Surgery alone is not the answer to gastric cardia cancer

Last Updated: 2015-01-09

By Will Boggs MD

NEW YORK (Reuters Health) - Outcomes of gastric cardia cancer are similar after esophagectomy or total gastrectomy. What matters, researchers say, is that patients receive multimodality therapy.

"We were surprised to find equivalent morbidity and mortality when comparing esophagectomy to total gastrectomy nationally," Dr. Ching-Wei D. Tzeng, from the University of Kentucky in Lexington, told Reuters Health by email.

"We were not surprised," Dr. Tzeng continued, "to find that tumor biology trumped all and that multimodality therapy was better than surgery alone. That is what led to our conclusions regarding finding the surgical approach with less morbidity and higher multimodality therapy completion rates at each institution."

Surgery is a key component of treatment for gastric cardia cancer (GCC), but significant controversy swirls around the ideal surgical approach to resect it.

Dr. Tzeng's team used data from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) and Surveillance Epidemiology and End Results (SEER) databases to compare short-term outcomes and long-term oncologic outcomes after esophagectomy versus total gastrectomy.

The NSQIP sample included 214 (18.2%) patients who underwent gastrectomy and 967 (81.8%) who underwent esophagectomy, while the SEER sample included 3815 patients, 28.9% of which underwent gastrectomy and 71.1% of which underwent esophagectomy.

Patients who had esophagectomy were more likely than patients who had gastrectomy to receive radiation therapy, which was the authors' surrogate for multimodal therapy, at 42.9% vs 29.6%, respectively (p<0.001), according to a report online December 29 in the Journal of the American College of Surgeons.

In a 1:1 propensity score-matched subgroup of 214 esophagectomy and gastrectomy patients, there was no difference in major postoperative morbidity (34% vs 33%, respectively; p=0.838) or 30-day mortality (1.9% vs 3.7%).

Unadjusted median overall survival was longer after esophagectomy (26.0 months) than after gastrectomy (21.0 months)(p=0.025), but after adjustment for receipt of multi-modality therapy, surgical approach did not influence overall survival.

T/N stages and radiation use were, however, independent predictors of overall survival, with multimodal therapy conferring a significant survival advantage that is most pronounced in the first two years after surgery.

"Every patient should realize that 99% of GI cancer is non-emergent and that there is time to find the right doctor, the right cancer center, and the optimal treatment sequencing plan/operative approach for their problem," Dr. Tzeng said. "This means either doing some research up front online to see if your doctor does research on the topic (your cancer) or has a true clinical interest in treating your disease. This means getting a second opinion even if you like your first doctor. This means asking your doctor point blank about his/her personal outcomes and that of the hospital."

"Do not accept a computer printout of the NSQIP risk calculator, because the national rates of morbidity and mortality have nothing to do with your chosen individual doctor/hospital," Dr. Tzeng said. "And very importantly, ask about their multimodality completion rates (how many patients get all intended therapy - how many patients actually finish the triathlon of therapy?)."

"This paper is just a microcosm of a major cancer surgery issue with high-risk GI cancers nationally," Dr. Tzeng concluded. "Surgery alone is never the correct answer for any high-risk GI cancer. As cancer surgeons, we must do all that we can to optimize the chances that patients get 100% of the multimodality treatment that is planned upfront by the tumor board."

This research was supported by the Markey Cancer Center Peter and Carmen Lucia Buck Clinical and Translational Research Award. The authors reported no disclosures.

SOURCE: http://bit.ly/1AxCZWS

J Am Coll Surg 2014.