Postop Complications Cut Survival in Gastric Cancer

Roxanne Nelson

January 17, 2014

SAN FRANCISCO — The effect of postoperative complications on survival has been well documented for many types of cancer and, according to new data, can significantly affect outcomes in gastric cancer.

In a new study, 5-year overall survival was significantly better in patients who did not experience any perioperative complications than in those who did (43% vs 27%; P < .001).

Complications were fairly common in the study cohort. Of the 850 patients with gastric cancer, 342 (40%) experienced at least 1 complication within 30 days of surgery. In the postoperative setting, there were 699 complications.

Preoperative characteristics associated with complications included older age, elevated American Society of Anesthesiologists class, previous gastrectomy, and upper gastrointestinal bleed, explained study author Ryan C. Fields, MD, from Washington University in St. Louis, Missouri, who presented the results here at the 2014 Gastrointestinal Cancers Symposium.

"Importantly, we did not find an association between postop complications and receipt of neoadjuvant therapy," he reported.

Previous research has shown that complications can affect outcomes in other types of gastrointestinal (GI) cancer. For example, one study showed that complications negatively affected outcomes and the receipt of adjuvant therapy in pancreatic cancer, Dr. Fields noted. Another showed that patients undergoing esophagogastrectomy who experienced complications had a 17% decrease in 3-year survival.

In this retrospective multi-institutional cohort, Dr. Fields and colleagues evaluated the effect of postoperative morbidity on survival after surgery for gastric cancer. All patients underwent surgery with curative intent for gastric adenocarcinoma at 1 of 7 centers participating in the US Gastric Cancer Collaborative from 2000 to 2012. The dataset excluded patients who died during surgery.

Overall Negative Impact

Median follow-up was 35 months. Overall survival was worse for patients with complications than for those without complications (25 vs 45 months; hazard ratio, 1.6). The rate of 5-year recurrence-free survival was also worse for patients with complications (23% vs 40%; P < .0001).

In addition, patients with postop complications were significantly less likely to receive adjuvant therapy than those without (48% vs 60%; P = .001).

The operative characteristics associated with more complex procedures — such as extensive gastric resection with total gastrectomy, the placement of feeding tubes and drains, intraoperative blood transfusion, longer operative times, and a higher estimated blood loss — were most strongly associated with complications. In addition, advanced American Joint Committee on Cancer stage was associated with decreased survival.

Patients with complications "also had a longer hospital stay and were more likely to be readmitted," Dr. Fields noted. "Over one third were of the grade 3/4 variety, and could significantly affect outcomes."

The fact that patients with complications were more likely to be older, have more advanced tumors, and undergo more complex surgeries is important, he noted, because these are patients "that we could potentially identify preoperatively to reduce the rate of complications."

He noted that one of the particular strengths of this dataset is that it is real-world data from across the United States. "This dataset represents a significant contribution to the literature, although it is limited" because the review was nonrandomized and retrospective, Dr. Fields explained.

Better Data Needed

Study discussant John G. Hunter, MD, from the Knight Cancer Institute, Oregon Health & Sciences University, in Portland, noted that the literature from randomized trials supports the hypothesis that excess early complications and more radical surgery influence the survival curve. "A limitation of randomized trials is that they do not compare survival in the different treatment groups," he said.

This study shows that gastrectomy is rare in the United States, and the "bottom line is that fewer complications equal better short- and long-term survival," Dr. Hunter said. However, retrospective trials indicating that complications deteriorate survival curves in upper GI cancer have not provided uniform results.

He said that he has seen "no fewer than 3 or 4 papers submitted to our journal" that show different results — that complications can impede survival or that complications make no difference. "The data are all over the place," Dr. Hunter noted, but it "makes sense" that complications would affect survival.

The authors have disclosed no relevant financial relationships.

2014 Gastrointestinal Cancers Symposium (GICS): Abstract 5. Presented January 16, 2014.

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