BOSTON—A substantial proportion of patients with nonmetastatic gastric cancer do not undergo surgery, according to the results of a new study.

The investigation also identified a number of nonmedical patient and provider characteristics that were associated with such surgical attrition, an insight the researchers said highlights clear opportunities for improving rates of potentially curative cancer surgery.

“I think surgery is the most critical part of treatment in early-stage gastric cancers, and anyone who can get it should,” said Richard S. Hoehn, MD, an assistant professor of surgery at University Hospitals Cleveland Medical Center. “Nevertheless, many patients with nonmetastatic gastric cancer fail to undergo surgical resection, for unclear reasons. As such, the line of investigation that we’re chasing right now has to do with disparities in cancer care associated with personal factors such as race, income, socioeconomic status and health insurance,” he added.

In a publication in the Annals of Surgery (2023;278[5]:e1103-e1109), Dr. Hoehn and his colleagues quantified rates of gastrointestinal cancer surgery in various neighborhoods across northeastern Ohio. The study found dramatic inequities in rates of such procedures, ranging as widely as 20% to 90% between neighborhoods.

“In light of those findings, we are now investigating different cancers using different data sources, to try and get an understanding of the specific barriers that may prevent people from undergoing these potentially curative surgeries,” Dr. Hoehn added.

To do so, the investigators first reviewed public data from clinical trials of neoadjuvant therapy for gastric cancer to set a benchmark for surgical rates and factors associated with receipt of definitive surgery. Then they queried the National Cancer Database for patients with stage I to III gastric adenocarcinoma presenting between 2004 and 2018.

As Dr. Hoehn reported at the Society of Surgical Oncology’s 2023 International Conference on Surgical Cancer Care, review of published clinical trials revealed that 10% of patients in so-called “surgery-first” arms do not undergo surgery, primarily because of disease progression, patient refusal and lack of follow-up. It was also found that 15% of patients in neoadjuvant therapy arms failed to reach surgery, with treatment side effects explaining the 5% increased attrition over surgery-first arms.

“It’s interesting because clinical trial patients tend to be young, healthy and well resourced compared to the general cancer population,” Dr. Hoehn said in an interview with General Surgery News. “Yet, even so, only 90% of the patients in the surgery groups and 85% of patients getting neoadjuvant chemotherapy actually made it to surgery, which we figure is the best-case scenario. This gives us a benchmark we can aim for, so if we’re going to design an intervention and want to improve rates of surgery, we know we’ll probably never get to 100%.”

Perhaps not surprisingly, analysis of the National Cancer Database found less encouraging results, where 61.7% of patients underwent definitive surgery. Furthermore, when Dr. Hoehn and his co-investigators examined a subset of patients in the database resembling those enrolled in clinical trials (age <80 years; Deyo-Charlson Comorbidity Index score <2; private insurance; and treated at high-volume academic centers), they found a 79.2% rate of surgery.

Logistic regression analyses found several factors to be associated with reduced likelihood of surgery, including:

• advanced age (odds ratio [OR], 0.97; P<0.01);
• a Deyo-Charlson score of at least 2 (OR, 0.90; P<0.01);
• T4 tumors (OR, 0.39; P<0.01);
• N+ disease (OR, 0.84; P<0.01);
• a low socioeconomic status (OR, 0.86; P=0.01);
• being uninsured (OR, 0.58; P<0.01);
• being on Medicaid (OR, 0.69, P<0.01);
• low facility volume (OR, 0.64; P<0.01); and
• treatment at nonacademic cancer programs (OR, 0.79; P<0.01).

When the researchers assessed the relative importance of each of these potential predictors to the likelihood of surgery, they found that advanced patient age had the highest predictive value (100% area under the curve [AUC]), followed by T stage (69.1% AUC), insurance status (35.5% AUC), facility volume (19.4% AUC), distance traveled (18.9% AUC), race (13.4% AUC), N stage (10.1% AUC), facility type (9.7% AUC), socioeconomic status (3.2% AUC), Deyo-Charlson score (3.2% AUC) and sex (0.5% AUC).

“Obviously what stood out here is that patients who were uninsured, on Medicaid and in the lowest socioeconomic status group were less likely to receive surgery, even after we accounted for such factors as comorbidities, age and the size of their tumor,” Dr. Hoehn said. “I guess I was hoping that these things wouldn’t play a role, but the fact that they did reaffirms that there is a problem here that we need to work on.”

Helping address some of the barriers identified by the investigation is the next step in the process, Dr. Hoehn said, but one that demands more effort by clinicians and administrators alike.

“We are trying to take a stepwise approach and narrow our focus to the point where we’re having conversations with our patients about the specific barriers they’re facing,” he added. “Ultimately, we’d like to use the insights gleaned from those interviews to develop an intervention at our hospital to address these barriers and hopefully eliminate these inequities, at least within our system.”