'Regionalized' Care Tied to Better Survival in Tough Cancer

Program Combines Local Service With Greater Expertise

Roxanne Nelson, RN, BSN

September 30, 2021

The experience and expertise cultivated within a "regionalized" gastric cancer center appears to improve patient outcomes in this difficult tumor type, which has a relatively low 5-year survival rate in the United States, according to researchers.

The Kaiser Permanente Northern California (KPNC) Gastric-Esophageal Cancer Program was established in 2016 to consolidate the care of patients with gastric cancer and increase physician specialization and standardization.

In a retrospective study, Kaiser Permanente investigators compared the outcomes of the 942 patients diagnosed before the regional gastric cancer team was established with the outcomes of the 487 patients treated after it was implemented. Overall, the transformation appears to enhance the delivery of care and improves clinical and oncologic outcomes.

For example, among 394 patients who received curative-intent surgery, overall survival at 2 years increased from 72.7% before the program to 85.5% afterwards.

"The regionalized gastric cancer program combines the benefits of community-based care, which is local and convenient, with the expertise of a specialized cancer center," said co-author Lisa Herrinton, PhD, a research scientist at the Kaiser Permanente Division of Research, in a statement.

She added that in their integrated care system, "it is easy for the different physicians that treat cancer patients — including surgical oncologists, medical oncologists, and radiation oncologists, among others — to come together and collaborate and tie their work flows together."

The study was published in JAMA Oncology.

Gastric cancer accounts for about 27,600 cases diagnosed annually in the United States, but the overall 5-year survival is still only 32%. About half of the cases are locoregional (stage I-III) and potentially eligible for curative-intent surgery and adjuvant therapy, the authors point out in the study.

As compared with North America, the incidence rate is 5-6 times higher in East Asia, but they have developed better surveillance for early detection and treatment is highly effective, as the increased incidence allows oncologists and surgeons to achieve greater specialization. Laparoscopic gastrectomy and extended (D2) lymph node dissection are more commonly performed in East Asia as compared with the US, and surgical outcomes appear to be better in East Asia.

Regionalizing Care

The rationale for regionalizing care was that increasing and concentrating the volume of cases to a specific location would make it more possible to introduce new surgical procedures as well as allow medical oncologists to uniformly introduce and standardize the use of the newest chemotherapy regimens.

Prior to regionalization, gastric cancer surgery was performed at 19 medical centers in the Kaiser system. Now, curative-intent laparoscopic gastrectomy with Roux-en-Y gastrojejunostomy or esophagojejunostomy and side-to-side jejunojejunostomy is subsequently performed at only two centers by five surgeons.

"The two centers were selected based on how skilled the surgeons were at performing advanced minimally invasive oncologic surgery," said lead author Swee H. Teh, MD, surgical director, Gastric Cancer Surgery, Kaiser Permanente Northern California. "We also looked at the center's retrospective gastrectomy outcomes and the strength of the leadership that would be collaborating with the regional multidisciplinary team."

Teh told Medscape Medical News that it was imperative that their regional gastric cancer centers have surgeons highly skilled in advanced minimally invasive gastrointestinal surgery. "This is a newer technique and not one of our more senior surgeons had been trained in [it]," he said. "With this change, some surgeons were now no longer performing gastric cancer surgery."

Not only were the centers selected based on the surgical skills of the surgeons already there, but they also took into account the locations and geographical membership distribution. "We have found that our patients' traveling distance to receive surgical care has not changed significantly," Teh said.

Improved Outcomes

The cohort included 1429 eligible patients all stages of gastric cancer; one third were treated after regionalization, 650 had stage I-III disease, and 394 underwent curative-intent surgery.

Overall survival at 2 years was 32.8% pre- and 37.3% post-regionalization (P = .20) for all stages of cancer; stage I-III cases with or without surgery, 55.6% and 61.1%, respectively (P = .25); and among all surgery patients, 72.7% and 85.5%, respectively (P < .03).

Among patients who underwent surgery, the use of neoadjuvant chemotherapy increased from 35% to 66% (P < .0001), as did laparoscopic gastrectomy from 18% to 92% (P < .0001), and D2 lymphadenectomy from 2% to 80% (P < .0001). In addition, dissection of 15 or more lymph nodes also rose from 61% to 95% (P < .0001). Post-regionalization, the resection margin was more often negative, and the resection less often involved other organs.

The median length of hospitalization declined from 7 to 3 days (P < .001) after regionalization but all-cause readmissions and reoperation at 30 and 90 days were similar in both cohorts. The risk of bowel obstruction was less frequent post-regionalization (P = .01 at both 30 and 90 days), as was risk of infection (P = .03 at 30 days and P = .01 at 90 days).

The risk of one or more serious adverse events was also lower (P < .01), and 30 day mortality did not change (pre 0.7% and post 0.0%, P = .34).

Generalizability May Not Be Feasible

But although this was successful for Kaiser, the authors note that a key limitation of the study is generalizability — and that regionalization may not be feasible in many US settings.

"There needs to be a standardized workflow that all stakeholders agree upon," Teh explained. "For example, in our gastric cancer staging pathway, all patients who are considered candidates for surgery have four staging tests: CT scan, PET scan and endoscopic ultrasound (EUS), and staging laparoscopy."

Another important aspect is that in order to make sure the workflow is smooth and timely, all subspecialties responsible for the staging modalities need to create a "special access." What this means, he continued, is for example, that the radiology department must ensure that these patients will have their CT scan and PET scans promptly. "Similarly, the GI department must provide quick access to EUS, and the surgery department must quickly provide a staging laparoscopy," Teh said. "We have been extremely successful in achieving this goal."

Teh also noted that a skilled patient navigator and a team where each member brings high-level expertise and experience to the table are also necessary. And innovative technology is also needed.

"We use artificial intelligence to identify all newly diagnosed cases of gastric [cancer], and within 24 hours of a patient's diagnosis, a notification is sent to entire team about this new patient," he added. "We also use AI to extract data to create a dashboard that will track each patient's progress and outcomes, so that the results are accessible to every member of the team. The innovative technology has also helped us build a comprehensive survivorship program."

They also noted in their study that European and Canadian systems, as well the Veterans Administration, could probably implement components of this, including enhanced recovery after surgery.

The study had no specific funding. Teh and Herrinton have disclosed no relevant financial relationships.

J Clin Oncol. Published online August 2, 2021. Abstract

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