Methods
Study Design
Patient Selection
Definition of Failure to Cure
Variables for Analyses
Statistical Analyses
Impact of Neoadjuvant Therapy on Failure to Cure
Results
Factors Associated with Failure to Cure
Total | Failure to cure | p Value (Chi square) | ||
---|---|---|---|---|
Yes | No | |||
Total | 3862 | 861 (22.3) | 3001 (77.7) | |
Sex | 0.97 | |||
Male | 2431 (62.9) | 541 (62.8) | 1890 (63.0) | |
Female | 1428 (37.0) | 317 (36.8) | 1111 (37.0) | |
Missing | 3 (0.1) | 3 (0.3) | 0 (0.0) | |
Age, years | < 0.01 | |||
< 65 | 1164 (30.1) | 227 (26.4) | 937 (31.2) | |
65–75 | 1424 (36.9) | 308 (35.8) | 1116 (37.2) | |
> 75 | 1270 (32.9) | 325 (37.7) | 945 (31.5) | |
Missing | 4 (0.1) | 1 (0.1) | 3 (0.1) | |
Preoperative weight loss, kg | < 0.01 | |||
None | 1067 (27.6) | 137 (15.9) | 930 (31.0) | |
1–5 | 936 (24.2) | 199 (23.1) | 737 (24.6) | |
6–10 | 882 (22.8) | 249 (28.9) | 633 (21.1) | |
> 10 | 454 (11.8) | 161 (18.7) | 293 (9.8) | |
Missing | 523 (13.5 | 115 (13.4) | 408 (13.6) | |
Body mass index | < 0.01 | |||
< 20 | 324 (8.4) | 88 (10.2) | 236 (7.9) | |
20–25 | 2017 (52.2) | 472 (54.8) | 1545 (51.5) | |
26–30 | 1059 (27.4) | 214 (24.9) | 845 (28.2) | |
> 30 | 379 (9.8) | 64 (7.4) | 315 (10.5) | |
Missing | 83 (2.1) | 23 (2.7) | 60 (2.0) | |
ASA score | < 0.01 | |||
I | 467 (12.1) | 87 (10.1) | 380 (12.7) | |
II | 2115 (54.8) | 449 (52.1) | 1666 (55.5) | |
III+ | 1258 (32.6) | 319 (37.0) | 939 (31.3) | |
Missing | 22 (0.6) | 6 (0.7) | 16 (0.5) | |
CCI | < 0.01 | |||
0 | 1658 (42.9) | 346 (40.2) | 1312 (43.7) | |
1 | 923 (23.9) | 188 (21.8) | 735 (24.5) | |
2+ | 1280 (33.1) | 327 (38.0) | 953 (31.8) | |
Missing | 1 (0.0) | 0 (0.0) | 1 (0.0) | |
Previous esophageal or gastric surgery | 0.03 | |||
No | 3553 (92.0) | 777 (90.2) | 2776 (92.5) | |
Yes | 287 (7.4) | 79 (9.2) | 208 (6.9) | |
Unknown/missing | 22 (0.6) | 5 (0.6) | 17 (0.6) | |
Tumor location | < 0.01 | |||
Corpus | 1204 (31.2) | 238 (27.6) | 966 (32.2) | |
Fundus | 354 (9.2) | 72 (8.4) | 282 (9.4) | |
Antrum | 1507 (39.0) | 307 (35.7) | 1200 (40.0) | |
Pylorus | 323 (8.4) | 74 (8.6) | 249 (8.3) | |
Total stomach | 215 (5.6) | 101 (11.7) | 114 (3.8) | |
Rest stomach/anastomosis | 161 (4.2) | 50 (5.8) | 111 (3.7) | |
Unknown location | 45 (1.2) | 8 (0.9) | 37 (1.2) | |
Missing | 53 (1.4) | 11 (1.3) | 42 (1.4) | |
