Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Ann Surg Oncol. 2023 Jul;30(7):4207-4216. doi: 10.1245/s10434-023-13469-5. Epub 2023 Apr 12.
We used a novel combined analysis to evaluate various factors associated with failure to surgical resection in non-metastatic gastric cancer.
We identified factors associated with the receipt of surgery in publicly available clinical trial data for gastric cancer and in the National Cancer Database (NCDB) for patients with stages I-III gastric adenocarcinoma. Next, we evaluated variable importance in predicting the receipt of surgery in the NCDB.
In published clinical trial data, 10% of patients in surgery-first arms did not undergo surgery, mostly due to disease progression and 15% of patients in neoadjuvant therapy arms failed to reach surgery. Effects related to neoadjuvant administration explained the increased attrition (5%). In the NCDB, 61.7% of patients underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (younger, healthier, and privately insured patients treated at high-volume and 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), uninsured or on Medicaid (OR 0.58 and 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).
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 potentially curative surgery rates.
我们采用了一种新的联合分析方法来评估非转移性胃癌手术切除失败的相关因素。
我们从公开的胃癌临床试验数据和国家癌症数据库（NCDB）中确定了与接受手术治疗相关的因素，这些数据针对 I-III 期胃腺癌患者。接下来，我们评估了在 NCDB 中预测手术接受程度的变量重要性。
在已发表的临床试验数据中，手术组中有 10%的患者未接受手术，主要原因是疾病进展，而新辅助治疗组中有 15%的患者未能进行手术。与新辅助治疗相关的效果解释了增加的损耗（5%）。在 NCDB 中，61.7%的患者接受了确定性手术。在 NCDB 患者的一个亚组中（与临床试验中招募的患者相似，包括年轻、健康、私人保险、在高容量和学术中心接受治疗的患者），手术率为 79.2%。手术可能性降低与年龄较大（OR 0.97，p < 0.01）、Charlson-Deyo 评分 2+（OR 0.90，p < 0.01）、T4 肿瘤（OR 0.39，p < 0.01）、N+疾病（OR 0.84，p < 0.01）、低社会经济地位（OR 0.86，p = 0.01）、无保险或医疗补助（OR 0.58 和 0.69，分别，p < 0.01）、低设施容量（OR 0.64，p < 0.01）和非学术癌症项目（OR 0.79，p < 0.01）相关。
对临床试验的回顾显示，由于不可避免的肿瘤和治疗因素（~15%）导致的损耗。NCDB 表明与损耗相关的非医疗患者和提供者特征（即年龄、保险状况、设施容量）。这种联合分析突出了提高潜在可治愈手术率的具体机会。
