Underuse of curative surgery for early stage upper gastrointestinal cancers in the United States

Background: Surgery is the cornerstone of potentially curative therapy for upper gastrointestinal cancer. We analyzed the patterns of treatment regarding the use of surgery for early-stage upper gastrointestinal cancer in the United States.

Methods: The Surveillance, Epidemiology, and End Research database was used to identify patients with cancer of the esophagus, stomach, pancreas, liver, gallbladder, biliary tract, or duodenum (2004-2007). Only patients with potentially resectable stage I and II disease were selected. The primary outcome measure was the use of curative intent surgery. The secondary outcomes were the predictors of surgery.

Results: We identified 29,249 patients with a median age of 69 years. Only 54% of the patients underwent cancer-directed surgical resection, ranging from 28% for liver cancer to 89% for gallbladder cancer. The remaining patients underwent either local excision (8%) or no surgery (38%). Among the no surgery group, most patients (79%) were documented as "not being recommended for resection." The independent variables on multivariate analysis predictive of a nonoperative approach included black race, age older than 75 years, tumor size greater than 5 cm, and high poverty level (P < 0.001). Patients who did not undergo surgery had worse median and overall survival at 3 years than patients undergoing surgery (11 months versus 36 months and 14% versus 43%, respectively; P < 0.001).

Conclusions: Almost one half of patients with early-stage upper gastrointestinal cancer did not receive potentially curative surgery, with an adverse effect on overall survival. A combination of demographic, tumor, and socioeconomic factors were predictive of a lack of surgical resection.