BACKGROUND: Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival. METHODS: The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS: Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05). CONCLUSIONS: For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.
BACKGROUND: Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival. METHODS: The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS: Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05). CONCLUSIONS: For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.
Authors: John D Birkmeyer; Andrea E Siewers; Emily V A Finlayson; Therese A Stukel; F Lee Lucas; Ida Batista; H Gilbert Welch; David E Wennberg Journal: N Engl J Med Date: 2002-04-11 Impact factor: 91.245
Authors: P van Hagen; M C C M Hulshof; J J B van Lanschot; E W Steyerberg; M I van Berge Henegouwen; B P L Wijnhoven; D J Richel; G A P Nieuwenhuijzen; G A P Hospers; J J Bonenkamp; M A Cuesta; R J B Blaisse; O R C Busch; F J W ten Kate; G-J Creemers; C J A Punt; J T M Plukker; H M W Verheul; E J Spillenaar Bilgen; H van Dekken; M J C van der Sangen; T Rozema; K Biermann; J C Beukema; A H M Piet; C M van Rij; J G Reinders; H W Tilanus; A van der Gaast Journal: N Engl J Med Date: 2012-05-31 Impact factor: 91.245
Authors: Salah-Eddin Al-Batran; Nils Homann; Claudia Pauligk; Thorsten O Goetze; Johannes Meiler; Stefan Kasper; Hans-Georg Kopp; Frank Mayer; Georg Martin Haag; Kim Luley; Udo Lindig; Wolff Schmiegel; Michael Pohl; Jan Stoehlmacher; Gunnar Folprecht; Stephan Probst; Nicole Prasnikar; Wolfgang Fischbach; Rolf Mahlberg; Jörg Trojan; Michael Koenigsmann; Uwe M Martens; Peter Thuss-Patience; Matthias Egger; Andreas Block; Volker Heinemann; Gerald Illerhaus; Markus Moehler; Michael Schenk; Frank Kullmann; Dirk M Behringer; Michael Heike; Daniel Pink; Christian Teschendorf; Carmen Löhr; Helga Bernhard; Gunter Schuch; Volker Rethwisch; Ludwig Fischer von Weikersthal; Jörg T Hartmann; Michael Kneba; Severin Daum; Karsten Schulmann; Jörg Weniger; Sebastian Belle; Timo Gaiser; Fuat S Oduncu; Martina Güntner; Wael Hozaeel; Alexander Reichart; Elke Jäger; Thomas Kraus; Stefan Mönig; Wolf O Bechstein; Martin Schuler; Harald Schmalenberg; Ralf D Hofheinz Journal: Lancet Date: 2019-04-11 Impact factor: 79.321
Authors: Cornelius A Thiels; Kristine T Hanson; Elizabeth B Habermann; Judy C Boughey; Travis E Grotz Journal: Cancer Date: 2019-12-10 Impact factor: 6.860
Authors: Karyn B Stitzenberg; Elin R Sigurdson; Brian L Egleston; Russell B Starkey; Neal J Meropol Journal: J Clin Oncol Date: 2009-08-31 Impact factor: 44.544