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Effect of Regionalization of Gastric Cancer Care in an Integrated Health-Care System


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In a retrospective cohort study reported in the Journal of Clinical Oncology, Teh et al found that regionalization of gastric cancer care in a U.S. integrated health-care system resulted in the increased use of laparoscopic gastrectomy and D2 lymphadenectomy, as well as improved overall survival among patients undergoing curative surgery.

Study Details

In 2016, Kaiser Permanente Northern California instituted regionalized gastric cancer care, employing a regional comprehensive multidisciplinary care team with the objectives of standardizing staging and chemotherapy and increasing use of laparoscopic gastrectomy and D2 lymphadenectomy in patients eligible for curative-intent surgery.

The study included data on 1,429 patients diagnosed with any-stage gastric cancer from January 2010 to May 2018 within the health-care system. The preregionalization cohort included patients diagnosed between 2010 and 2015, and the postregionalization cohort included those diagnosed between 2016 and May 2018. Data were obtained from electronic medical records, cancer registries, state vital statistics, and chart reviews.

KEY POINTS

  • Among patients undergoing surgery, use laparoscopic gastrectomy increased from 18% to 92% and D2 lymphadenectomy increased from 2% to 80%.
  • For pre- vs postregionalization, overall survival at 2 years was 32.8% vs 37.3% among patients with any-stage disease, 55.6% vs 61.1% among stage I to III cases with or without surgery, and 72.7% vs 85.5% among surgical patients.
  • No significant differences in intraoperative complications were observed.

Key Findings

Among the 1,429 patients with all stages of disease, 942 were diagnosed pre- and 487 postregionalization. Among the 942 preregionalization cases, 443 (47%) had locoregional (stage I–III) disease; of these, 272 (61%) underwent curative-intent surgery. Among the 487 postregionalization cases, 207 (43%) had locoregional disease; of these, 122 (59%) underwent curative-intent surgery.

Among patients undergoing surgery, use of neoadjuvant chemotherapy increased from 35% to 66% (P < .0001), laparoscopic gastrectomy from 18% to 92% (P < .0001), D2 lymphadenectomy from 2% to 80% (P < .0001), dissection of 15 or more lymph nodes from 61% to 95% (P < .0001), adjuvant chemotherapy from 34.9% to 63.1% (P < .001), and any chemotherapy from 62.5% to 79.5% (P < .001). Use of postoperative chemoradiation decreased from 26.5% to 5.7% (P < .0001).

For surgical patients, the median length of initial hospitalization decreased from 7 to 3 days (P < .001), with no significant differences observed in all-cause readmissions or reoperation at 30 or 90 days. No significant differences in intraoperative complications were observed.  

In terms of serious adverse events, bowel obstruction (17.7% vs 8.2% at 30 days and 20.2% vs 9.8% at 90 days, both P = .01) and infectious complications (3.7% vs 3.3%, P = .03, at 30 days; 11.0% vs 3.3% at 90 days, P = .01) were reduced postregionalization. Proportions of patients experiencing one or more serious adverse events decreased from 39.7% to 23.8% (P = .01) at 30 days and from 48.2% to 28.7% (P = .01) at 90 days. Mortality at 30 days was 0.7% vs 0% (P = .34).

For pre- vs postregionalization, overall survival at 2 years was 32.8% vs 37.3% (P =.20) among patients with any-stage disease, 55.6% vs 61.1% (P = .25) among stage I to III cases with or without surgery, and 72.7% vs 85.5% (P = .03) among surgical patients.

The investigators concluded, “Regionalization of gastric cancer care within an integrated system allowed comprehensive multidisciplinary care, conversion to laparoscopic gastrectomy and D2 lymphadenectomy, increased overall survival among surgery patients, and no increase in surgical complications.”

Swee H. Teh, MD, of The Permanente Medical Group, Gastric Surgery, San Francisco, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The investigators reported no external funding for the study. For full disclosures of the study authors, visit ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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