Clinical tumor stagea | < 0.01 | |||
T0–2 | 1045 (27.1) | 117 (13.6) | 928 (30.9) | |
T3–4 | 1947 (50.4) | 527 (61.2) | 1420 (47.3) | |
Tx | 817 (21.2) | 201 (23.3) | 616 (20.5) | |
Missing | 53 (1.4) | 16 (1.9) | 37 (1.2) | |
Clinical node stagea | < 0.01 | |||
N0 | 1928 (49.9) | 352 (40.9) | 1576 (52.5) | |
N+ | 1482 (38.4) | 394 (45.8) | 1088 (36.3) | |
Nx | 400 (10.4) | 97 (11.3) | 303 (10.1) | |
Missing | 52 (1.3) | 18 (2.1) | 34 (1.1) | |
Diagnostic laparoscopy | 0.11 | |||
No | 2755 (71.3) | 597 (69.3) | 2158 (71.9) | |
Yes | 1034 (26.8) | 249 (28.9) | 785 (26.2) | |
Missing | 73 (1.9) | 15 (1.7) | 58 (1.9) | |
Endoscopic ultrasound | 0.64 | |||
No | 2807 (72.7) | 621 (72.1) | 2186 (72.8) | |
Yes | 963 (24.9) | 220 (25.6) | 743 (24.8) | |
Missing | 92 (2.4) | 20 (2.3) | 72 (2.4) | |
Neoadjuvant therapy | < 0.01 | |||
Chemotherapy | 2154 (55.8) | 395 (45.9) | 1759 (58.6) | |
None | 1614 (41.8) | 448 (52.0) | 1166 (38.9) | |
Other neoadjuvant therapy | 87 (2.3) | 15 (1.7) | 72 (2.4) | |
Missing | 7 (0.2) | 3 (0.3) | 4 (0.1) | |
Surgical procedure | < 0.01 | |||
Minimally invasive | 1817 (47.0) | 362 (42.0) | 1455 (48.5) | |
Open | 2044 (52.9) | 498 (57.8) | 1546 (51.5) | |
Missing | 1 (0.0) | 1 (0.1) | 0 (0.0) | |
Hospital volume (gastric resections per year) | < 0.01 | |||
< 20 | 1103 (28.6) | 278 (32.3) | 825 (27.5) | |
20–39 | 2242 (58.1) | 485 (56.3) | 1757 (58.5) | |
≥ 40 | 517 (13.4) | 98 (11.4) | 419 (14.0) | |
Year of resection | < 0.01 | |||
Prior to 2016 | 2063 (53.4) | 501 (58.2) | 1562 (52.0) | |
2016 and later | 1795 (46.5) | 359 (41.7) | 1436 (47.9) | |
Missing | 4 (0.1) | 1 (0.1) | 3 (0.1) |
Factor | N | Univariable analysis | Multilevel multivariable analysis | ||||
---|---|---|---|---|---|---|---|
OR | 95% CI | p value | aOR | 95% CI | p Value | ||
Sex | |||||||
Male | 2431 | 1 | |||||
Female | 1428 | 1.00 | 0.86–1.17 | 0.97 | |||
Age, years | |||||||
< 65 | 1164 | 1 | 1 | ||||
65–75 | 1424 | 0.88 | 0.72–1.06 | 0.18 | 0.96 | 0.77–1.20 | 0.74 |
> 75 | 1270 | 0.70 | 0.58–0.85 | < 0.01 | 0.99 | 0.78–1.27 | 0.97 |
Preoperative weight loss, kg | |||||||
None | 1067 | 1 | 1 | ||||
1–5 | 936 | 0.55 | 0.43–0.69 | < 0.01 | 0.62 | 0.48–0.80 | < 0.01 |
6–10 | 882 | 0.37 | 0.30–0.47 | < 0.01 | 0.43 | 0.34–0.56 | < 0.01 |
> 10 | 454 | 0.27 | 0.21–0.35 | < 0.01 | 0.33 | 0.24–0.44 | < 0.01 |
