Department of Surgery, University of California, San Diego, Moores Cancer Center, 3855 Health Sciences Drive, Mail Code 0987, La Jolla, CA, 92024, USA.
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Gastric Cancer. 2020 May;23(3):550-560. doi: 10.1007/s10120-019-01028-5. Epub 2019 Nov 19.
Despite multiple clinical trials and practice guidelines for the treatment of gastric cancer, oncologic outcomes have not improved in the United States. One potential reason could be differences in the quality of surgery as performed in a controlled trial versus in practice.
Using the National Cancer Database, rates of adherence with operative standards for gastrectomy for cancer were analyzed. Of the numerous evidence-based operative standards outlined in the manual, two were reliably measured in the NCDB: (1) achieving and R0 resection, and (2) having > 16 lymph nodes examined. Univariable and multivariable Cox proportional hazard modeling and logistic regression were performed.
A total of 28,705 patients with gastric adenocarcinoma who underwent curative-intent gastrectomy during 2004-2014 were identified. Only 36.5% of stage 0/I patients, and 41.8% of stage II/III patients, met minimum standards. Predictors for meeting standards included age < 65, fewer comorbidities, Asian/Pacific Islander race, and treatment at academic and high-volume centers. Patients who met standards had longer OS (stage 0/I: 104.9 versus 66.6 months; stage II/III: 40.6 versus 26.0 months; p < 0.001 for both). Meeting standards was a significant predictor for improved OS for both stage 0/I and II/III patients (HR = 0.665 and HR = 0.747, respectively, p < 0.001 for both).
For standards that are measurable in the NCDB, adherence is poor. Improved adherence with operative standards may improve survival for gastric cancer patients in the U.S. There is a need for better measuring of, and adherence with, operative standards in gastrectomy for cancer.
尽管有多项针对胃癌治疗的临床试验和临床实践指南，但美国的肿瘤学治疗结果并未得到改善。一个潜在的原因可能是临床试验中与实践中手术质量的差异。
利用国家癌症数据库，分析了胃癌切除术符合手术标准的比例。在该手册中概述的众多基于证据的手术标准中，有两个在 NCDB 中得到了可靠的测量：（1）达到 R0 切除率，（2）检查>16 个淋巴结。进行单变量和多变量 Cox 比例风险模型和逻辑回归分析。
共确定了 2004-2014 年间接受根治性胃切除术的 28705 例胃腺癌患者。仅 36.5%的 0/I 期患者和 41.8%的 II/III 期患者符合最低标准。符合标准的预测因素包括年龄<65 岁、合并症较少、亚裔/太平洋岛民种族以及在学术和高容量中心接受治疗。符合标准的患者总生存期更长（0/I 期：104.9 与 66.6 个月；II/III 期：40.6 与 26.0 个月；两者均 p<0.001）。符合标准是 0/I 和 II/III 期患者总生存期改善的显著预测因素（HR=0.665 和 HR=0.747，两者均 p<0.001）。
对于 NCDB 中可测量的标准，其符合率较低。提高对胃癌手术标准的依从性可能会改善美国胃癌患者的生存。需要更好地测量和遵守胃癌切除术的手术标准。
