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National Underutilization of Neoadjuvant Chemotherapy for Gastric Cancer

  • 2019 SSAT Quick Shot Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Since the publication of the landmark MAGIC trial in 2006, neoadjuvant chemotherapy has become the standard of care for stage II/III gastric cancer. Nevertheless, many patients still do not begin their treatment with neoadjuvant chemotherapy. The objective of our study was to identify factors associated with underutilization of neoadjuvant chemotherapy for stage II/III gastric cancer.

Methods

Patients with pathological stage II and III primary gastric cancer between 2004 and 2015 were identified from the American College of Surgeons National Cancer Database. Patients who received neoadjuvant chemotherapy were compared with those who underwent surgery only or surgery followed by chemotherapy. Predictors of receipt of neoadjuvant chemotherapy were identified using multivariable logistic regression model. Median survival was calculated for each treatment strategy.

Results

We included 15,947 patients with pathological stage II/III gastric cancer. The proportion of patients receiving neoadjuvant chemotherapy increased from less than 5% before 2006 to 27.5% in 2015. On multivariable analysis, factors associated with no receipt of neoadjuvant therapy included treatment year before 2006 and age greater than 80. Treatment at high-volume centers, academic research programs, or integrated network cancer programs and undergoing total/subtotal or en bloc gastrectomy predicted receipt of neoadjuvant chemotherapy.

Conclusions

Ten years after the publication of the MAGIC trial, fewer than 1/3 of patients with stage II/III gastric cancer are receiving neoadjuvant chemotherapy, which has been shown to improve disease-specific survival. Further studies are needed to understand these disparities and ensure both patients and providers are having evidence-based discussions about multimodal therapy for gastric cancer.

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Funding

This work was supported in part by the NIH T32 Surgical Oncology Research Training Program (grant T32 CA090217-17). This content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH.

Author information

Authors and Affiliations

  1. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Natalie Liu, Yiwei Xu, Amir A. Rahnemai-Azar, Daniel E. Abbott, Sharon M. Weber & Anne O. Lidor

  2. Department of Surgery, Division of Minimally Invasive, Foregut, and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI, 53792-7375, USA

    Anne O. Lidor

Authors
  1. Natalie Liu
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Correspondence to Anne O. Lidor.

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Appendix. Univariate and multivariable logistic regression model for receipt of perioperative chemotherapy and surgery vs. other treatments for pathological stage II/III gastric cancer patients

Appendix. Univariate and multivariable logistic regression model for receipt of perioperative chemotherapy and surgery vs. other treatments for pathological stage II/III gastric cancer patients

Variable

Univariate

Multivariable

OR

p value

OR

95% CI

Year of diagnosis

    

2004–2006

ref

-

ref

-

2007–2009

2.96

< 0.001

3.22

2.50–4.13

2010–2012

6.91

< 0.001

7.51

5.97–9.44

2013–2015

11.26

< 0.001

13.18

10.51–16.52

Age categories

    

18–58

ref

-

ref

-

59–70

0.88

0.013

0.87

0.78–0.98

71–79

0.51

< 0.001

0.53

0.46–0.61

80+

0.13

< 0.001

0.14

0.11–0.18

Female (vs. male)

0.95

0.292

1.01

0.92–1.12

Race

    

White

ref

-

ref

-

Black

0.91

0.087

0.86

0.75–0.98

Asian/Pacific Island

0.77

< 0.001

0.58

0.48–0.69

Other

1.33

0.010

0.98

0.74–1.29

Spanish or Hispanic

1.19

0.003

0.93

0.80–1.08

Comorbidity

    

Score 0

ref

-

ref

-

Score 1

0.76

< 0.001

0.88

0.78–1.00

Score ≥ 2

0.48

< 0.001

0.61

0.49–0.76

Education 2008–2012 (not high school graduate)

    

21% or more

ref

-

ref

-

13–20.9%

1.04

0.522

1.06

0.91–1.24

7–12.9%

1.17

0.010

1.32

1.11–1.57

Less than 7%

1.43

< 0.001

1.77

1.44–2.18

Income 2008–2012

    

Less than $38,000

ref

-

ref

-

$38,000–$47,999

1.07

0.314

1.06

0.90–1.25

$48,000–$62,999

1.19

0.007

1.03

0.87–1.23

$63,000+

1.31

< 0.001

0.95

0.78–1.15

Insurance

    

Not insured

ref

-

ref

-

Insured

0.86

0.116

1.03

0.82–1.28

Insurance status unknown

0.68

0.034

0.73

0.48–1.13

Primary site

    

Pylorus and Gastric Antrum

ref

-

ref

-

Fundus

2.13

< 0.001

1.51

1.20–1.89

Body

1.61

< 0.001

1.19

1.00–1.41

NOS

1.41

< 0.001

1.23

1.10–1.39

Stage III (vs. stage II)

0.88

0.002

0.70

0.63–0.77

Surgical procedure of primary site

    

Partial gastrectomy

ref

-

ref

-

Total/subtotal gastrectomy

2.70

< 0.001

2.28

2.02–2.57

En bloc gastrectomy

2.19

< 0.001

1.73

1.50–2.01

Others

2.11

< 0.001

2.14

1.61–2.84

Great Circle Distance (miles)

1.0012

< 0.001

1.0008

1.0004–1.0012

Hospital volume

    

Quartile 11, 11 – mean 6.98

ref

-

ref

-

Quartile 2 [11, 22] – mean 16.51

1.34

< 0.001

1.11

0.94–1.30

Quartile 3 [22, 39] – mean 29.97

1.63

< 0.001

1.11

0.94–1.31

Quartile 4 [39, 273] – mean 74.81

2.26

< 0.001

1.31

1.10–1.56

Facility type

    

Community Cancer Program

ref

-

ref

-

Comprehensive Community Cancer Program

1.45

< 0.001

1.21

0.96–1.53

Academic/Research Program

3.14

< 0.001

2.16

1.69–2.76

Integrated Network Cancer Program

2.11

< 0.001

1.61

1.23–2.09

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Liu, N., Xu, Y., Rahnemai-Azar, A.A. et al. National Underutilization of Neoadjuvant Chemotherapy for Gastric Cancer. J Gastrointest Surg 24, 949–958 (2020). https://doi.org/10.1007/s11605-019-04439-y

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