Trends in the use and impact of neoadjuvant chemotherapy on perioperative outcomes for resected gastric cancer: Evidence from the American College of Surgeons National Cancer Database

doi:10.1016/j.surg.2015.11.004

Surgery

Volume 159, Issue 4, April 2016, Pages 1099-1112

Poster presentation at the American College of Surgeons 2015 Scientific Forum, Chicago, IL, October 4–8, 2015.

https://doi.org/10.1016/j.surg.2015.11.004 Get rights and content

Background

Standard of care for patients with advanced gastric cancer includes administration of neoadjuvant chemotherapy (NAC) before resection. This study assesses the pattern of use and impact of NAC on perioperative outcomes in US medical centers.

Methods

Using the American College of Surgeons National Cancer Database, 16,128 patients underwent gastrectomy for cancer from 2003 to 2012. Treatment groups were categorized as NAC or no NAC (ie, adjuvant chemotherapy and surgery only). Univariate and multivariate analyses were performed to estimate trends in utilization and impact of treatment on perioperative outcomes.

Results

Of patients undergoing gastrectomy, 36.6% received NAC and 63.4% did not receive chemotherapy in the neoadjuvant setting. Patients who received NAC were more frequently younger, male, white, privately insured, with fewer comorbidities, and treated at an academic center (all P < .0001). After controlling for demographics, comorbidities, and tumor-related factors, patients who received NAC had a postoperative duration of stay 0.43 days shorter than patients who did not receive chemotherapy (5.79 vs 6.22 days; P = .050). They had a 36% lower odds of 30-day mortality (odds ratio, 0.64, P < .0001) but nonsignificant lower odds of 90-day mortality. Use of NAC increased annually, with the greatest increases seen in academic facilities and in the Northeast and North Central United States.

Conclusion

With concerns regarding the toxicity of NAC, these findings suggest that NAC is not associated with worse postoperative outcomes. In light of evidence touting the benefits of NAC, its adoption as a component in the multimodality care of gastric cancer is slowly increasing, although use of NAC remains poor overall.

Section snippets

Data

This study was a retrospective cohort study using tumor registry data collected between 2003 and 2012 in the National Cancer Database (NCDB), a joint effort by the Commission on Cancer of the American College of Surgeons and the American Cancer Society. After securing approval in December 2014, access was obtained to this database, which currently captures approximately 80% of the cancer cases in the United States.

Our study population was restricted to patients who underwent definitive

Patient characteristics

Patients with surgically resectable gastric cancer who underwent definitive surgery between 2003 and 2012 were included in the study. The analysis cohort included 16,128 patients after excluding patients for which data was missing. Of these remaining patients, 5,909 underwent NAC and 10,219 received either adjuvant chemotherapy or surgery only without additional chemotherapy in the neoadjuvant setting.

Descriptive statistics are shown in Table I. Patients who underwent NAC were generally

Discussion

Strengthened by a solid foundation of level I evidence, the use of NAC for surgically resectable advanced gastric cancer has become the standard of care in the United States.9, 16, 17, 18, 22 Both in theory and in practice, NAC is associated with better patient outcomes, including tumor downstaging, better R0 resection rates, and improved patient survival. Because the majority of evidence originates from trials conducted in Europe and East Asia, missing from contemporary literature is an

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Cited by (29)

