P69: Understanding Factors Leading to Surgical Attrition for “Resectable” Gastric Cancer

Thursday, March 23, 2023

9:36 AM – 9:41 AM

Location: SSO HUB: Rare/Metastatic Cancers Zone

Poster Presenter(s)

Hanna Kakish, Doctor of Medicine (he/him/his)

Research fellow
University Hospitals, Cleveland Medical Center
Cleveland, Ohio, United States

Disclosure information not submitted.

Author(s)

Hanna Kakish, Doctor of Medicine (he/him/his)

Research fellow
University Hospitals, Cleveland Medical Center
Cleveland, Ohio, United States

Disclosure information not submitted.
WD

Weichuan Dong, Ph. D.

Research Associate
Case Western Reserve University School of Medicine, Cleveland, Ohio, United States

Disclosure(s): No financial relationships to disclose
FA

Fasih Ali Ahmed, M.D.

Research fellow
University Hospitals, Cleveland Medical Center, United States

Disclosure information not submitted.
LR

Luke D. Rothermel, M.D., M.P.H.

Assistant Professor of Surgery, Division of Surgical Oncology
University Hospitals, Cleveland Medical Center, United States

Disclosure information not submitted.
JA

John B. Ammori, M.D.

Associate Professor of Surgery/Program Director, Division of Surgical Oncology
University Hospitals Cleveland Medical Center/Case Western Reserve University, United States

Disclosure information not submitted.
Richard S. Hoehn, MD

Assistant Professor of Surgery
University Hospitals, Cleveland Medical Center
Cleveland, Ohio, United States

Disclosure(s): No financial relationships to disclose

Disclosure(s):

Weichuan Dong, Ph. D.: No financial relationships to disclose

Richard S. Hoehn, MD: No financial relationships to disclose

Introduction: Many patients with non-metastatic gastric cancer fail to undergo surgical resection for unclear reasons. We used a novel combined analysis to evaluate various factors associated with non-surgical management.

Methods: We reviewed publicly-available data from clinical trials of neoadjuvant therapy for gastric cancer and identified rates and factors associated with receipt of definitive surgery. Next, we queried the National Cancer Database (NCDB) for patients with Stage I-III gastric adenocarcinoma from 2004-2018. Logistic regression identified factors associated with receipt of curative surgery, and Area Under Curve (AUC) analyses were used to understand their relative importance.

Results: In published clinical trials data, 10% of patients in “surgery first” arms do not undergo surgery, mostly due to disease progression, patient refusal, and lack of follow up. 15% of patients in neoadjuvant therapy arms fail to reach surgery, with treatment side effects explaining the increased attrition (5%). In the NCDB, 61.7% underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (age < 80, Charlson Deyo score < 2, private insurance, treated at high volume 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), being uninsured or on Medicaid (OR=0.58 & 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). Figure 1 shows the ranked importance of these factors affecting receipt of surgery.

Conclusions: 38% of patients with non-metastatic gastric cancer do not undergo surgery. 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 rates of potentially curative cancer surgery.

Learning Objectives:

Upon completion, participants will be able to have better understanding for factors contributing to attrition to gastric cancer surgery in resectable stages, using a novel combined analysis.
Upon completion, participants will be able to recognize the relative importance of each variable that is associated with the receipt of surgery.
• Upon completion, participants will be able to point out opportunities to improve curative surgery rates.