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Updated: Feb 28, 2026
Laparoscopic Radical Gastrectomy for Remnant Gastric Cancer
Published on: October 31, 2025
Failure to operate on resectable gastric cancer: implications for policy changes and regionalization
Heather A Frohman1, Jeremiah T Martin2, Anh-Thu Le1
1Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky.
Background:
A significant proportion of patients never receive curative-intent surgery for resectable gastric cancer (GC). The primary aims of this study were to identify disparities and targetable risk factors associated with failure to operate in the context of national trends in surgical rates for resectable GC.
Methods:
The National Cancer Database was used to identify patients with resectable GC (adenocarcinoma, clinical stage IA-IIIC, 2004-2013). Multivariate modeling was used to identify predictors of resection and to analyze the impact of surgery on overall survival (OS).
Results:
Of 46,970 patients with resectable GC, 18,085 (39%) did not receive an appropriate operation. Among unresected patients, 69% had no comorbidities. Failure to resect was associated with reduced median OS (44.4 versus 11.8 mo, hazard ratio [HR]: 2.09, P < 0.001). In the multivariate analysis, the most critical factors affecting OS were resection (HR: 2.09) and stage (reference IA; HR range: 1.16-3.50, stage IB-IIIC). Variables independently associated with no surgery included insurance other than private or Medicare (odds ratio [OR]: 1.60/1.54), nonacademic/nonresearch hospital (OR: 1.16), non-Asian race (OR: 1.72), male (OR: 1.19), older age (OR: 1.04), Charlson-Deyo score >1 (OR: 1.17), residing in areas with median income <$48,000 (OR: 1.23), small urban populations <20,000 (OR: 1.41), and stage (reference IA; OR range: 1.36-3.79, stage IB-IIIC, P < 0.001).
Conclusions:
Over one-third of patients with resectable GC fail to receive surgery. Suitable insurance coverage and treatment facility are the most salient (and only modifiable) risk factors for omitting surgery. To mitigate national disparities in surgical care, policymakers should consider improving insurance coverage in underserved areas and regionalization of gastric cancer care.
Insights
Over one-third of patients with resectable gastric cancer (GC) do not receive curative surgery. Insurance and hospital type significantly impact access to this vital treatment, highlighting disparities in care.
Area of Science:
- Oncology
- Surgical Oncology
- Health Services Research
Background:
- A significant proportion of patients with resectable gastric cancer (GC) do not undergo curative-intent surgery.
- Understanding disparities and risk factors for failure to operate is crucial given national trends in GC surgical rates.
Purpose of the Study:
- Identify disparities and targetable risk factors associated with the failure to perform surgery for resectable gastric cancer.
- Analyze national trends in surgical rates for resectable GC.
Main Methods:
- Utilized the National Cancer Database to identify patients with resectable GC (adenocarcinoma, clinical stage IA-IIIC) from 2004-2013.
- Employed multivariate modeling to determine predictors of resection and assess the impact of surgery on overall survival (OS).
Main Results:
- Of 46,970 patients, 39% did not receive surgery; 69% of unresected patients had no comorbidities.
- Failure to resect was linked to reduced median OS (44.4 vs. 11.8 months, HR: 2.09, P < 0.001).
- Key factors for no surgery included non-private/Medicare insurance, non-academic hospitals, non-Asian race, male sex, older age, higher comorbidity scores, lower income areas, smaller urban populations, and advanced stage.
Conclusions:
- Over one-third of patients with resectable GC do not receive surgery.
- Insurance status and treatment facility type are primary modifiable risk factors for omitting surgery.
- Improving insurance coverage and regionalizing care are recommended to address national disparities in surgical access for GC.