Missing | 523 | 0.52 | 0.40–0.69 | < 0.01 | 0.62 | 0.45–0.84 | < 0.01 |
Body mass index | |||||||
< 20 | 324 | 1 | 1 | ||||
20–25 | 2017 | 1.22 | 0.93–1.59 | 0.14 | 1.06 | 0.79–1.41 | 0.71 |
26–30 | 1059 | 1.47 | 1.10–1.96 | < 0.01 | 1.15 | 0.84–1.58 | 0.38 |
> 30 | 379 | 1.84 | 1.28–2.65 | < 0.01 | 1.36 | 0.91–2.05 | 0.14 |
ASA score | |||||||
I | 467 | 1 | 1 | ||||
II | 2115 | 0.85 | 0.65–1.09 | 0.21 | 0.90 | 0.67–1.21 | 0.48 |
III+ | 1258 | 0.67 | 0.51–0.88 | < 0.01 | 0.81 | 0.58–1.12 | 0.20 |
CCI | |||||||
0 | 1658 | 1 | 1 | ||||
1 | 923 | 1.03 | 0.85–1.26 | 0.76 | 1.11 | 0.89–1.39 | 0.36 |
2+ | 1280 | 0.77 | 0.65–0.91 | < 0.01 | 0.87 | 0.70–1.07 | 0.18 |
Previous esophageal or gastric surgery | |||||||
No | 3553 | 1 | 1 | ||||
Yes | 287 | 0.74 | 0.56–0.97 | 0.03 | 0.94 | 0.61–1.46 | 0.79 |
Tumor location | |||||||
Corpus | 1204 | 1 | 1 | ||||
Fundus | 354 | 0.96 | 0.72–1.30 | 0.81 | 1.00 | 0.72–1.38 | 0.98 |
Antrum | 1507 | 0.96 | 0.80–1.16 | 0.70 | 1.02 | 0.83–1.25 | 0.85 |
Pylorus | 323 | 0.83 | 0.62–1.12 | 0.21 | 1.00 | 0.72–1.38 | 0.99 |
Total stomach | 215 | 0.28 | 0.21–0.38 | < 0.01 | 0.30 | 0.21–0.41 | < 0.01 |
Rest stomach/anastomosis | 161 | 0.55 | 0.38–0.79 | < 0.01 | 0.70 | 0.40–1.21 | 0.20 |
Unknown location | 45 | 1.14 | 0.55–2.66 | 0.74 | 1.32 | 0.52–3.35 | 0.56 |
Clinical tumor stagea | |||||||
T0–2 | 1045 | 1 | 1 | ||||
T3–4 | 1947 | 0.34 | 0.27–0.42 | < 0.01 | 0.40 | 0.31–0.51 | < 0.01 |
Tx | 817 | 0.39 | 0.30–0.50 | < 0.01 | 0.47 | 0.35–0.63 | < 0.01 |
Clinical node stagea | |||||||
N0 | 1928 | 1 | 1 | ||||
N+ | 1482 | 0.62 | 0.52–0.73 | < 0.01 | 0.68 | 0.57–0.82 | < 0.01 |
Nx | 400 | 0.70 | 0.54–0.90 | < 0.01 | 0.82 | 0.59–1.13 | 0.22 |
Diagnostic laparoscopy | |||||||
No | 2755 | 1 | |||||
Yes | 1034 | 0.87 | 0.74–1.03 | 0.11 | |||
Endoscopic ultrasound | |||||||
No | 2807 | 1 | |||||
Yes | 963 | 0.96 | 0.81–1.14 | 0.64 | |||
Neoadjuvant therapy | |||||||
Chemotherapy | 2154 | 1 | 1 | ||||
None | 1614 | 0.58 | 0.50–0.68 | < 0.01 | 0.49 | 0.40–0.60 | < 0.01 |
Other neoadjuvant therapy | 87 | 1.08 | 0.63–1.97 | 0.80 | 1.05 | 0.57–1.91 | 0.89 |
Surgical procedure | |||||||
Minimally invasive | 1817 | 1 | 1 | ||||
Open | 2044 | 0.77 | 0.66–0.90 | < 0.01 | 0.92 | 0.76–1.12 | 0.40 |
Hospital volume (gastric resections per year) | |||||||
