Clinical Research Papers:
Patterns of relapse in patients with localized gastric adenocarcinoma who had surgery with or without adjunctive therapy: costs and effectiveness of surveillance
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Elena Elimova1,8, Rebecca S. Slack2, Hsiang-Chun Chen2, Venkatram Planjery1, Hironori Shiozaki1, Yusuke Shimodaira1, Nick Charalampakis1, Quan Lin1, Kazuto Harada1, Roopma Wadhwa1, Jeannelyn S. Estrella3, Dilsa Mizrak Kaya1, Tara Sagebiel4, Jeffrey H. Lee5, Brian Weston5, Manoop Bhutani5, Mariela Blum Murphy1, Aurelio Matamoros4, Bruce Minsky6, Prajnan Das6, Paul F. Mansfield7, Brian D. Badgwell7 and Jaffer A. Ajani1
1Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
2Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
3Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
4Department of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
5Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
6Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
7Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
8Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
Jaffer A. Ajani, email: [email protected]
Keywords: localized gastric adenocarcinoma, cancer surveillance, cost-effectiveness analysis, imaging studies, esophagogastroduodenoscopy
Received: December 02, 2016 Accepted: June 02, 2017 Published: July 13, 2017
Purpose: After therapy of localized gastric adenocarcinoma (GAC) patients, the costs of surveillance, relapse patterns, and possibility of salvage are unknown.
Materials and Methods: We identified 246 patients, who after having a negative peritoneal staging, received therapy (any therapy which included surgery) and were surveyed (every 3–6 months in the first 3 years, then yearly; ~10 CTs and ~7 endoscopies per patient). We used the 2016 Medicare dollars reimbursed as the “costs” for surveillance.
Results: Common features were: Caucasians (57%), men (60%), poorly differentiated histology (76%), preoperative chemotherapy (74%), preoperative chemoradiation (59%), and had surgery (100%). At a median follow-up of 3.7 years (range, 0.1 to 18.3), the median overall survival (OS) was 9.2 years (95% CI, 6.0 to 11.2). Tumor grade (p = 0.02), p/yp stage (p < 0.001), % residual GAC (p = 0.05), the R status (p = 0.01), total gastrectomy (p = 0.001), and relapse type (p = 0.02) were associated with OS. Relapse occurred in 79 (32%) patients (only 8% were local-regional) and 90% occurred within 36 months of surgery. P/yp stage (p < 0.001) and total gastrectomy (p = 0.01) were independent prognosticators for OS in the multivariate analysis. Only 1 relapsed patient had successful salvage therapy. The estimated reimbursement for imaging studies and endoscopies was $1,761,221.91 (marked underestimation of actual costs).
Conclusions: The median OS of localized GAC patients was excellent with infrequent local-regional relapses. Rigorous surveillance had a low yield and high “costs”. Our data suggest that less frequent surveillance intervals and limiting expensive investigations to symptomatic patients may be warranted.
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