Kagedan D J, Dixon M E, Raju R S, Li Q, Elmi M, Shin E, Liu N, El-Sedfy A, Paszat L, Kiss A, Earle C C, Mittmann N, Coburn N G
Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.
Department of Surgery, Maimonides Medical Center, Brooklyn, NY, U.S.A.
Curr Oncol. 2016 Oct;23(5):334-342. doi: 10.3747/co.23.3205. Epub 2016 Oct 25.
In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use.
In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005-2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt.
Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 ( = 0.002), multivariate analysis revealed widespread variation between the treating hospitals ( = 0.001), and even between high-volume hepatopancreatobiliary hospitals ( = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx.
Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.
在本研究中，我们旨在描述在人群水平上，胰腺癌（PCC）根治性切除术后辅助治疗的使用模式，并确定辅助治疗使用的独立预测因素。
在这项观察性队列研究中，利用省级癌症登记处确定了2005年至2010年期间在安大略省（人口1300万）接受PCC切除的患者，并将其与行政数据库相链接，该数据库包含该省接受的所有治疗和经历的结局。患者被定义为接受了化疗（CTX）、放化疗（CRT）或观察（OBS）。通过卡方检验确定与使用CTX、CRT或OBS相关的临床病理因素。采用逻辑回归分析确定辅助治疗与观察、CTX与CRT的独立预测因素。
在纳入的397例患者中，75.3%接受了辅助治疗（27.2%为CRT，48.1%为CTX），24.7%接受了观察。在单一支付者医疗保健系统中，CTX和CRT费用普遍覆盖，观察到地理区域存在显著差异。尽管从2005年到2010年接受辅助治疗的可能性增加（P = 0.002），但多变量分析显示治疗医院之间存在广泛差异（P = 0.001），甚至在高容量肝胰胆医院之间也存在差异（P = 0.0006）。年龄较小、淋巴结阳性和手术切缘阳性预示接受辅助治疗的可能性增加。在接受辅助治疗的患者中，与CTX相比，切缘阳性和低合并症负担与CRT相关。
机构间医疗实践差异对PCC辅助治疗率的差异模式有显著影响。这种差异是否合理需要进一步研究。
