Frohman Heather A, Martin Jeremiah T, Le Anh-Thu, Dineen Sean P, Tzeng Ching-Wei D
Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky.
Department of Cardiothoracic Surgery, Southern Ohio Medical Center, Portsmouth, Ohio.
J Surg Res. 2017 Jun 15;214:229-239. doi: 10.1016/j.jss.2017.03.043. Epub 2017 Mar 31.
A significant proportion of patients never receive curative-intent surgery for resectable gastric cancer (GC). The primary aims of this study were to identify disparities and targetable risk factors associated with failure to operate in the context of national trends in surgical rates for resectable GC.
The National Cancer Database was used to identify patients with resectable GC (adenocarcinoma, clinical stage IA-IIIC, 2004-2013). Multivariate modeling was used to identify predictors of resection and to analyze the impact of surgery on overall survival (OS).
Of 46,970 patients with resectable GC, 18,085 (39%) did not receive an appropriate operation. Among unresected patients, 69% had no comorbidities. Failure to resect was associated with reduced median OS (44.4 versus 11.8 mo, hazard ratio [HR]: 2.09, P < 0.001). In the multivariate analysis, the most critical factors affecting OS were resection (HR: 2.09) and stage (reference IA; HR range: 1.16-3.50, stage IB-IIIC). Variables independently associated with no surgery included insurance other than private or Medicare (odds ratio [OR]: 1.60/1.54), nonacademic/nonresearch hospital (OR: 1.16), non-Asian race (OR: 1.72), male (OR: 1.19), older age (OR: 1.04), Charlson-Deyo score >1 (OR: 1.17), residing in areas with median income <$48,000 (OR: 1.23), small urban populations <20,000 (OR: 1.41), and stage (reference IA; OR range: 1.36-3.79, stage IB-IIIC, P < 0.001).
Over one-third of patients with resectable GC fail to receive surgery. Suitable insurance coverage and treatment facility are the most salient (and only modifiable) risk factors for omitting surgery. To mitigate national disparities in surgical care, policymakers should consider improving insurance coverage in underserved areas and regionalization of gastric cancer care.
相当一部分可切除胃癌（GC）患者从未接受过根治性手术。本研究的主要目的是在可切除GC手术率的国家趋势背景下，确定与未进行手术相关的差异和可靶向的风险因素。
利用国家癌症数据库确定可切除GC患者（腺癌，临床分期IA-IIIC，2004 - 2013年）。采用多变量建模来确定切除的预测因素，并分析手术对总生存期（OS）的影响。
在46970例可切除GC患者中，18085例（39%）未接受适当手术。在未接受手术的患者中，69%没有合并症。未进行切除与中位OS降低相关（44.4个月对11.8个月，风险比[HR]：2.09，P < 0.001）。在多变量分析中，影响OS的最关键因素是切除（HR：2.09）和分期（参照IA期；HR范围：1.16 - 3.50，IB-IIIC期）。与未进行手术独立相关的变量包括非私人或医疗保险以外的保险（优势比[OR]：1.60/1.54）、非学术/非研究医院（OR：1.16）、非亚裔种族（OR：1.72）、男性（OR：1.19）、年龄较大（OR：1.04）、Charlson-Deyo评分>1（OR：1.17）、居住在收入中位数<$48,000的地区（OR：1.23）、城市人口少<20,000（OR：1.41）以及分期（参照IA期；OR范围：1.36 - 3.79，IB-IIIC期，P < 0.001）。
超过三分之一的可切除GC患者未接受手术。合适的保险覆盖范围和治疗机构是未进行手术最显著（且唯一可改变）的风险因素。为减轻手术治疗方面的国家差异，政策制定者应考虑改善服务不足地区的保险覆盖范围以及胃癌治疗的区域化。
