Significant regional variation in adequacy of lymph node assessment and survival in gastric cancer

Abstract

BACKGROUNDLymph node (LN) status is a major determinant of prognosis and treatment of gastric adenocarcinoma. The 1997 American Joint Commission on Cancer/Union Internationale Contre le Cancer guidelines were revised, requiring examination of ≥15 LN for staging.METHODSWe investigated compliance with these guidelines and the correlation with overall survival (OS) by analyzing 10,807 resected gastric cancers in the Surveillance, Epidemiology and End Results (SEER) database, 1988–2002. Kaplan–Meier survival curves were constructed; survival was compared by using Cox proportional hazards.RESULTSOverall, 29% of cases had ≥15 LN examined. After 1997, the median number of LN assessed increased from 9 to 10 (P < .0001). Factors predictive of adequate LN assessment (ALNA) were higher stage, worse grade, age <74 years, later year of diagnosis, nonwhite race, more extensive surgery, female sex, and SEER region. Differences in the rate of ALNA between regions were noted, ranging from 19.7–53% (P < .0001). Of T1N0 patients, 19% had ALNA. Improved OS was predicted by earlier stage, lower grade, marital status, Asian race, younger age, T‐stage, female sex, SEER region, and ALNA. Median OS was highest in the region with the best ALNA rate and worst in the region with the lowest (33 mos vs. 17 mos, P < .0001). Inadequate LN assessment led to poorer survival at every stage (P < .001).CONCLUSIONThe overwhelming majority of patients have an inadequate LN assessment. ALNA was associated with improved OS, with significant variation across regions. Understaging due to inadequate LN assessment may affect eligibility for adjuvant therapy. Education is required to improve LN retrieval. Cancer 2006. © 2006 American Cancer Society.

Regional Variation in the Management of Metastatic Gastric Cancer in Ontario

“…Significant geographic variation in access to high-volume gastric cancer specialists was also noted. The present study supports other studies that describe regional variation in cancer care [29][30][31][32][33] . Despite attempts to standardize practice, variations in the provision of gastric cancer care have been demonstrated for multiple health care system variables, especially between geographic regions and centres of care [29][30][31][32][33] .…”

“…The present study supports other studies that describe regional variation in cancer care [29][30][31][32][33] . Despite attempts to standardize practice, variations in the provision of gastric cancer care have been demonstrated for multiple health care system variables, especially between geographic regions and centres of care [29][30][31][32][33] . Geographic variation in practice patterns commonly occurs when accepted standards of care do not exist for a particular disease, or if resources are limited or unavailable and alternative approaches are required [1][2][3]5,32,34 .…”

Lymphadenectomy for Gastric Adenocarcinoma: Should West Meet East?

“…An analysis of Ͼ6,000 gastric cancer patients treated at 691 U.S. hospitals found that Ͻ40% of patients undergoing surgical resection had the requisite 15 lymph nodes examined [29]. Using the Surveillance, Epidemiology, and End Results database, Coburn et al [30] found that only 29% of 10,807 resected gastric cancer patients had Ն15 lymph nodes examined. In a study from the United Kingdom analyzing 18 hospitals, only 31% of the 699 surgical resections resulted in Ն15 lymph nodes analyzed [31].…”

Surgeons' knowledge of quality indicators for gastric cancer surgery

“…A population-based Canadian study showed that over 60% of patients taken to the operating theater for the purpose of resection had stage III or IV disease, with median survivals of 12 or 3 months, respectively [2]. Similar survival data have subsequently been reported from the United States [3][4][5].…”

“…Quality gastric cancer surgery, defi ned as an R0 resection with a lymphadenectomy to include assessment of 15 or more LN, is an uncommon phenomenon in North America [3][4][5][14][15][16]. Inadequate LN assessment is directly correlated with poor long-term survival [3,17].…”