Union is strength: Textbook outcome with perioperative chemotherapy compliance decreases the risk of death in advanced gastric cancer patients
2022, European Journal of Surgical Oncology
Citation Excerpt :
However, only 10.5 % of patients received NAC. Adopting NAC as a component in the multimodal treatment of GC remains poor, even though NAC is not associated with worse postoperative course [26], which is consistent with the results of our study. Our findings are comparable to other studies investigating TO in GC13,14,17, as shown in Table 4.
Perioperative chemotherapy (POC) in advanced gastric cancer (GC) patients significantly increases the curative resection rate and overall survival (OS). Textbook outcome (TO) represents a composite of surgical quality metrics strongly associated with improved OS. However, the current definition of TO after resection for GC does not include POC. Herein we propose to supplement the current description of TO with an additional feature, POC compliance. The present study aimed to evaluate prognostic impact of thus defined textbook oncological outcome (TOO) among patients undergoing gastrectomy for advanced GC.
We collected data from a prospectively maintained database of all patients operated for GC between 2010 and 2020 in our institution. Patients with histologically confirmed and resectable advanced GC but without distant metastases, in whom multimodal treatment was planned by institutional MDT were included.
A total of 194 patients were analyzed. In the multivariate analysis, patients with TOO had a 50 % lower risk of death than patients without TOO (medians: NR vs 42 months; HR = 0.50, p = 0.0109). Patients treated with POC had a 43 % lower risk of death than patients treated with only preoperative chemotherapy (medians: 78 vs 33 months; HR = 0.57, p = 0.0450). Patients with a pathological response (PR) in the primary tumor had a 59 % lower risk of death than patients without PR (medians: NR vs 36 months; HR = 0.41, p = 0.0229). POC combined with TO surgery significantly decreased the risk of death in advanced GC patients (medians: NR vs 42 months; HR = 0.35, p = 0.0258).
Since TOO is associated with improved survival, it may serve as a multimodal treatment quality parameter in patients with advanced GC.
The Impact of Minimally Invasive Gastrectomy on Survival in the USA
2020, Journal of Gastrointestinal Surgery
Minimally invasive surgical approaches for gastric adenocarcinoma are increasing in prevalence. Although recent studies suggest such approaches are associated with improvements in short-term outcomes, long-term outcomes have not been well studied. This study aimed to evaluate the impact of minimally invasive gastrectomy on long-term survival.
The National Cancer Database (NCDB) was used to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. Patient characteristics were stratified by open and minimally invasive approaches and compared using chi-square and t tests. Unadjusted survival functions were estimated using Kaplan-Meier methodology. Multivariable modeling of risks factors for survival was analyzed with Cox proportional hazard models. Covariate imbalance was controlled using propensity score matching.
The study included 17,449 patients who underwent gastrectomy. Cox proportional hazard modeling demonstrated that minimally invasive surgery improved survival (hazard ratio = 0.86, P < 0.0001). Predictors of worsened survival included community facility type, comorbidities, tumor size, extent of gastrectomy, clinical T and N staging (P < 0.0060 for all). After propensity score matching, minimally invasive surgery had a significantly improved survival at 5 years compared to an open approach, 51.9% versus 47.7% (P < 0.0001). Survival was not significantly different between propensity score-matched patients who received laparoscopic and robotic approaches (P = 0.2611).
Minimally invasive approaches for gastric carcinoma are associated with improved long-term survival. There was no significant difference in survival when comparing laparoscopic to robotic gastrectomy. The mechanisms that drive these improvements deserve further investigation.
Assessing Malnutrition Before Major Oncologic Surgery: One Size Does Not Fit All
2020, Journal of the American College of Surgeons
Citation Excerpt :
A cancer-specific definition of malnutrition would allow for more targeted application of prehabilitation. As the treatment paradigms for several foregut cancers have shifted toward the use of neoadjuvant chemotherapy and chemoradiation,19-21 there are increasing windows of time in the preoperative setting for patients to participate in prehabilitation programs. Unfortunately, the neoadjuvant chemotherapy regimens for foregut cancers are associated with a loss of muscle mass and worse postoperative outcomes.22-24
There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types.
The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP’s variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity.
We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type.
The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting.
Preoperative Chemoradiation Therapy Does Not Increase Risk of Anastomotic Leak in Patients With Gastric Cancer
2017, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
These strategies are now established options for the treatment of resectable gastric cancer in the United States (5). Most notably, the use of preoperative chemotherapy has significantly increased over the past decade; according to the most recent reports, approximately 50% of patients treated for resectable gastric cancer at academic institutions in the United States receive preoperative chemotherapy (6). Nonetheless, which preoperative treatment regimen is best remains unclear.
We sought to determine whether preoperative chemoradiation therapy or chemotherapy increases the risk of anastomotic leak after gastrectomy in gastric cancer patients without gastroesophageal junction involvement.
We reviewed data from a prospectively maintained database of patients who underwent gastrectomy at our institution between 2001 and 2016. The incidence of anastomotic leak and symptomatic intra-abdominal fluid collection was determined and tested for associations with the type of preoperative therapy. Risk factors for these adverse events were identified by univariate and multivariable logistic regression models.
Of 346 included patients, 35% had upfront surgery, 44% had preoperative chemoradiation therapy, and 21% had preoperative chemotherapy. Anastomotic leak and intra-abdominal fluid collection were diagnosed in 3.5% and 7.5% of patients, respectively. Multivariable analysis revealed that concomitant organ resection was the only significant risk factor for anastomotic leak or intra-abdominal fluid collection (P=.014). The type of preoperative therapy was not a risk factor for anastomotic leak or intra-abdominal fluid collection.
Anastomotic leak and intra-abdominal fluid collection were rare after gastrectomy, and neither type of preoperative therapy increased the risk of these adverse events. Our results add to the existing literature that preoperative therapy, including preoperative chemoradiation therapy, is safe for patients with gastric cancer.
High symptom burden in patients undergoing gastrectomy for cancer
2024, Journal of Surgical Oncology
Lymph Node Evaluation after Neoadjuvant Chemotherapy for Patients with Gastric Cancer
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: Financial Disclosures: None.

: Disclaimer: The National Cancer Data Base (NCDB) is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC's NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

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StomachTrends in the use and impact of neoadjuvant chemotherapy on perioperative outcomes for resected gastric cancer: Evidence from the American College of Surgeons National Cancer Database

Background

Methods

Results

Conclusion

Section snippets

Data

Patient characteristics

Discussion

Lancet

J Thorac Oncol

Ann Oncol

HPB (Oxford)

J Clin Epidemiol

Surgery

Cancer Facts & Figures 2015

Comparison of disease-specific survival in the United States and Korea after resection for early-stage node-negative gastric carcinoma

J Surg Oncol

Long-term survival after gastrectomy for cancer in randomized, controlled oncological trials: comparison between West and East

Ann Surg Oncol

Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram

Ann Surg

Surgical management of gastric cancer: the East vs West perspective

J Gastrointest Oncol

Gastric cancer surgery: an American perspective on the current options and standards

Curr Treat Options Oncol

Adjuvant and/or neoadjuvant therapy for gastric cancer? A perspective review

Ther Adv Med Oncol

NCCN clinical practice guidelines in oncology. Gastric Cancer

Medullary thyroid cancer: are practice patterns in the United States discordant from American Thyroid Association guidelines?

Ann Surg Oncol

Stomach
Trends in the use and impact of neoadjuvant chemotherapy on perioperative outcomes for resected gastric cancer: Evidence from the American College of Surgeons National Cancer Database