< 20 | 1103 | 1 | 1 | ||||
20–39 | 2242 | 1.22 | 1.03–1.44 | 0.02 | 1.11 | 0.89–1.40 | 0.36 |
≥ 40 | 517 | 1.44 | 1.12–1.87 | < 0.01 | 1.27 | 0.92–1.75 | 0.15 |
Year of resection | |||||||
Prior to 2016 | 2063 | 1 | 1 | ||||
2016 and later | 1795 | 1.28 | 1.10–1.50 | < 0.01 | 1.19 | 0.98–1.45 | 0.08 |
Hospital Variation
Impact of Neoadjuvant Therapy on Failure to Cure
Factor | Multivariable multilevel analysis with random effects for each hospital | ||
---|---|---|---|
aOR | 95% CI | p Value | |
Observed/expected ratio of neoadjuvant chemotherapy administration when indicated for each hospital | 2.01 | 1.02–3.94 | 0.04 |
Age, years | |||
< 65 | 1 | ||
65–75 | 0.93 | 0.73–1.18 | 0.54 |
> 75 | 0.71 | 0.55–0.91 | < 0.01 |
Preoperative weight loss, kg | |||
None | 1 | ||
1–5 | 0.68 | 0.51–0.91 | 0.01 |
6–10 | 0.47 | 0.35–0.62 | < 0.01 |
> 10 | 0.33 | 0.24–0.45 | < 0.01 |
Missing | 0.63 | 0.44–0.89 | < 0.01 |
Body mass index | |||
< 20 | 1 | ||
20–25 | 1.03 | 0.74–1.43 | 0.86 |
26–30 | 1.05 | 0.74–1.50 | 0.77 |
> 30 | 1.28 | 0.81–2.02 | 0.29 |
ASA score | |||
I | 1 | ||
II | 0.82 | 0.59–1.14 | 0.24 |
III+ | 0.70 | 0.49–1.00 | 0.05 |
CCI | |||
0 | 1 | ||
1 | 1.11 | 0.87–1.42 | 0.40 |
2+ | 0.84 | 0.66–1.07 | 0.16 |
Previous esophageal or gastric surgery | |||
No | 1 | ||
Yes | 0.87 | 0.54–1.39 | 0.56 |
Tumor location | |||
Corpus | 1 | ||
Fundus | 1.06 | 0.74–1.53 | 0.74 |
Antrum | 0.95 | 0.75–1.20 | 0.68 |
Pylorus | 0.83 | 0.58–1.19 | 0.32 |
Total stomach | 0.29 | 0.20–0.42 | < 0.01 |
Rest stomach/anastomosis | 0.75 | 0.41–1.38 | 0.36 |
Unknown location | 1.09 | 0.42–2.84 | 0.86 |
Clinical tumor stagea | |||
T0–2 | 1 | ||
T3–4 | 0.37 | 0.24–0.56 | < 0.01 |
Tx | 0.39 | 0.24–0.62 | < 0.01 |
Clinical node stagea | |||
N0 | 1 | ||
N+ | 0.66 | 0.53–0.82 | < 0.01 |
Nx | 0.84 | 0.59–1.18 | 0.31 |
Year of resection | |||
Prior to 2016 | 1 | ||
2016 and later | 1.28 | 1.05–1.56 | 0.01 |
Model build-up | Variance | Median odds ratio | |
---|---|---|---|
1. | Failure to cure ~ random effect of hospital | 0.04901 | 1.235 |
2. | Failure to cure ~ patient and tumor characteristics + random effect of hospital | 0.05856 | 1.260 |
3. | Failure to cure ~ hospital’s tendency to administer neoadjuvant chemotherapy + patient and tumor characteristics + random effect of hospital | 0.04136 | 1.214 |