Kristen E. Rhodin, MD
General Surgery Resident
Duke University Medical Center
Durham, North Carolina, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of “fractured” care and its impact on outcomes, including concordance with NCCN guidelines and overall survival.
Methods:
The 2006-2016 National Cancer Database (NCDB) was queried for patients with clinical stage II/III gastric adenocarcinoma who received neoadjuvant or perioperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation therapy was performed at one versus multiple facilities (termed “coordinated” and “fractured” care, respectively). Multivariable logistic regression was performed to identify factors associated with fractured care. Survival between the two groups 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%) fractured care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fractured care included increasing age, lower rates of education, and distance travelled to the treating facility. Factors associated with coordinated care included residing in metropolitan regions, and treatment at academic and high-volume centers. Fractured care was associated with receipt of neoadjuvant chemotherapy alone versus guideline-concordant perioperative therapy (adjusted OR 0.79, 95% CI 0.65-0.96, p=0.02). Patients receiving coordinated care had improved five-year survival (44.8 vs. 36.9%, p< 0.001) (Figure).
Conclusions: For patients with stage II/III gastric cancer, fractured care is associated with inferior survival and failure to receive guideline-concordant perioperative treatment compared to patients receiving multimodality therapy at the same facility. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.