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Understanding Factors Leading to Surgical Attrition for “Resectable” Gastric Cancer

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Objectives

We used a novel combined analysis to evaluate various factors associated with failure to surgical resection in non-metastatic gastric cancer.

Methods

We identified factors associated with the receipt of surgery in publicly available clinical trial data for gastric cancer and in the National Cancer Database (NCDB) for patients with stages I–III gastric adenocarcinoma. Next, we evaluated variable importance in predicting the receipt of surgery in the NCDB.

Results

In published clinical trial data, 10% of patients in surgery-first arms did not undergo surgery, mostly due to disease progression and 15% of patients in neoadjuvant therapy arms failed to reach surgery. Effects related to neoadjuvant administration explained the increased attrition (5%). In the NCDB, 61.7% of patients underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (younger, healthier, and privately insured patients treated at high-volume and academic centers) the rate of surgery was 79.2%. Decreased likelihood of surgery was associated with advanced age (OR 0.97, p < 0.01), Charlson–Deyo score of 2+ (OR 0.90, p < 0.01), T4 tumors (OR 0.39, p < 0.01), N+ disease (OR 0.84, p < 0.01), low socioeconomic status (OR 0.86, p = 0.01), uninsured or on Medicaid (OR 0.58 and 0.69, respectively, p < 0.01), low facility volume (OR 0.64, p < 0.01), and non-academic cancer programs (OR 0.79, p < 0.01).

Conclusion

Review of clinical trials shows attrition due to unavoidable tumor and treatment factors (~ 15%). The NCDB indicates non-medical patient and provider characteristics (i.e., age, insurance status, facility volume) associated with attrition. This combined analysis highlights specific opportunities for improving potentially curative surgery rates.

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Availability of data and material

Supplementary table and publicly available clinical trial data and the de-identified National Cancer Database are available upon request.

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Funding

The authors did not receive support from any organization for the submitted work.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

    Hanna H. Kakish MD, Fasih Ali Ahmed MD, Mohamedraed Elshami MD, MMSc, Lee M. Ocuin MD, Luke D. Rothermel MD, MPH, John B. Ammori MD & Richard S. Hoehn MD

  2. Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Evonne Pei BA

  3. Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Weichuan Dong PhD

Authors
  1. Hanna H. Kakish MD
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  2. Fasih Ali Ahmed MD
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  4. Weichuan Dong PhD
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  5. Mohamedraed Elshami MD, MMSc
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  6. Lee M. Ocuin MD
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  9. Richard S. Hoehn MD
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Contributions

RH and HK came up with the idea; RH, HK, WD, and FA were responsible for the metholdology; HK wrote the original draft; HK, EP, FA, WD, ME, LO, LR, JA, and RH were responsible for review and editing; and RH was responsible for supervision. All authors read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Richard S. Hoehn MD.

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Disclosures

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This study was exempt from institutional review by the University Hospitals Cleveland Medical Center IRB committee.

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Kakish, H.H., Ahmed, F.A., Pei, E. et al. Understanding Factors Leading to Surgical Attrition for “Resectable” Gastric Cancer. Ann Surg Oncol 30, 4207–4216 (2023). https://doi.org/10.1245/s10434-023-13469-5

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  • DOI: https://doi.org/10.1245/s10434-023-13469-5

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