Abstract
Background
Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes.
Methods
The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival.
Results
Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63).
Conclusion
For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.
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Category 1
Conception and design of study:
Vikrom K Dhar, Richard S Hoehn, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
Acquisition of data:
Vikrom K Dhar, Richard S Hoehn, Young Kim, Brent T Xia, Andrew D Jung, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
Analysis and/or interpretation of data:
Vikrom K Dhar, Richard S Hoehn, Young Kim, Brent T Xia, Andrew D Jung, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
Category 2
Drafting the manuscript:
Vikrom K Dhar, Richard S Hoehn, Syed A Ahmad, Shimul A Shah.
Revising the manuscript critically for important intellectual content:
Vikrom K Dhar, Richard S Hoehn, Young Kim, Brent T Xia, Andrew D Jung, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
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Final approval of the version of the manuscript to be published:
Vikrom K Dhar, Richard S Hoehn, Young Kim, Brent T Xia, Andrew D Jung, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
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Agreement to be accountable for all aspects of the work:
Vikrom K Dhar, Richard S Hoehn, Young Kim, Brent T Xia, Andrew D Jung, Dennis J Hanseman, Syed A Ahmad, Shimul A Shah.
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This manuscript was accepted for presidential plenary presentation at the 2017 Society for Surgery of the Alimentary Tract Annual Meeting in Chicago, IL, held May 6–9, 2017.
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Dhar, V.K., Hoehn, R.S., Kim, Y. et al. Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals. J Gastrointest Surg 22, 98–106 (2018). https://doi.org/10.1007/s11605-017-3549-0
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DOI: https://doi.org/10.1007/s11605-017-3549-0