates based on age as “not clinical significant” but the magnitude of difference for age was at least if not more than for socioeconomic status. Do you really think that the data show a clinically significant bias against nodal recovery based on socioeconomic status or is this simply a byproduct of small differences becoming statistically significant in a very large dataset?

3. Nodal recovery is certainly a team sport. Both surgeon and pathologist need to participate to obtain a proper record of nodal recovery. Your discussion does not include consideration of the role of the pathologist in this issue. Why focus only on the surgeon?

4. Is it possible that palliative primary tumor resections are included in these data and may account for some of the patients with apparent “inadequate” nodal recovery? Can you tell in SEER if the resections had a curative vs. palliative intent?

Closing Discussant

Dr. Attila Dubecz: Thank You for Your comments.

1. Patients classified as “unknown number of lymphnodes removed” were excluded from the study population.

2. Socioeconomic status is the most important factor driving cancer disparities in the United States. Therefore, the measured differences in our study are not only statistical significant but also theoretically plausible and do not contradict previous data. On the other hand, our data must be interpreted with caution since several other unknown factors, for example insurance status could have much larger influence on these disparities.

3. It is impossible to distinguish from the SEER Database whether the inadequacy of lymph node dissection is caused by suboptimal surgical resection, pathologic work-up or documentation. There are some data from our study that could point to an inadequate pathologic nodal recovery. For example, the measured improvements in lymph node dissection over time in patients undergoing small bowel resection cannot be explained with surgical factors alone since the technique of small bowel resection (and therefore the amount of mesentery removed) has not changed significantly over time. It can be therefore postulated, that these changes are mainly caused by superior pathologic work-up and/or documentation.

4. SEER does not collect data on the intent of surgery. It is therefore possible that a very small subset of patients in our study population with inadequate lymphadenectomy underwent palliative surgery (with limited lymph node dissection) only but as palliative or esophagectomy is very rare and pancreatectomy with palliative intent is practically non-existent, this number is probably negligible.

DDW 2012 plenary presentation

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Dubecz, A., Solymosi, N., Schweigert, M. et al. Time Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: A Population-Based Analysis of 326,243 Patients. J Gastrointest Surg 17, 611–619 (2013). https://doi.org/10.1007/s11605-013-2146-0

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