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

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.

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.

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).

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.