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Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors
Danielle R Heller1, Raymond A Jean2, Jiajun Luo3
1Department of Surgery, Yale School of Medicine, New Haven, CT.
Background:
Surgical management of appendiceal carcinoid tumors is heavily debated, despite National Comprehensive Cancer Network guidelines recommending aggressive resection of tumors >2 cm. We investigated national practice patterns and the predictors and impact of guideline non-adherence.
Study Design:
The National Cancer Database was queried for cases of appendiceal carcinoids diagnosed from 2004 to 2015 treated with either appendectomy or hemicolectomy. Multivariable logistic regression, adjusted for demographic and clinical factors, identified associations with the procedure type among patients stratified by tumor size ≤2 cm and >2 cm. Cox Proportional Hazards then identified associations with overall survival among stratified patient groups.
Results:
Of 3,198 cases of appendiceal carcinoids, 1,893 appendectomies and 1,305 hemicolectomies were identified. Contrary to National Comprehensive Cancer Network guidelines, 32.4% of tumors ≤2 cm were treated with hemicolectomy and 31.3% of tumors >2 cm were treated with definitive appendectomy. Hemicolectomy for small tumors was associated with age 65 years and older (odds ratio [OR] 2.4; 95% CI 1.7 to 3.3; reference group age 18 to 39 years), history of malignancy (OR 2.0; 95% CI 1.6 to 2.6), tumor size 1.1 to 2 cm (OR 2.8; 95% CI 2.3 to 3.4; reference group size ≤1 cm), and lymphovascular invasion (OR 2.2; 95% CI 1.6 to 3.2); appendectomy for large tumors was associated with age 65 years and older only (OR 2.2; 95% CI 1.1 to 4.2). Procedure type was not associated with survival for small or large tumors (hazard ratio 1.0; 95% CI 0.7 to 1.4 and hazard ratio 1.1; 95% CI 0.6 to 2.0, respectively).
Conclusions:
Despite well-known size-based treatment guidelines for appendiceal carcinoids, one-third of patients in the US undergo hemicolectomy for small tumors and appendectomy for large tumors. Guideline non-adherence, however, is not associated with overall survival. Reasons for these practice patterns should be explored, and guidelines revisited.
Insights
Surgical management for appendiceal carcinoid tumors deviates from guidelines, with many patients receiving inappropriate procedures. However, this non-adherence does not impact overall survival rates.
Area of Science:
- Oncology
- Surgical Oncology
- Gastrointestinal Surgery
Background:
- Appendiceal carcinoid tumors are rare neuroendocrine neoplasms.
- Surgical management guidelines exist but adherence is debated.
- National Comprehensive Cancer Network (NCCN) guidelines recommend aggressive resection for tumors >2 cm.
Purpose of the Study:
- Investigate national practice patterns for appendiceal carcinoid tumor surgery.
- Identify predictors of adherence to NCCN guidelines.
- Determine the impact of guideline non-adherence on patient survival.
Main Methods:
- Analysis of the National Cancer Database (2004-2015).
- Inclusion of patients with appendiceal carcinoids treated with appendectomy or hemicolectomy.
- Multivariable logistic regression and Cox Proportional Hazards models used for analysis.
Main Results:
- 3,198 cases analyzed; 32.4% of small tumors (≤2 cm) and 31.3% of large tumors (>2 cm) received non-guideline-concordant surgery.
- Factors associated with non-adherence included older age, prior malignancy, larger tumor size within the ≤2 cm group, and lymphovascular invasion.
- Procedure type did not significantly impact overall survival for either small or large tumors.
Conclusions:
- Significant national non-adherence to NCCN guidelines for appendiceal carcinoid tumor surgery was observed.
- Despite non-adherence, overall survival was not affected by surgical procedure choice.
- Further investigation into practice patterns and potential guideline revisions is warranted.
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