gastric cancer resections in bc: how are we doing? trevor d hamilton md frcsc surgical oncology...
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Gastric Cancer Resections in BC:How are we doing?
Trevor D Hamilton MD FRCSC
Surgical Oncology NetworkNovember 7, 2015
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Gastric Cancer incidence declining
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Minimal Improvements in Survival
5-yr OS (resected) ~ 29%
Howlader et al. 2015 SEER Cancer Statistics
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In Western countries
Majority advanced disease
Multi-disciplinary treatmentis integral to care
Significant regionalvariations in survival
Cunningham et al. 2006 N Eng J MedBirkmeyer et al. 2002 N Eng J MedCoburn et al. 2006 Cancer
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…similar to pancreas, liver
Males FemalesCanada 11.4 4.9US 10.1 5.3UK 14.6 6.2
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M & M
Underappreciated
8-13% peri-op mortality (non-asian)
Considerably higher in very low-volume centres
Birkmeyer et al. 2002 N Eng J Med
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Hospital volume and survival
“High-volume gastric cancer hospital” >10/yearMahar et al. 2012 JACS
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Objective
… evaluate current outcomes of gastric cancer surgery in British Columbia
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Methods
2004-2012Population-based cohortAll patients referred to BC Cancer AgencyGastro-intestinal clinical outcomes unit (GICOU)
Inclusion:-Gastric cancer-Curative intent resection
Exclusion:-Metastatic-Esophageal
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BC Data
Gastric adenoCAN=37728 institutions~average 1.7 cases/hosp/year26% in hosp w >10 cases/year31% in hosp w <3 cases/year3 institutions performing half cases
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Hospital volume & survival
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g
201 171 124 84 60 41>=3 cases/yr175 140 99 73 53 39<=2 cases/yr
Number at risk
0 12 24 36 48 60
Months
<=2 cases/year>=3 cases/year
≤2/yr ≥3/yr PCase # 175 201Institution # 21 7Age>70 45.1% 44.3% NSMale gender 71.4% 64.8% NSECOG 3/4 2.4% 17.1% 0.02T stage 3/4 51.2% 48.8% NSNode positive 64.6% 65.5% NSDiffuse-type histology 39.3% 44.8% NSTotal gastrectomy 36.0% 42.8% NSDistal pancreatectomy 2.3% 3.0% NSSplenectomy 6.3% 2.0% 0.03Neoadjuvant chemo 10.3% 17.9% 0.05Postop chemorads 37.7% 38.8% NS
≤2 vs ≥3 cases/yr5-yr OS 42.5% vs 37.3%p=0.04
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Survival by resection
0.00
0.20
0.40
0.60
0.80
1.00P
rop
ort
ion
su
rviv
ing
18 13 8 4 2 2MVR221 189 142 102 77 52Subtotal137 109 73 51 34 26Total
Number at risk
0 12 24 36 48 60
Months
TotalSubtotalMVR
MVR – Multi-visceral resection (pancreas or spleen) = 4.8%
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Multivariate analysis
Factor HR P
Age <70>=70
-1.01
0.96
T stage 1/23/4
-1.43
0.02
N stage NegPos
-2.10
<0.001
LN harvest >=15 nodes<15 nodes
-1.02
0.87
Final Margins NegativePositive
-2.35
<0.001
Periop adjuvant therapy NoYes
-0.68
0.009
Hospital volume <=2 cases/yr>=3 cases/yr
-0.75
0.05
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Similar results in Ontario
Coburn et al. 2010 JSO
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Hospital volume
Likely a marker for:– Rapid access to diagnostic procedures– Skilled pre-op staging (i.e. EUS)– Peri-op infrastructure– Access to peri-op Med/Rad Onc– Access to peri-op rescue therapy (ICU, IR)
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How can we as surgeons ensure that patients are getting the best possible treatment?
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What are our Quality Indicators?
“Most patients with curative GC should undergo resection with D2 lymphadenectomy assessing at least 16 LNs. …
Frozen section analysis and subsequent consideration of re-resection to ensure negative margins is appropriate if the gross margin is <5 cm, or the lesion is T3 or T4.”
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Quality Indicators
• Negative margins (R0), with frozen section• Lymphadenectomy with ≥16 LNs• Multi-disciplinary treatment
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Margins
0 20 40 60 80 100Percent of cases
>=10 cases/yr
<10 cases/yr
Negative Positive
0 20 40 60 80 100Percent of cases
>=10 cases/yr
<10 cases/yr
Yes No
Final Margin Status, p=0.02 Use of Frozen Section, p=0.001
18.3%
8.2%
27.8%
47.5%
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Margins
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g
59 39 21 10 4 4Final pR1316 272 202 147 109 76Final pR0
Number at risk
0 12 24 36 48 60
Months
pR0pR1
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g
58 30 16 8 4 4Final pR1316 261 185 141 104 73Final pR0
Number at risk
0 12 24 36 48 60
Months
pR0pR1
Overall Survivalp<0.001
Recurrence-free Survivalp<0.001
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Frozen
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g
133 106 73 48 29 16No frozen done72 64 44 30 17 8Frozen done
Number at risk
0 12 24 36 48 60
Months
Frozen doneNo frozen
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g133 103 71 48 29 16No frozen done72 63 42 30 17 8Frozen done
Number at risk
0 12 24 36 48 60
Months
Frozen doneNo frozen
Overall Survivalp=0.02
Recurrence-free Survivalp=0.02
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LN Harvest
0 20 40 60 80 100Percent of cases
>5 cases/yr
1-5 cases/yr
<1 case/yr
>=15 nodes examined <15 nodes examined
22.6%*
47.6%
36.4%
Only 14.3% of OR reports state D1 or D2
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LN Harvest
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g
224 189 138 98 75 52<15 nodes151 122 85 59 38 28>=15 nodes
Number at risk
0 12 24 36 48 60
Months
>=15 nodes<15 nodes
0.00
0.20
0.40
0.60
0.80
1.00
Pro
po
rtio
n s
urv
ivin
g224 175 124 91 72 51<15 nodes150 116 77 58 36 26>=15 nodes
Number at risk
0 12 24 36 48 60
Months
>=15 nodes<15 nodes
Overall SurvivalNS
Recurrence-free SurvivalNS
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Multi-disciplinary
17.9%
10.3%
38.8%
37.7%
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Discussion
Room for improvement in gastric cancer treatment in BC
– Reduce (+)margins (routine frozen)– Adequate nodal harvest– All patients reviewed at multi-disciplinary
conference pre-op (consider peri-op chemo)– Minimize low-volume hospital resections
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Acknowledgements
Dr. Yarrow McConnell
Dr. Andy McFaddenDr. Hannah AdamsonDr. Noelle DavisDr. Rona CheifetzDr. Howard LimDr. Hagen KenneckeDr. Winson CheungCaroline SpeersGICOU
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Gastric Cancer Resections in BC:How are we doing?
Trevor D Hamilton MD FRCSC
Surgical Oncology NetworkNovember 7, 2015