Authors: Vikas Dudeja Elizabeth B Habermann Anasooya Abraham Wei Zhong Helen M Parsons Jennifer F Tseng Waddah B AlRefaie
Publish Date: 2011/11/17
Volume: 16, Issue: 2, Pages: 238-247
Abstract
The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survivalUsing 2001–2008 California Cancer Registry we identified 2229 patients who underwent gastrectomy with adequate nodal evaluation ≥15 lymph nodes for American Joint Committee on Cancer stage I–IV M0 gastric adenocarcinoma Cox proportional hazard analyses were used to evaluate the impact of surgery alone on survivalNearly 70 of our cohort had T1/2 tumors and 29 had N0 disease Fortynine percent of the cohort underwent surgery alone These patients were more likely to be older Medicareinsured with T1 and N0 disease On unadjusted analyses persons who underwent surgery alone for stage I or N0 disease experienced 1 and 3year overall and cancerspecific survival comparable to those who received adjuvant therapy On multivariate analyses for stage I or N0 disease surgery alone predicted superior survival outcomes than when combined with adjuvant therapiesSurgery alone with adequate nodal evaluation may have a role in lowrisk gastric cancer To corroborate these findings surgery with adequate lymphadenectomy alone as treatment arm deserves consideration in the design of gastric cancer trials to provide effective yet resourceconserving rather than maximally tolerated treatmentsDr Samuel S Yoon MD Boston MA USA In the presentation by Dr Dudeja and his colleagues the authors retrospectively examine over 2000 gastric cancer patients from the California Cancer Registry who underwent gastrectomy and had at least 15 nodes examined Specifically they examine the effects of adjuvant chemoradiation or adjuvant chemotherapy on survival and find that adjuvant therapy is associated with improved survival However in a subset of patients with early tumors stage I–T1/T2 N0 or T1/N1 or nodenegative tumors adjuvant therapy is associated with a worse survival I would like to congratulate the authors on a very nice analysis and presentation This data suggests that there is a subset of gastric cancer patients with early stage tumors who could be treated with surgery aloneMy primary critique of this study is that it is retrospective and thus one must be very cautious in making any conclusions based on subset analysis It is quite possible that the patients with earlystage disease ended up getting adjuvant therapy because there were other factors that put them at higher risk of recurrence These factors could include positive resection margin and lymphovascular invasion A retrospective database analysis of this nature would not identify this selection bias If the subgroup of early stage patients who received adjuvant therapy had a poorer baseline prognosis than the subgroup of early stage patients who did not receive adjuvant therapy any benefit to adjuvant therapy could be hidden
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