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Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer

  • Global Health Services Research
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of “fragmented” care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival.

Methods

The 2006–2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed “coordinated” and “fragmented” care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods.

Results

Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05).

Conclusions

For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.

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Acknowledgment

The American College of Surgeons is in a Business Associate Agreement that includes a data use agreement with each of its Commission on Cancer accredited hospitals. The data used in the study are derived from a deidentified National Cancer Data Base file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used or the conclusions drawn from these data by the investigators. K. Rhodin, A. Eckhoff, and A. Liu are each supported by NIH 5T32CA093245-15 and acknowledge support from the Duke Cancer Institute as part of the P30 Cancer Center Support Grant (Grant ID: P30 CA014236).

Funding

K. Rhodin, A. Eckhoff, and A. Liu are each supported by NIH 5T32CA093245-15 and acknowledge support from the Duke Cancer Institute as part of the P30 Cancer Center Support Grant (Grant ID: P30 CA014236).

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Authors and Affiliations

  1. Department of Surgery, Duke University Medical Center, Durham, NC, USA

    Kristen E. Rhodin MD, Vignesh Raman MD, MHS, Austin Eckhoff MD, Annie Liu MD, PhD, Daniel P. Nussbaum MD & Dan G. Blazer MD

  2. The Oregon Clinic, Portland, OR, USA

    John Creasy MD

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  1. Kristen E. Rhodin MD
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  2. Vignesh Raman MD, MHS
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  3. Austin Eckhoff MD
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  4. Annie Liu MD, PhD
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Correspondence to Kristen E. Rhodin MD.

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Rhodin, K.E., Raman, V., Eckhoff, A. et al. Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer. Ann Surg Oncol 29, 5422–5431 (2022). https://doi.org/10.1245/s10434-022-12031-z

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  • DOI: https://doi.org/10.1245/s10434-022-12031-z

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