Assessment of advanced gastric cancer management in the United States

Background: Increasing attention is being placed on utilization of treatment for advanced malignancies. Though some suggest it is futile, recent reports have advocated noncurative surgery for advanced gastric cancer. Our objectives were to (1) assess treatment trends, (2) identify predictors of surgery, and (3) evaluate the effect of treatment on outcomes. Methods: Patients with stage IV gastric adenocarcinoma were identified from the National Cancer Data Base (1998-2007). Patients who underwent emergent surgery were excluded. Models were developed to identify factors associated with treatment receipt and to compare adjusted overall survival by treatment group. Results: Twenty-four percent (n = 22,430) of patients presented with stage IV gastric adenocarcinoma; 1.5 % (n = 414) underwent emergent surgery. Of the remaining 21,039 patients, 62.4 % underwent treatment (87.0 % chemotherapy with or without radiotherapy (C ± RT), 5.6 % surgery, 7.2 % combined surgery and C ± RT). Over the decade, surgery rates increased by 43 %, and C ± RT use increased by 16 % while receipt of no treatment decreased by 26 % (all p < 0.001). Patients who were younger, white, and insured, as well as those with distal tumors were more likely to undergo surgery. Reasons for receiving no treatment were multifactorial but were most strongly associated with advanced age and being uninsured. Median survival was longest for patients selected to undergo surgery and C ± RT (13.5 months) versus C ± RT alone (6.1 months), surgery alone (4.8 months), or no treatment (1.7 months, all p < 0.001). Conclusions: Utilization of nonemergent surgical treatment and C ± RT for metastatic gastric adenocarcinoma has increased considerably over time, especially in certain patient populations; however, the true utility and cost of these treatments remain unknown.